I LIBRARY OF CONGRESS. 



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i UNITED STATES OF AMERICA. 



LECTURES 

ON THE 

PRINCIPLES AND PRACTICE 

OF 

PHYSIC; 

DELIVERED AT KING'S COLLEGE, LONDON, 



BY 

sir THOMAS WATSON, M.D., 

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS J LATE PHYSICIAN TO THE MIDDLESEX HOSPITAL ; 
AND FORMERLY FELLOW OF ST. JOHN'S COLLEGE, CAMBRIDGE- 
SECOND AMERICAN, EROM THE SECOND LONDON EDITION. 

REVISED, WITH ADDITIONS, 
BY 

D. FRANCIS CONDIE, M.D., 

SECRETARY OF THE COLLEGE OF PHYSICIANS J AUTHOR OF A TREATISE ON DISEASES 
OF CHILDREN, &C. &C. 




PHILADELPHIA: 
LEA AND BLANCHARD. 
1845. 



Entered according to the Act of Congress, in the year 1845, by 
LEA AND BLANCHARD, 

In the Clerk's Office of the District Court for the Eastern District of Penn- 
sylvania. 



b h 1 s 



LC Control Number 




tmp96 029106 



PHILADELPHIA: * 
T. K. & P. G-. COLLINS, 
PRINTERS. 



PREFACE BY THE EDITOR. 



The very full and accurate exposition presented by Dr. Watson of the 
present state of pathology and therapeutics, in reference to nearly all of 
the diseases embraced in these Lectures, has rendered it unnecessary to 
augment materially the size of the work by the addition of frequent and 
extended notes. In regard, however, to a few of the forms of disease 
more particularly interesting to the American physician, the account 
given by the Author will be found somewhat defective, while he has 
omitted to notice one or two affections endemic in the United States, 
his lectures being chiefly confined to a consideration of the diseases most 
prevalent in Great Britain. It is to remedy these deficiencies that the 
Editor, in preparing the present edition, has mainly directed his atten- 
tion. In the notes he has added to Dr. Watson's lectures on diarrhoea 
and dysentery, he has endeavoured to fill up the very brief sketch pre- 
sented in the text, of the chronic forms of those diseases; he has 
attempted, also, to supply, in part, the omissions of the Author, by his 
notes on the history, pathology and treatment of typhoid pneumonia, 
remittent fever, &c. 

The intrinsic merits of Dr. Watson's Lectures are sufficient to ensure 
for them a favourable reception. If, by the few notes he has been in- 
duced to append to the present edition, the Editor has succeeded in 
adding in some slight degree to their value, he will be amply repaid for 
his labour. 

Philadelphia, September, 1845. 



AUTHOR'S ADVERTISEMENT 

TO 

THE SECOND EDITION. 



The unexpected exhaustion of the former edition of these Lectures 
within the space of a twelvemonth, has left but little opportunity to the 
Author, whose leisure is small, for such revision as might render them 
more worthy of the encouragement they have received. Some errors 
have been corrected, but in substance, as well as in form, the Lectures 
are nearly the same as before. 



ADVERTISEMENT 

TO 

THE FIRST EDITION. 



The following Lectures were put together, with unavoidable haste, 
during the Medical Session of 1836-37, in which they were first deli- 
vered. They were repeated, with slight variations, for four successive 
years ; the Author always meditating, but never finding time to accom- 
plish, their thorough reconstruction and revision. They were afterwards 
printed, to fulfil a rash promise, in the pages of the Medical Gazette: 
and they are now published, in a collected form, at the request, formally 
conveyed to him in writing, of many who had heard or read them, 
including several of his colleagues at King's College. 

Writing for mere beginners, and without any thought of future publi- 
cation, the Author took no pains to note authorities as he went along. 
He may often, therefore, have used, without acknowledgment, not only 
the facts and reasonings, but sometimes, perhaps, the very words of 
others. This omission he regrets, but is now unable to supply. Neither 
has he leisure to correct, if that were desirable, the colloquial and 
familiar style in which the Lectures were originally composed. 

Should they attract the notice of any who are no longer in statu pupil- 
lari, he would request such readers to bear in mind for whom these 
lessons were intended. They do not profess to present a formal and 
complete treatise on the Practice of Physic, much less to exhaust the 
various subjects upon which they touch. His chief hope is that they 
may prove useful as a text-book for students. 

As they are passing through the press, such additions and alterations 
have been introduced as the Author would have made had he continued 
to deliver the Lectures orally. 

Henrietta Street, Cavendish Square, 
September, 1843. 



C 0 N T E NT S. 



LECTURE I. 

PAGE 

Introductory, - - - - - - - - - -17 

LECTURE II. 

Pathology — meaning of the term. Pathology, general and special. Morbid alterations of 
the solid parts of the body. Alterations in bulk. Hypertrophy — law of its production — 
its effects. Atrophy — its causes and consequences. Changes in form. Alterations in 
consistence. Induration — its various kinds, ------ 25 

LECTURE III. 

Softening; its causes and varieties. Transformations of Tissue; Changes of situation — in 
the Chest, of the Lung, of the Heart — in the Abdomen and Pelvis, Hernia, Intussuscep- 
tion, Prolapsus, ----------34 

LECTURE IV. 

Morbid alterations of the Fluids, especially of the Blood. Changes in its quantity and 
distribution. General and Local Plethora. Poverty of Blood. Active Congestion — 
its Phenomena — state of the Vessels, as seen by the Microscope. Mechanical Conges- 
tion. Passive Congestion. Relations of these forms of Congestion to Inflammations — 
to Hemorrhages — to Dropsies, - -- -- -- - 40 

LECTURE V. 

Different modes of Dying. Pathology of Sudden Death. Death by Anaemia ; its Course, 
Phenomena, and Anatomical Characters. Death by Asthenia; its Course, Phenomena, 
and Anatomical Characters. Syncope. Death by Inanition. Death by Apnoea : Death 
by Coma: their Course and Phenomena, and the Anatomical Characters common to both. 
Application of the Principles obtained from the investigation of the Phenomena of Sudden 
Death, in elucidating the Symptoms and Tendencies of Disease, - - - 50 

LECTURE VI. 

Causes of Disease : distinction between predisposing and exciting causes. Enumeration 
of causes, as connected with the Atmosphere — Food and Drink — Poisons — Exercise — 
Sleep — Mental and Moral Conditions — Hereditary Tendencies — Malformations. Tem- 
perature. Effects of Heat and of Cold, -------59 

LECTURE VII. 

Causes of Disease, continued. Laws by which the operation of Cold upon the Bodily 
Health is regulated. Circumstances that favour its injurious Effects, and respect, first, 
the Body itself; secondly, the manner in which the Cold is applied. Modifying influence 
of certain states of the Mind — of Sleep — of Habit. Means of protection. Influence of 
the different Seasons. Impurity of the Air. Hereditary tendencies to Disease, - 70 

LECTURE VIII. 

Symptoms. Their Uses in relation to the Diagnosis, the Prognosis and the Treatment of 
Diseases. Signs, as distinguished from Symptoms. Pathognomonic, Commemorative, 
Direct and Indirect Symptoms. Examples of Symptoms as they consist of uneasy Sensa- 
tions, disordered Functions, or changes of Sensible Qualities, - - - - 81 

LECTURE IX. 

Inflammation. Its Morbid and its Salutary Effects. Sketch of the Local and Constitutional 
Phenomena of Inflammation as it occurs in External Parts. Examination of the Symp- 
toms of Inflammation ; Pain ; Heat ; Redness ; Swelling. State of the Capillary Blood- 
vessels and of the Blood in a part inflamed, ------ 94 

LECTURE X. 

Inflammation, continued. Buffy Coat of the Blood. Terminations or Events of Inflamma- 
tion. Resolution — Delitescence — Metastasis. Effusion of Serum. Effusion of Coagulable 
Lymph, or Fibrin. Organization of this Lymph, Suppuration. Ulceration, - - 105 



10 



CONTENTS. 



PAGE 

LECTURE XI. 

Mortification, as an event of Inflammation. Inflammatory Fever. Hectic Fever. Typhoid 
Fever. Modification of Inflammation by differences of Tissue ; Areolar Tissue ; sub- 
stance of Glands and Solid Viscera; Serous Membranes ; Synovial Membranes; Tegu- 
mentary Membranes — Skin — Mucous Membranes; Muscular Tissue; Arteries; Veins; 
substance of the Brain, - - - - - - - - -115 

LECTURE XII. 

Varieties of Inflammation : Acute and Chronic ; Latent; Specific. Scrofulous Inflammation. 
Tubercles. Relative frequency of Scrofulous Disease in different Organs. Signs of the 
Strumous Diathesis, ------ 127 

LECTURE XIII. 

Cancer; its Species or Varieties. Scirrhus; Encephaloid Cancer; Colloid Cancer. Its 

mode of Growth and Dissemination. Habitudes of the several Varieties'. 
Treatment of Inflammation. Antiphlogistic Regimen. Blood-letting. - - 138 

LECTURE XIV. 

Treatment of Inflammation, continued. Recapitulation. Bleeding. Purgatives. Mercury. 

Antimony. Digitalis. Colchicum. Opium. 
Local Remedies. External Cold. External Warmth. Counter-Irritation. - - 152 

LECTURE XV. 

Hemorrhage : — most commonly by Exhalation. Habitual Hemorrhages. Vicarious Hemor- 
rhages. Idiopathic Hemorrhages. Active and Passive. Symptomatic Hemorrhages. 
Usual Situations of Hemorrhage. Symptoms and Diagnosis. Principles of Treatment. 162 

LECTURE XVI. 

Dropsy: its General Pathology. Passive Dropsy; Cardiac and Renal. Active, Acute, or 

Febrile Dropsy. Prognosis; and General Principles of Treatment in Dropsies, - 171 

LECTURE XVII. 

Diseases of the Eye. Catarrhal Ophthalmia. Purulent Ophthalmia of Adults, - - 184 

LECTURE XVIII. 

Purulent Ophthalmia, continued. Gonorrhceal Ophthalmia. Purulent Ophthalmia of Infants. 

Strumous Ophthalmia, - - - - - - . - -194 

LECTURE XIX. 

Strumous Ophthalmia, continued. Recapitulation. Treatment of Strumous Ophthalmia. 
General Remarks on Conjunctival Inflammations. Iritis: its Symptoms and Treatment. 
Causes of Iritis, - - - - - - - - - 209 

LECTURE XX. 

Iritis concluded. Rheumatic Ophthalmia. Amaurosis, ----- 219 

LECTURE XXI. 

Diseases of the Brain and Nervous System. Difficulties of the subject. Short Review of 
some points in the Physiology of the Brain and Nerves. Peculiarity of the Cerebral 
Circulation. Pressure, - -- -- -- -- 226 

LECTURE XXII. 

Symptoms of Cerebral Diseases. Inflammation of the Dura Mater and Arachnoid, from 
external injury ; from Disease of the Bones of the Ear, and of the Nose. Inflammation 
of the Pia Mater, - - - - - - - - -235 

LECTURE XXIII. 

Acute and general Inflammation of the Encephalon. Period of Excitement. Modes in 

which the disease may commence. Period of Collapse. Treatment. Delirium tremens, 246 

LECTURE XXIV. 

Delirium Tremens, concluded ; treatment [note] . Chronic Inflammation of the Brain. 

Softening, Suppuration, Abscess, Induration, Tumours in the Brain, - 254 

LECTURE XXV. 

Hypertrophy of the Brain ; Atrophy. Acute Hydrocephalus ; Premonitory signs ; Different 

Modes of Attack ; Stages of the Disease ; Anatomical Characters ; Causes, - - 266 



CONTENTS. 



11 



PAGE 

LECTURE XXVI. 

Acute Hydrocephalus, continued. Prognosis and Mortality of the Disease. Treatment; 
Blood-letting ; Purgatives ; Cold ; Mercury; Blisters. Prophylaxis. Spurious Hydroce- , 
phalus. Chronic Hydrocephalus, or Dropsy of the Brain. Shape of the Head and Face. 
Anatomical Conditions. Symptoms, - - - ... - - 277 

LECTURE XXVII. 

Treatment of Chronic Hydrocephalus ; Internal Remedies : Mechanical Expedients ; Band- 
ages, Tapping. Meningitis Encephalica [note] . Symptoms of Spinal Disease. Inflam- 
matory conditions of the Spinal Marrow, 288 

LECTURE XXVIII. 
Inflammatory and Structural Diseases of the Spinal Cord, continued. Treatment. 
Apoplexy. Its General Symptoms and Diagnosis. Different forms of the attacks. Predis- 
position to Apoplexy — Natural, and Accidental. Precursory Symptoms, - - 302 

LECTURE XXIX. 

Apoplexy continued. Symptoms characterizing the Apoplectic State. Pressure the ordinary 
Physical cause. Hemiplegia. Affection of Involuntary Muscles. Anatomical Characters. 
Situation of the Clot of Blood. Disease of the Cerebral Blood-Vessels, - 312 

LECTURE XXX. 

Apoplexy continued. Relations between the Symptoms and the Appearances found in the 

brain after death. Exciting Causes. Prognosis. Treatment, - 324 

LECTURE XXXI. 

Spinal Hemorrhage. Paraplegia. Facial Palsy and Facial Anaesthesia ; their Symptoms, 

Prognosis, and Treatment. Other Forms of Local Paralysis, and Local Anaesthesia, - 338 

LECTURE XXXII. 

Tetanus. Its Symptoms and Varieties. Causes. Diagnosis. Pathology. Treatment : 

Opium ; Blood-letting; the Warm Bath ; the Cold Bath, - 351 

LECTURE XXXIII. 

Treatment of Tetanus continued. Wine; Mercury ; Purgatives ; Digitalis ; Tobacco ; Musk ; 
Prussic Acid ; Belladonna ; Carbonate of Iron; Oil of Turpentine ; Strychnia; Surgical 
Expedients ; General Rules. Hydrophobia, - _____ 362 

LECTURE XXXIV. 

Hydrophobia concluded. Various Questions considered respecting the Disease as it appears 
in the Human Subject, and respecting Rabies in the Dog. Pathology of the Disorder. 
Treatment. Preventive Measures, -__.___ 375 

LECTURE XXXV. 

Epilepsy. Its Symptoms and varieties ; duration and recurrence of the paroxysms ; periods 
of life at which they commence ; warnings. Effects of the paroxysms, immediate and 
ultimate. Pathology. Anatomical characters, _-__-- 387 

LECTURE XXXVI. 

Epilepsy continued. Recapitulation. Exciting causes. Simulated epilepsy. Diagnosis. 

Prognosis. Treatment : during the fit ; during the intervals ; during the warnings, - 396 

LECTURE XXXVII. 

Chorea. Symptoms ; Pathology ; Complications ; Causes ; Treatment. Chronic Chorea. 

Other Nervous Disorders to which the same name has been applied, - 408 

LECTURE XXXVIII. 
Paralysis Agitans. Mercurial Tremor. Hysteria ; Two Forms of Hysteric Paroxysm ; 
Diagnosis from Epilepsy ; Class of Persons most liable to Hysteria ; Diseases apt to be 
simulated by Hysteria ; Treatment; Prevention. Salaam Convulsions [note] , - - 420 

LECTURE XXXIX. 

Catalepsy. Ecstacy. Neuralgia ; Tic Douloureux ; Sciatica ; Hemicrania, - - 433 

LECTURE XL. 

Intermittent Fever. Phenomena of an Ague Fit. Species and varieties of Intermittents. 
Predisposing causes. Exciting cause. Malaria: known only by its effects; places which 
it chiefly infests; conditions of its production ; its effects upon the human body; influence 
of soils in evolving it, - - - - - - - 445 



12 



CONTENTS. 



PAGE 

LECTURE XLI. 

Ague, continued. Speculations respecting its periodicity. Habits and properties of the 
malaria ; most noxious at night ; lies near the ground ; is carried along by winds; cannot 
pass across water ; attaches itself to trees ; is diminished by the increase of cultivation and 
of population. Ultimate effects of the poison on the body. Ague formerly thought salu- 
tary. Prognosis. Propriety of stopping the disease, ----- 458 

LECTURE XLII. 

Treatment of Intermittent Fever ; during the paroxysm ; during the intermissions. Prophy- 
laxis, ---------- - 468 

LECTURE XLIII. 

Epistaxis. Bronchocele ; Cretinism; their Phenomena and probable Causes. Medical and 

Surgical Treatment of Bronchocele, ------- 478 

LECTURE XLIV. 

Cynanche Parotidaea. Spontaneous Salivation. Aphtha? ; pathology of [note] . Cynanche 

Tonsillaris, - -- -- -- -- -491 

LECTURE XLV. 

Acute Laryngitis. Symptoms. Treatment; Blood-letting. Tracheotomy, Mercury, Anti- 
mony. Anatomical Characters of the Disease. Causes. Secondary Laryngitis. (Edema 
of the Glottis. Chronic affections of the Larynx, ----- 504 

LECTURE XL VI. 

Cynanche Trachealis: Symptoms; Pathology; Prognosis; Treatment. Tracheotomy [note] . 

Child-crowing, or Spurious Croup, - - - - - 515 

LECTURE XL VII. 

Diseases of the Thorax. General observations. Dyspnoea. Cough. Methods of exploring 
the physical conditions of the Chest, by the senses of sight, touch and hearing, - 528 

LECTURE XLVIII. 

Catarrh; its varieties. Acute Bronchitis. Dry sounds attending the Respiration; Rhonchus 
and Sibilus ; Moist sounds ; Large and Small Crepitation : how these are produced, and 
what they denote. Treatment of Acute Bronchitis. Peripneumonia Notha. Sudden 
Infarction of a large Bronchus, ------ 540 

LECTURE XLIX. 

Influenza. Symptoms and progress. Conjectures as to its Cause. Treatment. Hay 

Asthma. Chronic Bronchitis. Its varieties. Morbid Anatomy of these affections, - 551 

LECTURE L. 

Hooping-cough ; symptoms; duration; complications ; pathology; treatment. Pneumonia: 

its stages and morbid anatomy ; auscultatory signs, - 565 

LECTURE LI. 

Pneumonia, continued ; its general symptoms ; pain, dyspnoea, cough, expectoration. Course 

of the disease. Prognosis. Treatment, ------ 577 

LECTURE LII. 

Pleurisy. Its anatomical characters ; false membranes ; liquid effusion ; effects of these 
upon the shape and contents of the Chest, and upon its healthy sounds. Symptoms of 
Pleurisy, - - - - - - - - - -588 

LECTURE till. 

Pleurisy, continued. Recapitulation of symptoms; of diagnostic signs. Causes of Pleu- 
risy. Pneumothorax; its condition, and signs. Treatment of Pleurisy. Empyema. 
Paracentesis Thoracis. Typhoid Pneumonia [note] , - - - - 599 

LECTURE LIV. 

Pulmonary Hemorrhage ; its varieties ; its connection with pulmonary consumption, and 
with disease of the heart. Pulmonary Apoplexy^ Prognosis in Haemoptysis. Symptoms. 
- Treatment, - - - - - - - - - '-617 

LECTURE LV. 

Pulmonary Emphysema ; vesicular and interlobular. Anatomical characters of vesicular 
Emphysema; physical signs; general symptoms; causes; treatment. Interlobular Em- 



CONTENTS. 



13 



PAGE 

physema; its anatomical characters, symptoms, cause, and cure. (Edema of the Lungs. 
Phthisis Pulmonalis, - --------628 

LECTURE LVI. 

Phthisis, continued. Vomicae ; adhesions of the pleurae ; ulceration of the larynx and trachea 
— of the intestines; fatty liver; auscultatory signs of a vomica; gurgling; cavernous 
respiration, pectoriloquy. General Symptoms of Phthisis : cough, expectoration, dys- 
pnoea, pain, hectic fever, diarrhoea, wasting, oedema, aphthae, - - - - 639 

LECTURE LVII. 

Phthisis, continued. Diagnosis. Forms and varieties of Phthisis. Ordinary duration. Age 
at which it is most frequently fatal. Influence of sex, and of occupation. Question of 
contagion. Treatment, - - - - -. - - - -651 

LECTURE LVIII. 

Melanosis of the Lung ; true, and spurious. Accidental intrusion of solid substances into 

the air-passages, - 662 

LECTURE LIX. 

Diseases of the Heart ; usually partial. Changes in its muscular texture. Mechanism of 
those changes. Natural dimensions of the Heart. Natural sounds. Modifications of 
these by disease. Review of the physical and general signs that accompany Cardiac 
Disease, - -- -- -- -- -- 670 

LECTURE LX. 

Diseases affecting the muscular texture of the Heart, and their treatment. Changes to 
which the valves of the Heart are subject. Effects and diagnosis of those changes. 
Angina Pectoris, --------- - 683 

LECTURE LXI. 

Pericarditis; its frequent connection with Acute Articular Rheumatism. Rheumatic Car- 
ditis. Anatomical characters of acute inflammation of the Pericardium; of the Endo- 
cardium. General symptoms. Auscultatory signs. Relations of Carditis with Rheumatic 
Fever, - -- -- - 694 

LECTURE LXII. 

Treatment of Acute Pericarditis and Endocarditis: blood-letting; mercury; blisters. Chro- 
nic and partial inflammation of the Pericardium. Disease of the Aorta. Thoracic 
Aneurisms; their various situations and symptoms ; plan of treatment, - - 710 

LECTURE LXIII. 

Diseases of the Veins. Phlebitis ; adhesive and suppurative ; consecutive scattered Ab- 
scesses. Treatment of Inflammation of Veins. Effects of the gradual obstruction of 
large Venous Trunks, - -- -- -- -- 720 



LECTURE LXIV. 

Asthma : its nature ; complications ; exciting causes ; and treatment. Diseases of the 

CEsophagus; Inflammation of Infants [note]; Stricture; Spasm: Dilatation, - - 729 

LECTURE LXV. 

Diseases of the Abdomen ; sometimes difficult to identify. Method of investigating these 
diseases ; by the eye, the hand, the ear. Inflammation of the Peritoneum : its symp- 
toms ; and causes. Puerperal Peritonitis. Peritonitis from Perforation, 

LECTURE LXVI. 

Treatment of Acute Peritonitis ; Bleeding, Mercury, Opium. Chronic Peritonitis; Granular 
Peritoneum. Ascites ; Ovarian Dropsy ; Diagnosis of these diseases. Other forms of 
Abdominal Dropsy, - 750 

LECTURE LXVII. 

Pathology of*Chronic Ascites ; of Ovarian Dropsy. Treatment of these two disorders. 

Internal remedies : Extirpation of the ovarian sac ; Paracentesis Abdominis, - - 759 

LECTURE LXVIII. 

Acute Gastritis ; symptoms ; anatomical characters ; treatment. Acute Gastritis of Infants 
[note] . Chronic Inflammation of the Stomach ; thickening of the Mucous Membrane ; 
Ulceration : symptoms and treatment of the disorder. Cancer of the Stomach, - 768 



741 X 



14 



CONTENTS. 



PAGE 

LECTURE LXIX. 

Hemorrhage from the Stomach: sometimes from a large vessel, usually by exhalation. 
Idiopathic Haematemesis. Vicarious Haematemesis. Haematemesis from gastric disease 
or injury : from disease and other organs. Melaena. Haematemesis from a morbid state 
of the blood. General phenomena of Haematemesis. Diagnosis. Treatment. - 781 

LECTURE LXX. 

Dyspepsia. Physiology of Digestion. Symptoms of Dyspepsia. Treatment and Preven- 
tion, Dietetic and Medicinal, 790 

LECTURE LXXI. 

Enteritis : its symptoms ; causes ; treatment. Mechanical occlusion of the Intestinal Tube. 

Colic. Colica Pictonum ; its symptoms, complications, treatment, and prevention, - 800 

LECTURE LXXII. 

Diarrhoea. Chronic Diarrhoea [note] . Sporadic Cholera. Epidemic Cholera, - . 815 

LECTURE LXXIII. 

Dysentery: Morbid Anatomy [note] ; Chronic [note] . Diarrhoea Adiposa. Intestinal Con- 
cretions. Worms, - -- -- -- -- 829 

LECTURE LXXIV. 

Entozoa, continued. Hydatids. Trichina Spiralis. The Guinea Worm. Strongulus Gigas. 
Origin of Entozoa. Question of Spontaneous Generation. General Symptoms of the 
presence of Intestinal Worms. Particular symptoms, and remedies, of the common 
Round Worm, of Thread Worms, of Tape Worms, - 844 

LECTURE LXXV. 

Diseases of the Liver. Acute Inflammation. Abscess of the Liver. Causes and Treat- 
ment of Acute Hepatitis. Chronic Hepatitis. Jaundice. Its symptoms, causes, species, 
and pathology [note] , - - - - - - - - 857 

LECTURE LXXVI. 

Treatment of the various species of Jaundice. Diseases of the Gall-bladder; of the Spleen ; 
of the Pancreas. Diseases of the Kidneys. Nephritis and Nephralgia. Phenomena 
constituting a « fit of the Gravel." Different kinds of Gravel. Diseased states of the 
Urine. Description and Remedies of the Lithic, Phosphatic, and Oxalic Diatheses, - 870 

LECTURE LXXVII. 

Suppression of Urine. Diabetes : Qualities of the Urine ; symptoms ; anatomical appear- 
ances j general pathology of the disease ; treatment. Diuresis, - - 882 

LECTURE LXXVIII. 
Albuminous Urine. Means of detecting the Albumen. What it imports. Anatomical 
characters of Bright's Kidney. Symptoms to which this renal disease gives rise. Nature 
of the Affection, ------ ----894 

LECTURE LXXIX. 

Anasarca; its consideration resumed. Distinction of Chronic General Dropsy into Cardiac 

and Renal. Characters and signs of each of these varieties. Treatment, - - 904 

LECTURE LXXX. 

Chylous Urine. Hematuria; its diagnosis, general and particular; Local Disorders of the 

Urinary Organs on which it depends ; treatment. Abdominal Tumours, - - 914 

LECTURE LXXXI. 

Acute Rheumatism ; symptoms ; varieties ; treatment. Chronic Rheumatism ; phenomena ; 
plan of cure. 

Gout : description of a paroxysm ; progress of the disease ; general state of the health in 
gouty persons ; causes of the disease ; diagnosis between Gout and Rheumatism^ - 924 

LECTURE LXXXII. 

Pathology of Gout. Prognosis. Prejudices respecting the disease. Treatment : during 

the paroxysms ; during the intervals. Cutaneous diseases, - - - - 936 

LECTURE LXXXIII. 
Exanthemata. They are contagious ; sometimes epidemic. Period of the eruption ; period 
of incubation. Theory of contagious Febrile Diseases. Continued Fever, - - 944 



CONTENTS. « 15 

PAGE 

LECTURE LXXXIV. 
Continued Fever, continued. Phenomena of the second week; Delirium, an Eruption, 
Diarrhoea : of the third week ; Recovery, or death in the way of Coma, of Apncea, of 
Asthenia. Symptoms that usher in those modes of death ; morbid changes found after 
them, 957 

LECTURE LXXXV. 

Varieties of Continued Fever. Its causes, exciting and predisposing. Prophylaxis, - 966 

LECTURE LXXXVI. 
Continued Fever, concluded. Treatment. Bilious Remittent Fever [note] . Small-pox. 
Its essential symptoms. Distinction into discrete and confluent. Periods and modes in 
which it proves fatal, - 977 

LECTURE LXXXVII. 
Small-pox, continued. Inoculation. Vaccination. Their comparative advantages. Treat- 
ment of Small-pox, ------- - 999 

LECTURE LXXXVIII. 
Chicken-pox. Measles. Scarlet Fever, - - - - - - -1013 

LECTURE LXXXIX. 

The Plague. Erysipelas. Erythema Nodosum. Urticaria. Prurigo. Scabies, - - 1026 

LECTURE XC. 

Herpes; Eczema; Pompholix; Lepra; Psoriasis; Impetigo; Boils ; Carbuncle ; Purpura; 

Scurvy. Conclusion of the Course, 1037 

Index, - 1051 



LECTURES 

ON THE 

PRINCIPLES AND PRACTICE OF PHYSIC. 



INTRODUCTORY LECTURE. 

Gentlemen: — In approaching any new course of systematic inquiry, there 
are certain points concerning which the inquirer should always be careful to 
satisfy himself. He should comprehend, distinctly, what it is that he proposes 
to learn; its subject-matter, and its objects: he should consider whether he is 
about to adopt the most easy, direct, and effectual means for obtaining his pur- 
pose ; and whether he is qualified, by the possession of the requisite preliminary 
information, for pursuing his inquiries with intelligence and profit. To these 
points, and to some others, as they are connected with the duties with which I 
have been entrusted in this college, I wish briefly to direct your attention on the 
present occasion. It will be my endeavour to furnish you, at the outset, with 
clear notions of the nature and the ends of that branch of study upon which you 
are now about to enter; to explain why it is taught, and how far it may be taught, 
by oral discourses ; to point out to you what may reasonably be expected from 
me, and what, to render my attempts prosperous, will be required on your parts. 
Something also it is expedient you should know beforehand respecting the gene- 
ral order and arrangement of the course; and a short explanatory comment upon 
some of the terms that we shall constantly be employing, will dear the way for 
the succeeding lectures, which forming, more strictly than the present, a part of 
the series, will also be more strictly didactic in their character. 

The subject of our study is that wonderful thing, the animal body — and more 
particularly the human body ; its construction and qualities ; its actions and its 
sufferings ; its derangements ; its decay. 

In this study, which affects the mind with a strong feeling of curiosity, not 
unmixed with awe, you have already advanced a certain way : for you have 
observed the outward form and configuration of the body ; examined its internal 
composition and structure ; and learned what is known of its various endow- 
ments, the working and the uses of its several parts. 

This amount of knowledge was indispensable to your further progress. But 
it forms a portion only of what you assemble here to learn : or rather it is the 
necessary preparation for that ulterior knowledge which it is your main purpose 
to acquire. The sublimer speculations springing naturally from the researches 
in which you have as yet been engaged, have not, I trust, been unregarded. You 
cannot have looked into the mechanism of that intricate but perfect work, — you 
cannot have contemplated its fullness of exquisite contrivance, its endless examples 
of means adjusted to ends; its prospective expedients against future needs, its 
compensations for inevitable disadvantages, its direct provisions for happiness and 
enjoyment, — without receiving the profoundest conviction of the being and the 
attributes of its Maker. It is upon human anatomy that Paley, in his unrivaled 
argument for Natural Theology, 44 takes his stand and sixteen centuries before 



18 



INTRODUCTORY LECTURE. 



him, Galen had felt that, in writing his anatomical treatises, he was composing a 
hymn to the Deity ; that a declaration so plain of the wisdom, the power, and 
the goodness of God, was an act of piety and praise. But beyond, though not 
above, these higher objects of a diligent investigation of man's bodily fabric, we 
have another and still a nobler end ; and it is my business to take you one step 
nearer to that end. Hitherto you have been told of structure and of function. 
Henceforward our theme must be of health and of disease. Of health, that we 
may understand disease ; of disease, that we may, under Providence, restore 
health. Our objects are to preserve the one ; to prevent, remove, or mitigate 
the other. 

What then do these contrasted terms denote? 

Health we regard as a standard condition of the living body. But it is not 
easy to express that condition in a few words, nor is it necessary. My wish is 
to be intelligible rather than scholastic; and I should probably puzzle myself as 
well as yon, were I to attempt to lay down a strict and scientific definition of the 
term health. It is sufficient for our purpose to say, that it implies freedom from 
pain and sickness; freedom also from all those changes in the structure of the 
body that endanger life, or impede the easy and effective exercise of the vital 
functions. 

It is plain that health does not signify any fixed and immutabte condition of the 
body. The standard of health varies, in different persons, according to age, sex, 
and original constitution ; and in the same person even, from week to week, or 
from day to day, within certain limits it may shift and oscillate. 

Neither does health necessarily imply the integrity of all the bodily organs : it 
is not incompatible with great and permanent alterations, nor even with the loss, 
of parts that are not vital; as of an arm, a leg, or an eye. 

If we can form and fix in our minds a clear conception of the state of health, 
we shall have no difficulty in comprehending what is meant by disease, which 
consists in some deviation from that state : some uneasy or unnatural sensation of 
which the patient is aware ; some embarrassment of function perceptible by him- 
self, or by others ; or some unsafe, though hidden condition, of which he may be 
quite unconscious : some mode, in short, of being, or of action, or of feeling, 
different from those which are proper to health. 

I use the word disease generically. Various terms in our language bear nearly 
the same meaning, and endeavours have been made to appropriate some of these 
more distinctively. Thus the word disorder has sometimes been applied to 
" simple derangements of function, where no alteration of structure is seen, or can 
reasonably be inferred to exist; while the term disease has been restricted to 
maladies, which are attended with appreciable change of texture, or which run a 
short and definite course. I see no great utility, but, on the contrary, some risk 
of confusion, in tying ourselves rigidly down to such distinctions : indeed, we 
cannot always make them. During life it is often no easy thing to determine 
whether the parts, of which the functions are disturbed, preserve their integrity 
of structure or not: and even when the peccant organ is placed before our eyes 
after death, and the most careful scrutiny fails to discover in it any faultiness of 
texture, there may still be ground for suspecting that some material change, too 
subtle for detection by our senses, may have been wrought in its finer and more 
delicate organization. I shall take care to point out to you, as we go along, the 
cases in which we can trace organic change, and the cases in which we cannot ; 
but, for the sake of simplicity, I shall call all deviations from the healthy standard, 
whether of function or of structure, by the generic term disease; and to avoid the 
perpetual and tiresome recurrence of the same word, I shall not scruple to 
employ the several terms disorder, complaint, malady, distemper, illness, as its 
synonyms. 

The number of these deviations from the standard of health, (in other words, 
the whole number of diseases,) if we include all their differences in kind and in 
degree, is scarcely calculable ; and the first thing requisite towards investigating 



INTRODUCTORY LECTURE. 



19 



the laws that govern their phenomena, is, that we should break them into groups, 
and dispose them according to some principle of order. 

Now, there are various methods in which this first broad classification of dis- 
eases might be framed. 

The most cursory examination of the animal economy suffices to show that it 
is made up, not merely of separate parts, but of several distinct systems. There 
is one set of organs for the mechanical circulation of the blood ; there is an appa- 
ratus expressly designed for the repeated exposure of the blood to the air ; a system 
for regulating the movements and the feelings of the body ; another for receiving, 
preparing, and appropriating its nourishment ; another for the elaboration of 
matters that are useful or essential to its functions ; another for carrying off its 
impurities, and for removing its superfluous or effete materials ; and another for 
the continuance of the species. 

Now each of these systems is liable to changes of structure and interruptions of 
function, peculiar to itself; and these peculiarities must be taken into account, 
whatever may be the order adopted in treating of diseases in detail. But I shall 
not divide the subject, as some have done, into diseases of the circulating system 
— diseases of the respiratory system — diseases of the nervous system — and so 
on; for this, among other reasons, that there are many forms of disorder that 
affect all these systems in common, or simultaneously, and comparatively few 
that are strictly confined to any one of them. 

Neither, in the lectures which I am about to commence, shall I classify diseases 
according to the several tissues of which the animal frame is composed. In 
speaking of diseases in general, it will, indeed, be both proper and necessary to 
explain in what manner the same morbid process may be modified by the nature 
of the special tissue affected. But as the entire body is more or less penetrated 
and pervaded by the intermixture of several of these tissues, so no useful nor lucid 
arrangement of diseases could be founded on this basis. 

Nor shall I attempt to construct a nosological system by grouping together 
certain sets of symptoms, and calling each set, in its collective form, a disease. 

To say the truth, I shall consider convenience and usefulness, in framing my 
plan, rather than an appearance of scientific precision ; and if I make one principle 
of arrangement more prominent than another, it will be that which relates to the 
anatomy of regions, — the place and situation of organs. At the same time, I 
shall not omit to borrow in part from some of those other methods to which I 
have just been referring. 

Before, however, we treat of the nature of particular diseases, it will be requi- 
site to give some general account of the different ways in which the various parts 
of the body are liable to be altered in structure, or disordered in function; and 
before we speak of the signs of particular diseases, it will be proper to take a 
general view of symptoms, and of their ascertained relations with the several 
forms of altered structure: for doubtless you are aware that, although diseases are 
not constituted by symptoms, they are, in the living body, disclosed by symp- 
toms. Sometimes the symptoms are outward signals which alone reach our 
senses, and through which internal changes declare themselves ; and we then have 
to decipher and to interpret those signals. Sometimes we see the morbid changes 
themselves on the surface of the body, or in parts within our ken. Some internal 
changes we can appreciate as surely by the touch, or by the sense of hearing ; 
and of some we infer the existence from alterations in the chemical or in the sen- 
sible qualities of the natural excretions. 

After death, diseases are often to be traced by visible changes of structure in 
the internal parts of the body. These changes are extremely interesting, as illus- 
trative of morbid processes : they throw light upon what is past ; they afford some 
guidance for the time to come. But, for obvious reasons, those signs which 
reveal diseases during life are, practically, of chief moment. In truth, the great 
object of our art is to prevent or postpone the disclosure of the others. The 



20 



INTRODUCTORY LECTURE. 



instruction afforded by the dead body comes too late to be of use in that particular 
case. 

I have already intimated that the morbid physical conditions from which the 
symptoms flow, are not always to be detected, either before or after dissolution. 
Neither, when they are detected, is their connection with the symptoms always 
evident. 

Besides inquiring into the modes in which the various organs and textures of 
the body may be spoiled, and into the signals or symptoms by which the presence 
of disease may be ascertained, it will be expedient to premise something, in a 
general manner, of the causes of disease, both with a view to its cure, and, what 
is much better, to its prevention. We shall also find it very useful to institute a 
short inquiry into the different ways in which death may take place — the differ- 
ent processes of dying. 

There is one morbid condition or process, to which all parts of the body are 
liable, and which contributes so largely and so frequently to alterations both of 
texture and function, that it claims our especial attention when discussing the 
more general facts and doctrines of pathology : I allude to that change, or series 
of changes, which we comprehend under the term inflammation. 

It will be necessary', therefore, in the preliminary part of the course, to give a 
general account of inflammation ; and this account must chiefly be drawn from 
those of its phenomena which are most familiar to us — which we can see and 
handle ; those which we witness when the disorder is seated in or near the sur- 
face, in the skin, in some of the mucous membranes, or in the subjacent areolar 
tissue. Then we shall pursue the examination of its peculiar phenomena as they 
are presented in the other tissues of the body — the mucous, serous, fibrous, paren- 
chymatous, muscular, and nervous tissues; and here the general principles of 
treatment applicable to inflammation may be laid down, with the modifications 
required according to the tissues interested. 

In this part of the course may also be conveniently discussed the modifications 
of inflammation, and of morbid conditions generally, by the influence of certain 
diatheses, or peculiar dispositions of the body. Some constitutional morbific 
tendencies we shall find to be innate or hereditary; such are the scrofulous and 
the cancerous dispositions : others, again, are plainly acquired, as that in which 
the whole system is tainted for a longer or shorter period by the venereal poison. 

Hemorrhages, also, and serous accumulations, or dropsies, as they are liable 
to occur in all parts of the body, require to be treated of generally, before they 
pass under our notice in the list of particular maladies. There are certain facts 
and reasonings common to all inflammations, to all hemorrhages, to all dropsies. 
By combining these "generalities" into one comprehensive statement, we help 
the memory, avoid needless repetitions, and find room for the exposition of prin- 
ciples. 

Diseases themselves, in the mass, are sometimes distinguished according as 
they are local, or general. 

Taking these epithets in their popular sense, we should say that local diseases 
are those which occupy a definite portion only of the body ; general diseases, 
those which pervade the whole body. 

But let us endeavour to obtain clear notions upon these points. 

Certainly there are many diseases which, occupying a definite portion only of 
the body, leave all the remaining parts, and the system at' large, healthy both 
in texture and in function. Such diseases we have no hesitation in calling local. 

Again, there are many other diseases which, occupying a definite portion only 
of the body, yet occasion a manifest and serious disturbance in the functions of 
various other parts, and (it may perhaps be said) of the whole system. Inflam- 
mation of a small portion of the frame may give rise to much secondary or symp- 
tomatic fever; but here also we properly speak of the disease as being local : the 
secondary general disorder resulting from the local and primary, following it in 
point of time, and subsiding upon its cessation. 



INTRODUCTORY LECTURE. 



21 



But there are still other forms of disease which show themselves, not like 
inflammation now in this and now in that part, but in many or most parts of the 
body at the same time. I will take the complaint called purpura, characterized 
by the universal appearance of purple spots, as an example of what I mean. It 
is in truth a hemorrhage affecting many or all the tissues of the body simulta- 
neously. For this reason it is commonly regarded as a general disease. 

But if we look somewhat closer into the matter, we shall, I think, perceive 
that most, if not all, of those which have been thus reputed general, are, in fact, 
reducible to the class of local diseases. The fluids are as much parts of the body 
as the solids ; and if it be true, as I believe it is, that the essential and primary 
change in purpura is a change in the blood, its characteristic phenomena will be 
apt 10 present themselves wherever there is blood circulating — that is, throughout 
the whole system. The disease is local, inasmuch as its original seat is in that 
particular fluid, the blood: it appears to be general, because the morbid blood is 
everywhere present. 

The same observations apply to a large class of febrile contagious diseases ; to 
that state of the general system which is sometimes called anaemia; also to certain 
spasmodic affections, where the seat of the actual disorder is in the whole nerv- 
ous system. 

What are called general diseases, therefore, are those in which the whole of 
some one system that pervades the entire body happens to be similarly deranged. 
Whether diseases can ever be truly called general in any more strict or absolute 
sense than this, is much to be doubted. 

I have mentioned dropsy as a malady which, like hemorrhage or inflammation, 
may occur in various parts of the body separately. It may also extend at once 
to all parts capable of receiving and retaining serous effusions: i. c, besides filling 
the large serous cavities, the effused fluid may occupy the universal areolar tissue. 
But even this apparently general dropsy will be found, upon careful investigation, 
to resolve itself, in most cases at least, into local disease within the thorax, or the 
abdomen. 

The diseases which, in the sense now explained, maybe called general, I shall 
arrange among the diseases of those parts of the system from which they have 
been ascertained, or may be presumed, to arise. 

The first part, then, of the course will embrace an outline of general pathology, 
with an especial reference to those morbid conditions which fall to the care of the 
physician. In its relations to surgery and to midwifery, pathology will be more 
particularly taught by the respective professors of those distinct though kindred 
departments of medicine. Do not, however, imagine that I take no interest in 
these, or that there can be any thing different in the principles upon which the 
several branches of pathological knowledge are founded. The truth is, that you 
cannot, if you would, separate the one from the other. You can neither under- 
stand what may be called medical, without learning much which as strictly belongs 
to surgical pathology ; nor can you be ignorant of either, without being in many 
important respects deficient in the other also. But the open field of pathology is 
of wide extent, and although we may, and must, survey the whole, yet its arti- 
ficial divisions, its enclosures and allotments, will be cultivated best, and most 
improved, by a division of labour. 

Afterwards, separate diseases are to be described and considered: all such, at 
least, as admit of being individualized, or presented under a definite shape. And 
here, I repeat, I shall chiefly pursue an anatomical order, as being comprehensive 
and inartificial, and as tending to facilitate diagnosis. The diseases of parts which 
lie near each other are the most liable to be confounded. 

I shall begin, therefore, with the diseases of the parts that appertain to the head 
and spinal cord, and then proceed in succession to those of the parts belonging to 
the neck, the thorax, and the abdomen; to those of the joints, the muscles, and 
the skin. I shall not hesitate, however, to deviate from this order, whenever, by 
doing so, I can promote your convenience or advantage. 



22 INTRODUCTORY LECTURE. 

With that portion of the course which relates to particular diseases, I shall also 
interweave certain pathological considerations, applicable not so much to the 
whole body as to the several great systems of which it is made up. Thus, when 
I come to the brain, I shall speak of the functions peculiar to the nervous system, 
and^of the obstructions and disturbances to which those functions are obnoxious, 
by way of preface to a detailed examination of the various affections of the several 
parts of that system. Before discussing the diseases of the chest, I shall bring 
before you, in a general view, the manner in which the great functions of respira- 
tion and of circulation are liable to be impeded, or otherwise disordered. As 
preparatory to the consideration of the diseases of the abdomen, I shall treat, in 
the same way, of the function of nutrition; and of waste, which implies an in- 
terruption of those functions. 

Still there would remain certain diseases, which would not necessarily find a 
place in this arrangement, inasmuch as their seat is uncertain or only guessed at. 
Ague is one of these. Cholera, perhaps, another. It is quite unimportant where- 
abouts in the course such maladies are considered. I feel no concern about any 
imputations of imperfect or clumsy arrangement with which the plan that I pro- 
pose to adopt may appear chargeable. I had rather not be cramped and hampered 
by attempting what abler heads than mine have failed to achieve, and what, in 
truth, 1 believe, in the present state of our science, to be impossible, a complete 
methodical system of nosology. My object will be to furnish as much instruction 
and information as I can, in the way that seems most likely to be practically 
useful to you. 

Ague I shall take leave to include among the disorders of the nervous system ; 
and with it, the important subject of malaria will necessarily engage much of our 
attention. 

The great question of contagion I shall consider in connection with continued 
fever, which I rank among that remarkable class of diseases, the contagious exan- 
themata of Cullen. 

Of sympathetic and of hectic fever, I must speak when upon the subject of 
inflammation. 

This, then, is a sketch of the method I propose to follow. In the earlier lec- 
tures, with the general pathology, I shall endeavour to lay down principles. To 
these principles I shall continually refer, as occasions offer, both in those prefa- 
tory remarks with which I purpose to introduce the diseases belonging to the 
several great systems that contribute to form the body ; and also in what I shall 
subsequently have to say concerning those diseases themselves in detail. In this 
way I hope to combine the advantage of repetition, which was the peculiar advan- 
tage of two short courses in a season, with that of greater completeness, which 
forms the recommendation of a single extended course. The same great advan- 
tage of repetition — or I should rather say of recapitulation — will be further aimed 
at in the stated examinations of the class. 

Such being a summary of the topics to be embraced in the ensuing series of 
lectures, and of the order in which I hope to take up those topics, it seems proper 
that I should now say a few words in explanation of the scope and objects of the 
course. The prospectus informs you that it will comprehend the Principles and 
Practice of Physic. What are the true import and promise of these words? 

By the principles of medicine are meant those general truths and doctrines 
which have been ascertained and established, slowly, indeed, and irregularly, but 
still with considerable precision, by the continued observation of attentive minds 
throughout the entire progress of medicine as a science. These principles I pro- 
fess to teach you. The practice of medicine, or the particular application of those 
general facts and doctrines, I shall describe to you ; but I cannot profess to teach 
it in this room : nor can you learn it, except in a very imperfect sense,. from my 
description of it. It is the science that I shall here endeavour to unfold. Skill 
and facility in turning that science to useful purposes I am unable to impart. 



INTRODUCTORY LECTURE. 



23 



These are qualities that do not admit of being communicated from one mind to 
another. The practice of physic, like every other practical art, is to be learned 
by its repeated exercise ; by habit ; by carrying its various acts into direct effect 
again and again ; or, if they happen to require no manual dexterity, by looking 
on, and seeing them done again and again. There is this capital difference, how- 
ever, between the art of healing and some other arts : that the blunders of early 
attempts may be both grievous and irremediable — may hurt or spoil the goodly 
and precious machine they are intended to repair. There is this also peculiar to 
our art — that it proceeds upon observations made at the very time when its exer- 
cise is wanted ; and that it requires skill in observing as well as skill in acting. 
You will find what, perhaps, previously to positive trial, you might not suspect, 
that the senses — the eye, the ear, the touch — however sharp or delicate they may 
naturally be, require a special course of training and education before their evi- 
dence can be trusted in the investigation of disease. I do not know that these 
views are capable of being rendered plainer by illustration; for you must have 
observed a similar distinction between the science and the art in various other 
branches of human knowledge. The principles of navigation may be thoroughly 
comprehended by a person who scarcely knows a rudder from a cable, and who 
would not be trusted, nay, who would not trust himself, with the conduct of the 
simplest boat. A man may master the beautiful science of astronomy — may 
acquire the power of working upon paper its sublimest and most abstruse pro- 
blems — and yet remain in complete ignorance of the method of adjusting and 
using a telescope, and unable to ascertain for himself the position or the move- 
ments of a single star. But place such a person night after night in an observa- 
tory — let him notice and imitate the proceedings of some one already skilled in 
examining the phenomena of the heavens — and he will soon acquire the requisite 
tact and facility himself. Just so it is with that branch of knowledge with which 
we are concerned. It is in the wards of a hospital, or in the domestic chamber — 
it is among the sick and the dying — and there alone — that you can either tho- 
roughly or safely learn to practice physic. 

In what, then, you may fairly ask, consists the value or the use of lectures on 
the practice of physic, if the practice of physic cannot be taught by lectures ? 

The main object of systematic lectures, explanatory of the principles, and de- 
scriptive of the practice of medicine, is to prepare the hearer for observing, to 
the best advantage, the actual phenomena of disease, and the power of remedies 
over it. They are intended to fit him for seeing with intelligence — to enable him 
to read, and understand, and interpret, the book of nature when it is laid open 
before him — in short, to qualify him for clinical study. One man shall travel 
into a foreign land, knowing nothing beforehand of its scenery or its climate, of 
its natural productions, its manufactures, or its works of art, and ignorant alike 
of the manners, customs, history, laws, and language of its inhabitants ; another 
shall visit it after having furnished his mind with information on these subjects by 
reading, and by conversing with men who have already passed over the same 
ground. Supposing the visit to be limited in each case to a certain, but not long 
period of time, and I need not ask your opinion as to which of these travelers 
will reap the greatest harvest of enjoyment and of profitable knowledge from his 
journey. Not less striking is the difference, in point of instruction and of interest, 
perceived by different students, upon their admission to the bedsides of the sick, 
according as they have been well or ill prepared for the multiform spectacle of 
bodily suffering then first displayed before them. There are persons, indeed, 
who seriously, and I make no doubt in perfect good faith, warn the student against 
bringing to the contemplation of disease any preconceived opinions ; who tell him 
that he must come with a free and unprejudiced mind, and see, and note, and judge 
of all things for himself. I also would have him exercise, and ultimately abide 
by, his own judgment; but surely if every man were to depend upon his own 
unassisted observation for his knowledge of disease, every man would be marvel- 
ously ignorant, and the science of medicine would stand still, or cease to be. " If 



24 



INTRODUCTORY LECTURE. 



no use be made (says Dr. Samuel Johnson) of the labours of past ages, the world 
must remain always in the infancy of knowledge." In truth, a person who, without 
any previous information concerning diseases, should betake himself to a hospital 
with the design of impartially and resolutely investigating their phenomena, such 
a person, however clear and strong his intellect might be, would find himself, for 
a long time, more puzzled than instructed by what he saw around him. He would 
be perplexed by the shifting and seemingly contradictory characters presented by 
the same malady in different patients ; or in the same patient at different times ; 
and not less so by the outward resemblance of disorders essentially unlike. He 
could not but be confused by the multitude of symptoms that crowded upon his 
attention on every side ; and at a loss to distinguish important facts from those 
which, for the chief ends of his pursuit, were trivial, or useless. 

The business, therefore, of a lecturer upon the Principles and Practice of 
Medicine, or, as it is sometimes worded, the Nature and Treatment of Diseases, is 
first to fix upon some order in which to treat of the various subjects comprised in 
his course. The simpler and less artificial his arrangement, the better. The chief 
use of this classification is to facilitate the recollection of particular facts ; and I 
have already told you that if I can distribute and connect the multifarious forms 
of disease in such a manner as that they shall appear plain to your understanding, 
and take a secure hold upon your memory, I shall not trouble myself nor you 
with a vain search after that phantom — a perfect methodical nosology. " In all 
such classifications," writes Lord Brougham, " we should be guided by views of 
convenience rather than by any desire to attain perfect symmetry ; and that arrange- 
ment may be best suited to a particular purpose which plants the same things in 
one order, and separates them and unites them in one way, when an arrangement 
which should dispose those things differently might be preferable, if we had 
another purpose to serve." 

Having settled this framework of his discourses, the next aim of the lecturer 
must be to collect and arrange from the voluminous and bewildering records of 
medicine, and from the necessarily more slender stores of his personal experience, 
whatever it may seem of consequence that his hearers should know concerning 
each distinct form of disease, as it comes before them for consideration: to state 
all the facts which are well ascertained, and which tend to explain its symptoms, 
to elucidate its origin, to identify its nature, to direct its treatment, to accomplish 
its prevention : to sift the true facts from the false, the important from the trivial, 
the essential from the accidental: to analyze the relations of these facts, and 
ascending from particulars to generals, to point out those great principles and 
precepts which constitute the keys both to the knowledge and to the management 
of all diseases of the same kind. It may even sometimes be his duty to notice 
and discuss mere theoretical opinions; to express his own sentiments upon dis- 
puted or undecided questions ; and to admonish his audience against the danger 
of being led away by ingenious refinements, by the speciousness of novelty, or 
the boldness of speculation, from the more secure and settled results of careful 
observation improved by patient thought. 

These duties of a lecturer on medicine are metaphorically, but aptly, expressed 
in the following passage from Lord Bacon : — 

" Formica colligit, et utitur, ut faciunt empirici ; aranea ex se fila educit, neque 
a particularibus materiam petit, ita faciunt medic speculativi ac mere sophistici ; 
apis denique caeteris se melius gerit. Hsec indigesti e floribus mella colligit, 
deinde in viscerum cellulis concocta maturat, iisdem tamdiu insudat, donee ad 
integram perfectionem perduxerit." 

I may venture to paraphrase it thus: — 

The lecturer must not be the ant, collecting all things indiscriminately from all 
quarters, as provender for his discourses ; 

Nor the spider, seeking no materials abroad, but spinning his web of speculative 
doctrine from within himself ; 

But rather the bee, extracting crude honey from various flowers, storing it up 



INTRODUCTORY LECTURE. 



25 



in the recesses of his brain, and submitting it to the operation of his internal 
faculties, until it be matured, and ready for use. 

Such, gentlemen, are the main objects which I shall endeavour to keep steadily 
in view during the series of lectures I am about to commence; and I should ill 
deserve the chair I have the honour to occupy, if I did not feel the great responsi- 
bility under which I speak to you. The subjects with which we have to deal 
are not matters of mere speculative curiosity or intellectual amusement — to be 
taken up to-day and dismissed perhaps with unconcern to-morrow — but they 
involve questions of life and death. The opinions you are now to form or to 
embrace, are for the most part the opinions upon which in after life you will con- 
fidently and constantly be acting. The comfort or the misery of many families 
may probably hang upon the notions that each of you will carry from this place. 
Therefore it is that I feel myself to be engaged in a very serious undertaking. 
Doctrines and maxims, good or bad, flow abroad from a public teacher as from a 
fountain, and his faulty lessons may become the indirect source of incalculable 
mischief and suffering to hundreds who have never even heard his name. These 
reflections fill my mind with an almost painful sense of the obligation imposed 
upon me, by my present office, of closely sifting the facts, and of carefully examin- 
ing the principles to be derived from those facts, which I propose to employ for 
your instruction and guidance. 

But amid all the responsibilities, gentlemen, both of teacher and of learner, the 
profession which you and I have chosen, or which circumstances have prescribed 
to us, is a noble profession, and worthy the devotion of a lifetime. If you fit 
yourselves now for its high functions, and pursue it hereafter in earnestness and 
truth, it will probably conduct you to an honourable competence, and it will 
assuredly prove a salutary school of mental and of moral discipline. Trials, no 
doubt, belong to it, and difficulties; but it has also privileges and immunities 
peculiar to itself. Affording ample scope and exercise for the intellect, it is con- 
versant with objects that tend to elevate the thoughts, to chastise the feelings, and 
to touch the heart. I have already reminded you how it brings beneath our 
minute and daily notice that most remarkable portion of matter, which is destined 
for a season to be the tabernacle of the human spirit, and which, apart from that 
singularly interesting thought, excites increasing wonder and admiration the more 
closely we investigate its marvelous construction. The sad varieties of human pain 
and weakness with which our daily vocation is familiar, should rebuke our pride, 
while they quicken our charity. To us are entrusted, in more than ordinary 
measure, opportunities of doing good to our afflicted fellow-creatures — of showing 
love towards our neighbour. Let us beware how we idly neglect, or selfishly 
abuse, a stewardship so precious, yet so weighty. The profession of medicine, 
having for its end the common good of mankind, knows nothing of national enmi- 
ties, of political strife, of sectarian dissensions. Disease and pain the sole condi- 
tions of its ministry, it is disquieted by no misgivings concerning the justice and 
honesty of its client's cause ; but dispenses its peculiar benefits, without stint or 
scruple, to men of every country, and party, and rank, and religion, and to men 
of no religion at all. And like the quality of mercy, of which it is the favourite 
handmaid, "it blesseth him that gives and him that takes;" reading continually 
to our own hearts and understandings the most impressive lessons, the most 
solemn warnings. It is ours to know in how many instances, forming indeed a 
vast majority of the whole, bodily suffering and sickness are the natural fruits of 
evil courses ; of the sins of our fathers, of our own unbridled passions, of the 
malevolent spirit of others. We see, too, the uses of these judgments, which are 
mercifully designed to recall men from the strong allurements of vice, and the 
slumber of temporal prosperity: teaching that it is good for us to be sometimes 
afflicted. Familiar with death in its manifold shapes, witnessing from day to day 
its sudden stroke, its slow but open siege, its secret and insidious approaches, we 
are not permitted to be unmindful that our own stay also is brief and uncertain. 



26 



PATHOLOGY. 



our opportunity precarious, and our time, even when longest, very short, if mea- 
sured by our moral wants, and intellectual cravings. 

Surely, gentlemen, you will not dare, without adequate and earnest preparation, 
to embark in a calling like this ; so capable of good if rightly used, so full of peril 
to yourselves and to society if administered ignorantly or unfaithfully. And even 
when you have made it, as you may, the means of continual self-improvement, 
and the channel of health and ease to those around you, let not the influence you 
will thus obtain beget an unbecoming spirit of presumption ; but remember that, 
in your most successful efforts, you are but the honoured instruments of a superior 
power — that, after all, " It is God who. healeth our diseases, and redeemeth our 
life from destruction." 

.4 



LECTURE II. 

Pathology — meaning of the term. Pathology, general and special. Morbid 
alterations of the solid parts of the body. Alterations in bulk. Hypertrophy 
— law of its production — its effects. Atrophy — its causes and consequenes. 
Changes in form. Alterations in consistence. Induration — its various kinds. 

I propose to devote several lectures, in the commencement of the course, to 
pathology, as it relates to medicine. 

And I must first of all explain to you what I mean by the word Pathology. 

Many persons speak of pathology as if it were the same thing with morbid 
anatomy. That is not the sense in which I purpose to use the term. Pathology 
is morbid anatomy, but it is something more. 

A knowledge of pathology (in the full and proper acceptation of the word) 
implies indeed a knowledge of altered structures and of diseased conditions ; — but 
it implies also an explanation of these — a knowledge of what precedes them, and 
a knowledge of what results from them. 

It comprehends, therefore, the following particulars: — 1. A knowledge of the 
material changes to which the several parts of the living body are subject: 2. 
A knowledge of the processes or actions whereby these changes maybe wrought: 
3. A knowledge of the causes which may set these processes on foot: and 4. A 
knowledge of the consequences of the same changes, or of the symptoms they 
occasion. 

On some of these points our actual knowledge is still scanty and imperfect. 
Yet a good deal of valuable information concerning each of them has been col- 
lected ; and this I shall endeavour to place before you as distinctly, and at the 
same time in as small a compass, as I can. 

Pathology is general or special. General pathology treats of the morbid con- 
ditions which are common to the entire system, or to the whole of each of the 
several tissues that pervade and compose the system. Special pathology contem- 
plates particular diseases. An acquaintance with general pathology prepares us 
for, and conducts us to, that which is special ; and when I say that the earlier 
lectures of the course will be given to a consideration of the leading facts and 
doctrines of pathology, you will of course understand me to speak of general 
pathology. 

I shall begin by inquiring what are the changes to which the component parts 
of the living frame are liable : and I speak chiefly of sensible changes ; leaving 
unnoticed for the present those conditions which are perceptible only through the 
microscope. 

There are, then, various ways, capable of intelligible description, in which the 
different parts of the body may be sensibly altered by disease. 

The solid parts may be altered in bulk; inform; in consistence; in their 



ALTERATIONS OF SOLIDS. 



27 



intimate texture, i. e., in the qualities and arrangement of their component parti- 
cles ; and in situation. 

The fluid parts may also be altered in quantity ; in quality ; and in place. 

And many of these alterations may exist in combination with each other. 

Let us first consider the solids. 

They may be simply altered in bulk without any change of texture ; and that 
in two ways. They may become larger than natural, or smaller than natural. 
In the one case the change is called hypertrophy, in the other atrophy. 

We find the best illustrations of hypertrophy in the muscular system. The 
huge fleshy masses visibly prominent in the arm of a blacksmith or a pugilist, 
and in the leg of an opera dancer, afford familiar examples of it. In these cases 
the increased bulk, although it may be unsightly, as being out of proportion to 
other parts, is not disease, and does not interfere with the most perfect health. 
By constant exercise the muscles acquire preternatural volume, and weight, and 
power. It seems to be a law which prevails extensively in the animal economy, 
that increase of function should lead to augmentation of bulk. The function of 
the muscular system is contraction, and more frequent and energetic contraction 
begets an addition of substance. But the same principle obtains in various other 
parts and tissues. It is especially noticeable in some of the organs that are 
double. If one kidney wastes, or is spoiled by disease, an increase of function 
is thrown upon the other, and by a beautiful law of compensation, the sound 
organ, without any alteration of its peculiar fabric, enlarges. The same is 
observed to be the case with the lungs. The law resembles, somewhat, one 
that is familiar to political economists, and is expressed by them in the maxim — 
that the supply of a marketable commodity is regulated by the demand for it. 
If, in respect to a muscle, increase of force be habitually needed, the necessity 
generates the requisite addition of bulk, which implies an augmentation of force. 
One kidney becoming inefficient, it is necessary that the other should secrete a 
larger quantity of urine ; and this faculty is obtained by the enlargement of the 
secreting organ. 

I say this law is of extensive operation in the living body : but it is not uni- 
versal. It does not hold, for instance, in respect to the organs of the special 
senses. One eye does not become hypertrophic when the other is blind ; nor 
one ear grow larger or longer because the other is deaf. And we see at once 
why the law in question does not apply in such cases. These organs differ from 
such as I mentioned before — from muscular and glandular parts — in this : that 
increase of their size would not further or facilitate the purpose they are designed 
to serve. A muscular arm will strike a harder blow, and lift a heavier weight, 
in proportion to the greater bulk of its muscles : but we should gain nothing in 
distance or distinctness of vision by the enlargement of an eye ; nor should we 
hear more acutely or more clearly if our ears were of twice the ordinary magni- 
tude. 

Hypertrophy of this unmixed kind — unattended by any change of texture— 
(and it is to this that the term should as much as possible be restricted) — is be- 
lieved to depend upon more active nutrition of the part (vnsp tpo^). More ma- 
terials are laid down in the part by the blood, and assimilated, than are received 
back from the part into the blood to be taken out of the body. The nutritive 
process preponderates over the re-absorbent. That hypertrophy does thus result 
from an excess in the process by which parts are nourished and built up, and not 
from a defect in the process by which they are continually unmade and removed, 
is rendered probable by the fact that an increased quantity of mutrient blood is 
sent to the hypertrophied part; its arteries grow larger: this we perceive by 
comparing these vessels with others where no accession of bulk has occurred. 
This opinion is further strengthened by the converse effect produced upon an 
hypertrophied part (the thyreoid gland, for instance), by tying its principal nutri- 
ent artery. The magnitude of the bronchocele diminishes. It is curious that no 



28 



HYPERTROPHY. 



such alteration of size has been noticed in the nerves supplying the hypertrophied 
parts. 

Now these examples of hypertrophy clearly have not the nature of disease. 
But hypertrophy is often plainly connected with disease, while still it is not itself 
a morbid process. Thus we have it in the hollow contractile organs, the office 
of which is to propel fluids : — in the heart when the progress of the blood suffers 
some mechanical impediment : in the bladder when the urine, and in the intes- 
tinal canal when its contents are somehow hindered in their natural course ; or 
when, from some undue stimulus or irritation, these parts respectively sre urged 
for a long time together to excessive, or too frequent, action. I show you pre- 
served specimens of each of these changes. You will find that muscular tissue 
may become apparent, under the influence of disease, where very slight traces of 
it, or none at all, were visible before. We sometimes observe this in the air- 
tubes, the trachea and bronchi, when the respiratory functions have been long 
embarrassed ; and in the gall-bladder, when the exit of the bile has been chroni- 
cally obstructed. And it is worth remarking that this new, or greatly exaggerated 
appearance of muscular tissue, which is the consequence of disease in the human 
body, is a part of the natural and healthy structure in the corresponding organ of 
some of the inferior animals. 

The several instances of hypertrophy that I have now been mentioning, if they 
are to be looked upon as morbid, are morbid in a particular and limited sense — 
morbid, merely as being associated with disease, but not so either in their own 
processes or in their tendencies. Many, indeed, of the writers who notice them, 
speak of the hypertrophy as constituting a source of disease, and a cause of dan- 
ger to the patient. But I shall have occasion to show you hereafter that in most 
cases it is really a compensatory change, and conservative of life; — a resource of 
nature by which impending danger is postponed, and existence prolonged. 

It may be said of hypertrophy, that its relation to disease depends very much 
upon its seat. As regards the muscular system — in the voluntary muscles it is 
generally innocent, in the involuntary it is generally connected with disease ; 
sometimes as a cause, much oftener as a consequence, sometimes as both cause 
and consequence. One way in which hypertrophy may manifestly be a cause of 
disease is by the pressure of an enlarged organ upon the parts in its neighbour- 
hood, and a consequent interference with the functions or the sensations of those 
parts. 

I am not sure, whether to those among you who are beginners, I make myself 
understood. An example or two will render my meaning obvious. • 

It often happens that the aortic orifice of the left ventricle of the heart becomes 
narrow and constricted, in consequence of disease in the semilunar valves there 
situate. Under these circumstances it is requisite, for the due propulsion of the 
obstructed blood, that the ventricle should contract with increased force; and its 
walls become, accordingly, thicker and stronger. Here the hypertrophy of the 
left chamber is evidently a consequence or effect of the disease that previously 
existed at its outlet. 

On the other hand, when the thyreoid gland is enlarged, it sometimes presses 
so much upon the parts that lie behind it, as to impede the breathing, or the swal- 
lowing. In this case the hypertrophy is the cause of consecutive disease. 

Hypertrophy is exceedingly common in other tissues as well as in the mus- 
cular. Of its affecting the glandular system we have good examples in what I 
have just mentioned, the true bronchocele; in certain forms of enlarged prostate; 
in the thymus gland not unfrequently. Of a state of the brain which is considered 
to constitute hypertrophy, I shall speak more particularly when we come to the 
morbid conditions of that organ. Hypertrophy is also said (I am not certain with 
how much propriety always) to occur in the cutaneous, mucous, and vascular 
systems, in the bronchial, mesenteric, and mammary glands, in the liver, spleen, 
and pancreas. Of these parts I suspect that the enlargements to which the term 
hypertrophy has been sometimes applied, most frequently combine some alter- 



HYPERTROPHY. 



29 



ation of texture with the increase of size, and therefore are not strict examples of 
hypertrophy. 

You ought to be -ware that hypertrophy of one or more of the component 
tissues of an organ may exist, while the others either remain unaltered, or are 
changed in some other way. It frequently happens that when one component 
part is thus over-nourished, it is so at the expense (as it would seem) of another 
which becomes atrophied. There are parts of the heart upon which a certain 
quantity of fat is usually deposited. It is not uncommon to meet with this fat in 
excess, and at the same time to find the muscular texture of that organ pale, flabby, 
soft, and wasted. What has been deemed hypertrophy of the female breast con- 
sists, almost always, I believe, in excessive development of its adipose tissue, 
without any enlargement of the gland itself — or even with its diminution. 

Hypertrophy of the adipose tissue is often general throughout the body, pro- 
ducing obesity ; and this may become so extreme as to amount to disease, when 
it is called by nosologists polysarcia. I have seen one fatal instance of this kind. 
The mother of a large family, whom I long knew as a slender and elegant woman, 
began suddenly to grow fat; and in about fifteen months, without any other dis- 
coverable malady, she gradually enlarged into a corpulent unwieldy monster. At 
length her legs and thighs became oedematous as well as fat, her lips blue, her 
breath was short, and her pulse feeble. One night she was found dead in her 
bed. The body was not examined; but her death was mainly owing, as I be- 
lieve, to fat collected upon the heart, oppressing its movements, and at last stop- 
ping them altogether. 

In the majority of cases the size of an hypertrophied organ is augmented ; it 
has a larger superficies than is natural : and therefore I have introduced hyper- 
trophy to your notice among the alterations to which parts are liable in bulk. 

But it is not always so. There may be hypertrophy of an organ without 
enlargement — in at least three different ways: — 

1st. In hollow organs, where the additional substance is deposited centrically, 
and the hypertrophy takes place at the expense of the cavity: 

2dly. In any organ, whereof the hypertrophy is confined to one or more tissues, 
while the others are proportionably wasted ; and, 

3dly. Hypertrophy may even be consistent with no alteration of shape, or 
increase of bulk in any direction, the organ occupying exactly the same space, 
and preserving the same absolute dimensions as before, but becoming more full of 
component particles, more compact, heavier. This slate is well exemplified in 
certain cases of hypertrophy of bone: the spongy or cancelous texture of the 
bone disappears ; its specific gravity is increased ; it becomes hard, firm, and like 
ivory. The structure appears, to the eye, to be changed, yet remains the same, 
except in respect of its density. 

I have told you that hypertrophy is usually a conservative and salutary change. 
"We shall meet with many illustrations of this as we proceed. But I may take 
the present occasion for pointing out to you some of the beneficial tendencies of 
this change when it takes place in hone. For, since the diseases of the bones do 
not belong to my province, I shall have no other opportunity. 

You probably know that in the disorder called rickets, occurring principally 
during childhood, the bones are soft and deficient in their more solid ingredient; 
so that they bend under the weight of the body, or the contraction of the muscles 
attached to them. After a certain period this disproportion in the constituent par- 
ticles of the osseous tissue ceases; but the bones are permanently distorted, and, 
therefore, less adapted to their office, and less strong, than if they had remained 
straight. Now the natural remedy that ensues is very striking and beautiful. 
The bent bones become hypertrophied in certain places ; they grow thicker, 
denser, harder, and consequently strong, at the very concave part where the 
stress of the pressure is the greatest. 

The following experiment showed the same thing in a somewhat different 
manner. An inch of the middle part of the fibula of a quadruped was cut out. 



30 



HYPERTROPHY. 



A long time afterwards the animal was killed. The tibia was then found to have 
become considerably larger exactly in that part of it which corresponded to the 
defect in the fibula.* 

The same principle appears still more conspicuously in a case of disease related 
by Cruveilhier. He saw in the hospital at Limoges a young man who had lost 
(from necrosis with suppuration) the middle third of his tibia ; of the larger of the 
two bones of the leg. The lost bone had not been reproduced, but the fibula, the 
naturally slender bone, had become thick and strong enough to support the whole 
weight of his body. 

I was explaining to you that hypertrophy may exist without enlargement. On 
the other hand there may be enlargement without any change of structure, and 
yet no hypertrophy. The liver and spleen are apt to acquire a considerable 
increase of bulk from mere congestion and distension of their vessels by blood. 
An immense spleen will shrink into its proper size in a few hours, after hemor- 
rhage from the stomach, whereby the gorged venous system of the abdomen has 
been relieved. Dr. Townshend mentions a remarkable example of the same kind 
respecting the liver. The inferior cava has been compressed by an aneurismal 
tumour, so that the passage of blood from the liver was greatly impeded. Under, 
these circumstances the liver became so large as nearly to reach the crest of the 
ilium. Suddenly the aneurism burst, the pressure was taken from the cava, the 
hepatic veins were allowed to empty themselves, and before the body was opened 
for inspection, the liver had nearly resumed its natural situation and dimensions. 

Of the causes of hypertrophy little more is known than I have already told 
you. The most important circumstance for you to remember is, that increase of 
function produces increase of nutrition. This is nearly a general fact; but 
whether the converse proposition be as generally true — whether hypertrophy of 
a part always denotes increased activity in its function — is much less certain. If 
that were ascertained, we might hope to discover the actual office of certain parts 
of the body, the uses of which we dojiot yet understand (of the thryreoi'd gland, 
for example), by investigating the circumstances under which they become sub- 
ject to hypertrophy. In Mr. Mayo's Outlines of Human Pathology, a case is 
related of hypertrophy of the tongue, in a young child, treated by Mr. Hodgson, 
of Birmingham. It would seem to be impossible to account for this by any in- 
creased energy in the known functions of that member. 

A few isolated facts, bearing upon some points connected with this inquiry, 
have been made out. 

In the first place, certainlocalities appear to be influential in the production of certain 
forms of hypertrophy. Thus bronchocele is very frequent among the inhabitants 
of certain districts; especially in close or marshy valleys at the feet of high moun- 
tains. Its real cause is to be sought in some condition, hitherto undetermined, of 
the air in those places, or of the water, or of both. 

2dly. Certain congenital or acquired conditions of the body tend to produce 
local hypertrophy. In that peculiar diathesis which we call the strumous — and 
of which I shall have much to say hereafter — certain parts of the body, as the 
upper lip, and the extremities of the long bones, undergo a kind and degree of 
enlargement that seem properly to fall within the definition of hypertrophy. 

3dly. Certain habits of life have a distinct effect in promoting certain forms of 
hypertrophy. Full diet, with bodily inactivity, leads to hypertrophy of the 
adipose tissue. So general is this tendency, that we confidently act upon it in 
the fattening of animals. Shut a healthy pig up in a small sty, and give him as 
much food as he is willing to eat, and you ensure his rapid pinguescence. If you 
cannot so certainly attain the same result by similar means in the human animal, 
it is chiefly, I believe, because moral causes, and especially mental anxiety, will 
effectually counteract those means. A healthy man, with a quiet mind, using 
habitually a full nutritious diet, and leading a sedentary life, will fatten, I appre- 

* Mr. Stanley's Lectures, Coll. Surg. 



ATROItflY. 



31 



hend, as unfailingly as a calf, or a turkey. Sometimes, indeed, fat accumulates 
to an enormous extent, in spite of abstinent habits, and very active exercise. 

4thly. It is a curious fact that the removal of certain parts of the body, as the 
testicles from male animals, and the ovaries from females, increases the disposi- 
tion to accumulate fat. The same tendency appears to be given, for a time, by 
the extirpation of the spleen. 

Of the curative methods that hypertrophy may require it would be premature 
to speak at present. 

The bulk of parts may be also augmented in various other ways. The hollow 
organs may be inordinately distended by an undue accumulation of their natural 
contents : or by matters that do not enter them in health. The solid organs may 
have their size increased by the presence of matter foreign- to their natural com- 
position, collected in their interior, or distributed through the insterstices of their 
proper tissues, or deposited upon their surface : and in either case the functions 
of the part itself may be disturbed or suspended ; or the functions of parts imme- 
diately contiguous to it may sustain damage from its pressure ; or the functions of 
distant parts connected with it by dependency of office may be disordered ; or all 
these consequences may exist together. Numerous examples of them all will 
hereafter be brought under your notice. 

Let us next attend to that condition which is the opposite of hypertrophy — to 
atrophy, namely, in which parts become notably smaller than natural, without 
other alteration of texture. 

The two conditions contrast strongly with each other in their nature and origin, 
as well as in their physical character. 

• Hypertrophy depends essentially upon an increase — atrophy upon a diminution 
or defect, of the nutritive functions. You will find that atrophy plays an import- 
ant part in altering the bodily organs, both in health and in disease. 

Of the effect of atrophy in causing alterations consistent with health, I shall 
merely remind you of some instances, that you may the better comprehend its 
morbid operation. 

There are parts of the body, as you well know, destined for a temporary pur- 
pose only. Upon the cessation of their especial function they dwindle, or disap- 
pear. We have examples of this in the thymus gland, in the supra-renal capsules, 
and in those parts of the mechanism of the circulation which are peculiar to the 
foetal state. The atrophy here begins as soon as the child is born, and is not only 
consistent with, but necessary to, its perfect health. As life advances, we see 
the same principle at work, remodeling from time to time those structures of 
which the office has only a limited duration. After the child-bearing period in 
women is over, when the functions of the ovaries expire, these organs shrink, 
through atrophy. It is so with the testes of old men. Indeed, atrophy, to a 
certain extent, pervades all parts of the system in old age ; the muscles diminish 
in size, the whole body is less plump, the bones lose a portion of their substance, 
and become brittle. 

Even in the period of foetal life this process, by which parts are starved and 
stunted, sometimes displays itself. But here it is no longer compatible with the 
integrity and well-being of the system. The arrest or retardation of the nutritive 
function produces changes of great interest, and gives rise to various kinds of 
monstrosity. Harelip — fissure of the palate — certain malformations of the heart 
— are familiar examples of the consequences of intra-uterine atrophy. 

Atrophy, considered as a morbid change, is conspicuous, no less than hyper- 
trophy, in the muscular system. We see it in the voluntary muscles, whenever 
a limb remains long in a state of inaction — whether from palsy depending upon 
disease^in the brain or spinal cord ; or from pain connected with disease of a joint; 
or from perversion of the will, as in the self-inflicted penance of the Fakir. The 
same law, therefore, obtains here, which was previously announced ; the develop- 
ment of a part is proportioned to the activity of its function. In most cases, I 



32 



ATROPHY. 



believe, the atrophy will be found to resolve itself into a deficient supply of healthy 
arterial blood. Building materials are not provided, or are provided inadequately. 
Mere inaction will produce atrophy ; but it is probable that the inaction operates 
simply by abridging the flow of arterial blood to the muscle. If (as some sup- 
pose) what is called a change in the innervation of a part tends sometimes to 
occasion its atrophy ; if, for example, the altered state of the nervous influence 
has some share, beyond the inaction which it produces, in causing the atrophy of 
a paralyzed limb — it still acts, I conceive, indirectly, and by reducing somehow 
the supply of healthy arterial blood. The nerves belonging to palsied and 
atrophied muscles are said not to diminish in size. It is with the arterial circula- 
tion, certainly, that atrophy is most concerned. It is upon a diminution of the 
number of the smaller, and perhaps also of the capacity of the larger arteries, that 
senile atrophy depends. We find atrophy of the brain accompanying certain 
diseased conditions of its main arteries. So the testicle withers when the sper- 
matic artery is tied for the cure of varicocele. 

Pressure of any kind, exercised either upon the large arterial trunks, or upon 
the capillary vessels, so as to lessen without completely preventing the supply of 
blood, will be found to give rise to atrophy, whenever the due quantity of blood 
is not furnished by the establishment of a collateral circulation. Chronic inflam- 
mation is sometimes attended by the wasting of the part which it occupies. It 
acts, in all probability, by unfitting the capillary arteries for transmitting the 
requisite quantity of blood. Various diseases, by which the supply of nutriment 
to all parts of the body is checked at its source in the digestive organs, or by 
which some unnatural drain upon the system is kept up — by which, in short, the 
quantity of the nutrient fluid is diminished, or its quality impaired — produce a 
greater or less degree of general atrophy ; but to this universal wasting we usually 
apply the term emaciation. 

Atrophy, then, such at least as is morbid in its nature, may be the consequence 
of inaction, of compression, of chronic inflammation, and of various diseases ; but 
in all cases the defect of nutrition which constitutes the atrophy seems to be 
resolvable into a diminished supply of healthy blood through the arteries. 

As in hypertrophy, so likewise in atrophy, the change may be limited to some 
one or more of the component tissues of a part; and by these altered propor- 
tions of its constituent tissues the appearance of the part may be remarkably 
modified. 

So, also, as hypertrophy may exist without any increase of absolute size, 
atrophy may occur without any decrease: as in the heart, when the cavities are 
dilated in the exact degree in which their walls become thinner. Bones, exter- 
nally sound in appearance, have had their specific gravity so greatly reduced by 
internal atrophy, that they would float upon water like a cork. 

It is a curious fact — which I mentioned in other terms before — that an atrophied 
part is sometimes plentifully encompassed by fat. But this is by no means a 
necessary accompaniment. Why it happens in one case, and not in another — 
whether the adipose hypertrophy is ever the cause of the atrophy associated with 
it, or the atrophy the cause of the hypertrophy: — these are questions which, 
in the present state of the science of medicine, do not admit of any positive 
solution. 

It is scarcely necessary to observe that the changes of bulk which we have been 
considering, imply often, though not always, changes of form also. You will 
have one or two of the chambers of the heart greatly enlarged, while the others 
remain of their natural size. Of course this altered proportion modifies the shape 
of the organ. 

Signal changes of form are produced also by inflammation, by pressure, and in 
various other ways. But, after all, modifications of figuie are rather to be con- 
sidered as accidents of disease than among its important elements: and I "pass on 
to other alterations. 



INDURATION. 



33 



Various parts of the body are liable to be changed in consistence. They may 
become harder and firmer than before : or they may become softer. To the state 
of increased or unnatural hardness the term induration has been applied : the 
same word is used also to express the process of hardening. To the state of 
diminished consistence we give the name of softening. The French patholo- 
gists, who first noticed this condition as an element of disease, call it ramollisse- 
ment. 

You are already aware — those of you who have attended the lectures of the 
professors of midwifery and of anatomy — that a slow process of natural and 
healthy induration is going on throughout the body from the earliest period of 
uterine life to extreme old age. 

There are several ways in which emnatural induration may take place. 

Induration of an organ may happen, without any other alteration of its proper 
tissue, in consequence of inordinate fullness of its blood-vessels. This is apt to 
occur in the lungs, or liver, whenever the free exit of blood from these organs is 
in any way impeded. They become stretched, tense, resisting, hard. 

In like manner induration of the hollow organs, or of cellular parts, will arise 
(without any change of their texture) from an undue accumulation of fluids within 
them; — of bile, for example, in the gall-bladder; of urine, in its receptacle; of 
gases in the stomach and intestines ; of serosity in the cellular tissue. 

In either of these kinds of induration the unnatural hardness may be temporary 
only, or it may be the permanent accompaniment of other disease. It is neces- 
sary that you should be aware of its occurrence, and of its nature. I say of its 
nature, because this is not always understood. In the induration arising from 
the last circumstance I mentioned, viz., from infiltration of the cellular tissue 
with the serous or albuminous parts of the blood — from oedema, in short — the 
hardness has sometimes been erroneously ascribed to some other morbid condi- 
tion. Dr. Carswell has shown that in the curious disease of new-born children 
who are said to be skin-bound, the hardness of the surface is the consequence cf 
simple oedema of the subcutaneous cellular tissue. The same phenomenon is 
remarkable in oedema of the tongue. I believe the induration belonging to oedema 
will be found to be the greater, in proportion as the effusion is recent, and has 
taken place rapidly. 

Again, induration may accompany, and be a consequence of, simple hypertro- 
phy. Of this I have already shown you examples ; especially in the eburnation 
(as it has been called) of hypertrophied bone. 

Induration of an organ may also result from the expression of its fluid, and the 
compression of its solid parts. We see this extremely well in the lung, when it 
has been thrust and flattened against the vertebral column by fluid effused into 
the pleura; or when it is still more tightly bound down by an investing layer of 
plastic lymph. In this way, therefore, induration may be consistent with atrophy. 
That the natural structure of the hardened lung is not always lost in these cases 
we know, because we can restore, to a certain extent at least, its bulk and spongy 
feel, by forcibly inflating it. The spleen sometimes exhibits the same kind of 
induration, under the constrictive force of an investing false membrane. I am 
mentioning samples only of these changes. 

More frequently induration depends upon the presence, in the internal texture 
of parts, in the little spaces left between their component tissues, of fluid or solid 
matters which are not found there in the healthy state. Bony or earthy particles 
are sometimes laid down, and the part thus changed is said to be ossified. There 
are few parts of the body in which this kind of induration does not occasionally 
take place. It is especially common in the coats of arteries, and in the subserous 
tissues. Blood, or fluids separated from the blood, may fill and obliterate the 
natural interstices, and concreting, tend to solidify and harden the part which they 
occupy. What is called hepatization of the lung is a good instance. I need not 
tell you that the healthy lung is spongy and crepitant under pressure: in this 
altered state it no longer crackles between the fingers ; its spongy character is 



34 



SOFTENING. 



lost; it resembles liver in its compactness and colour, and it is therefore said to 
be " hepatized." This is a consequence of inflammation; and induration of this 
kind is a very common consequence (as we shall see) of the same morbid process 
in various other parts and organs. Another instance of induration of the pulmo- 
nary substance we have in what is badly called pulmonary apoplexy. This is 
independent of inflammation. Blood is collected and coagulates in a part of the 
lung which should contain air — in the vesicles of one or more of its lobules ; the 
lobules thus gorged with blood become even harder and firmer than when hepa- 
tized ; but by a different process. 

In the instances last mentioned, fluids after escaping from their proper vessel^, 
i. e., in technical phrase, after being extravasated, pass into the solid form, and 
thereby render the parts which they pervade harder and more firm. But fluids 
may concrete and harden within their proper vessels, and so lead to another form 
of induration. Thus the blood, under certain circumstances, coagulates in the 
living veins — nay, sometimes even in the heart itself: and we may hereafter have 
to consider the conditions under which this coagulation is liable to occur, and the 
serious consequences which it involves. The bile, again, as you probably know, 
sometimes concretes, by a rude kind of crystallization, into what are called gall 
stones: and the passage of these calculi through the narrow ducts that connect 
the gall bladder with the bowel is apt to be attended with pain the most intense. 
The formation of urinary calculi is not exactly of the same kind. 

Numerous specimens of all the changes I have been describing are on the table 
before you. You may examine them at leisure after lecture, or in the museum. 

I have yet to notice another source of unnatural induration, in the deposition or 
growth of irregular masses of matter within the body, differing remarkably from 
any of the solids or fluids that enter into its healthy composition. These unnatu- 
ral formations vary considerably in their nature and appearance, and in their con- 
sistence, at different periods. Sometimes they exist in distinct and separate 
masses, and whether hard or soft in themselves, cause induration by their pressure 
upon surrounding textures : sometimes they are diffused through or among the 
natural tissues of a part, which thus they indurate. All the varieties of tubercle, 
and of cancer, and other forms of disease which have been styled malignant, fall 
under this head. 

These new and morbid products play a fearful part in disorganizing the bodily 
frame, and in embittering and shortening life. They will necessarily occupy 
much of our attention in the progress of the course. At present I merely point 
them out as illustrations of the manner in which the consistence of parts may be 
increased. 



LECTURE III. 

Softening ; its causes and varieties. Transformations of Tissue ; Changes of 
situation — in the Chest, of the Lung, of the Heart — in the Abdomen and 
Pelvis, Hernia, Intussusception, Prolapsus. 

We were occupied with that branch of pathological inquiry which relates to 
the various ways in which the several parts and organs of the living body are 
liable to be sensibly altered by disease. 

We considered the changes to which the solid parts are subject in bulk and 
form; and that alteration of their consistence which constitutes hardening or 
induration. 

The opposite condition to this is softening, diminished consistence, a less 
degree of cohesion of parts and tissues than is natural. 

This also is a state of which it is important that you should comprehend the 



SOFTENING. 



35 



nature, and causes, and varieties ; and the share that it often has in breaking down 
the structure of organs, and in destroying life. 

There is scarcely any tissue of the living body in which softening may not 
take place. I shall here, however, as before, mention a few illustrations only of 
its occurrence, taking those instances in which the phenomenon is most evident, 
or is best understood. 

Softening is perhaps never more strikingly obvious to our senses than when it 
affects the brain or spinal cord. We find portions of these organs manifestly 
softer than the rest. You are familiar with the usual consistence of the adult 
brain : you will find it sometimes reduced, in places, to the consistence of cream : 
a gentle stream of water suffered to fall upon the softened pulp suffices to wash it 
away, and a cavity is left in its place. 

The cellular tissue — or rather let us call it, with Professor Todd, the areolar 
tissue, since minute anatomists now affirm that all the tissues in their embryonic 
state are cellular — the areolar tissue is another part in which softening is exceed- 
ingly common, although the change is not so readily perceived. This is the 
great connecting tissue of the body ; and we are made sensible of its diminished 
consistence when parts which it unites become separable with unusual ease. 
Thus you may sometimes, by exerting a very slight degree of force, strip off a 
serous membrane from the parts which it invests, or a mucous membrane from 
the surface lined by it. This ready separation is a consequence of the diminished 
consistence of the subserous, or the submucous, areolar tissue. The membranes 
themselves, in such cases, may be in a perfectly natural state. 

Muscles, again, are often palpably softer than they should be : the fleshy sub- 
stance of the heart, for example. Here the muscular fibre may itself have under- 
gone a change of consistence; or the muscle may simply appear to be softened, 
in consequence of the softening of the threads of areolar tissue by which its fibres 
are tied together. 

The mucous membranes very frequently present the phenomenon of softening. 
This is more commonly seen in the stomach than elsewhere. Instead of being 
raised from the subjacent tissues in large flakes, the mucous membrane, when 
seized between the forceps, breaks off in small fragments ; or it may be crushed 
and mashed by the pressure of the finger, or washed away in shapeless pulp by a 
little current of water. This condition of its lining membrane is usually limited 
to parts of the stomach ; but occasionally it is general. 

Even the bones are liable to this change of consistence. There is a disease 
called mollities ossium, in which the bones even of adults become soft and pliant, 
and capable of bending in any direction. There is a deficiency in their earthy 
constituents ; atrophy of that particular tissue. Indeed, softening is often a con- 
comitant or a result of atrophy. 

The accidental products to which I adverted when speaking of induration — 
especially some of the varieties of cancer — are sometimes remarkably soft, resem- 
bling brain in consistence and appearance, or cream, or jelly. But in these cases 
we can scarcely consider the change as an example of softening of the textures 
of the body ; it rather consists in the addition of parts that are themselves soft 
and half fluid. 

Now softening may occur under very different circumstances. One very gene- 
ral cause of softening is inflammation. Every part, I believe, that is inflamed, 
undergoes, in the first instance, a diminution of its consistence. This appears to 
be almost the necessary consequence of stagnation of the blood, the effusion of 
serosity, and the suspension of healthy nutrition. These are circumstances to 
which I shall recur. I cannot avoid alluding occasionally to things with which 
you are supposed to be as yet but little acquainted, and which will engage our 
particular attention as the course advances. 

It would be a great mistake, however, to suppose that all softening results from 
previous inflammation. Doubtless it often proceeds directly and simply from 
deficiency of nutrition, and is then closely allied, as I said before, to atrophy. 



36 



TRANSFORMATIONS OF TISSUE. 



Thus softening of the brain is, sometimes, due to inflammation : we meet with it 
where the inflammation has been unequivocal, and was caused by external injury ; 
but sometimes also it is quite independent of inflammation, and is owing to disease 
of the cerebral arteries, whereby the brain, or a portion of it, is deprived of its 
full supply of arterial blood, and ceases to be properly renovated : hence a loosen- 
ing of its texture, a separation of its component particles, an approach to the fluid 
state. I shall, of course, hereafter endeavour to point out to you more particu- 
larly the means we possess of distinguishing these two forms of cerebral soften- 
ing; they constitute morbid conditions of the highest interest. 

I may observe, that we have an illustration of the principle now laid down, in 
that general softness, flaccidity, and slight cohesion of parts, noticeable in chil- 
dren, and others, who are imperfectly nourished. We find this general absence 
of the natural firmness coincident with paleness, and a thin watery condition of 
the blood. Magendie kept animals upon food unsuitable to them, containing no 
azote, and incapable of supplying sufficient nourishment ; and one curious con- 
sequence that followed was a loss of substance in the cornea, which melted down 
and disappeared. 

There is another source of softening which requires to be mentioned — I mean 
the gastric juice, which has the power of dissolving not only food that is submitted 
to its action, but the mucous membrane of the stomach itself, and even all its 
tissues and coats. This cause of softening operates, however, in the dead body 
only; but its effects have often been mistaken for the consequences of disease; 
and therefore it will be necessary for me hereafter to call your attention to the 
circumstances under which they tnay be expected, and to the means we possess 
of discriminating them from similar changes, which are more properly called 
morbid. 

Upon the whole, it may be said that every form and kind of softening in the 
living body — whether it proceed from inflammation, from disease of the arteries, 
from insufficient sustenance, or from altered qualities of the blood — may ulti- 
mately (like atrophy) be resolved into suspended or defective nutrition. 

Furthermore, as there is a hardness of parts resulting from repletion and dis- 
tension, so there is a softness rather than a softening, from their emptiness and 
flaccidity : as of the breast immediately after the child has sucked ; of the abdo- 
men soon after delivery ; of the integuments in those who, having been fat, have 
wasted, either from disease or from advancing age ; and so on. 

On former occasions, I thought it right to lay before you the views of M. Andral 
(which appear to have been adopted also by Dr. Carswell) respecting what has 
been called the transformation of tissues. " In the proper place of one natural 
tissue (I remarked) we sometimes find another, which last is thus tmnatural in 
regard to its situation, but natural in all other respects. The new tissue is such 
as we meet with elsewhere in the body, but it is not such as properly belongs to 
the place it occupies. Either the original tissue has been gradually converted 
into the new, or the original tissue has disappeared, and the new tissue has been 
substituted for it: that, for example, which should be cartilage we sometimes find 
to be bone." 

" In most cases the tissue that has been changed or displaced is in one of the 
two following predicaments : 

" Either its natural function has been for a long time suspended ; 

** Or, it has been accidentally called upon to fulfil a purpose for which it was 
not originally designed. 

"In the former case it gradually approximates towards areolar tissue, which at 
length is all that remains. 

" In the latter, it assumes the characters of that other tissue of which it has 
taken up the office." 

Now the analogy which M. Andral thought he could perceive between changes 
of this kind, and those changes which occur during the growth and progressive 



TRANSFORMATIONS OF TISSUE. 



37 



development of the human body, does not in reality obtain. More recent and 
more exact microscopical researches have shown that the several tissues do not 
commence by being areolar tissue — which is the sense in which M. Andral uses 
the word cellular — and therefore, that in the dwindling of any given tissue into 
the areolar, there is no return, as he had supposed, towards the primitive state of 
the tissue so wasting. A muscle remaining for a long time in complete inaction, 
loses bulk, but does not pass from the condition of muscular into that of areolar 
tissue: when wasted to the utmost, it still retains its proper anatomical elements. 
The areolar tissue is quite as complex and advanced a tissue as the muscular. 
There is no true conversion of the one tissue into the other. It is commonly 
stated, indeed, that when a muscle comes accidentally to invest a dislocated joint, 
the dislocation remaining unreduced, it assumes by degrees the characters, toge- 
ther with the uses, of those tissues which naturally inclose the joint, and is con- 
verted from muscular into fibrous or ligamentous tissue — just as in the vegetable 
kingdom, the cut branch of a willow tree, planted in the earth, takes up the office, 
and gradually acquires the form and properties of a root. But here again the 
analogy is more fanciful than real. The formation of a false joint implies no 
actual conversion of tissues. The muscular fibres shrink and disappear, while 
the areolar tissue augments, and is transformed only into the fibrous ; these two, 
the fibrous and the areolar, being essentially and primarily the same tissue. 

The change from cartilage to bone approaches more nearly than any other to 
actual transmutation; but even this resolves itself into a simple increase of one 
of the natural constituents of both the tissues concerned ; phosphate of lime, 
which exists in healthy cartilage. 

A curious and common change is the so-called transformation of other tissues 
into adipose tissue. The fat, however, does not take the place of the natural 
elements of the tissue. It is deposited among them, and wastes them, yet they 
still remain, and are easily distinguishable. If you examine a fat heart — such as 
is not unfrequently met with in very fat persons — you will generally find a 
combination of hypertrophy of the adipose tissue with atrophy of the muscular, 
rather than any conversion of the one into the other. The fat is deposited around 
and between the attenuated muscular fibres, and the two may usually be separated 
from each other. It would seem that here the converse of one of the propositions 
which I lately mentioned holds good — of the proposition, namely, that suspension 
of the function of a tissue leads to its degeneration into adipose or areolar tissue. 
In the instance before us, the increase of adipose tissue tends to lessen, and at 
length to destroy, the function of the part. What is called the fatty liver affords 
another instance of this morbid accumulation. The altered liver is of a light 
tawny colour, of diminished specific gravity, retains the impression of one's 
finger, is tender, and tears easily ; it greases the knife that cuts it, or bibulous 
paper in which it is wrapped. By boiling it you may obtain a concrete oil, which 
has all the characters of fat. The change is wrought by an enormous augmenta- 
tion in quantity of the fat which is a natural constituent of the texture of the liver, 
and which thus comes to predominate immeasurably over all its other elements. 

What is very curious in respect to this morbid condition of the liver is, that we 
can produce it, at will, in some at least of the lower animals. You know that 
the "foie gras" procured from certain birds, is an article of great luxury among 
epicures. It is obtained by a very cruel process. Geese or ducks are confined 
in baskets just large enough to contain them, but not large enough to allow them 
any motion ; they are kept continually in the dark also ; sometimes even, I am 
afraid, their eyes are put out, but this I should imagine to be a useless and super- 
fluous piece of cruelty, it being the absence of light, and not the absence of the 
power of vision, which helps to bring about the desired effect. At the same time 
the birds are sedulously crammed with food. Under this discipline their livers 
acquire the requisite size, and greasiness, and the true flavour. 

An ingenious theory has been constructed, in reference to the modus operandi 
of this process. The excessive supply of nutriment tends, no doubt, of itself, as 



TRANSFORMATIONS OF TISSUE. 



it always does, to the production of fat; the constrained state of inaction inter- 
feres probably with the right and healthful formation of blood, a matter in which 
the liver is believed to be a good deal concerned ; then we know, by experience, 
that the privation of light has the effect of blanching animals as well as vege- 
tables, and thus further interferes with the due renovation of the blood. In this 
way, the transformation of the liver into a fatty mass has been sometimes attempted 
to be explained. To what extent the explanation is correct, I will not pretend 
to say : but it is worth remarking that the fatty liver is very frequently met with 
in persons who die of consumption ; and in that disease there are various causes 
in operation tending to modify the constitution of the blood. 

The history of these unfortunate fowls is not barren of instruction in respect 
to the more limited bad effects of full diet, want of exercise, and a short allow- 
ance of day-light, upon the " featherless biped" man. 

These accumulations of fat are morbid changes. The transformations that are 
effected in false joints are evidently methods of accommodation and repair. The 
same may be said of the transformation — which is riot conversion — of areolar 
tissue into synovial membrane. Synovial membrane consists chiefly of condensed 
areolar tissue. Sir B. Brodie, in his book on Diseases of the Joints, gives instances 
of synovial membranes being formed, where none before existed. " In a young 
lady who had attained the age of ten or twelve years, labouring under the incon- 
venience of a club-foot, a large bursa was distinctly to be felt on that part of the 
instep which came in contact with the ground in walking. In another young 
lady, who had apparently recovered of a caries of the spine, attended with a con- 
siderable angular curvature, a bursa appeared to have been formed between the 
projecting spinous process and the skin." 

In like manner we find that sinuses, fistulous openings and tubes, in various 
parts, become lined, through the intervention of the areolar tissue, with a surface 
which in its appearance and in its properties resembles the mucous membranes. 
Like them it is with difficulty made to take on adhesive inflammation: and there- 
fore it is that sinuses of this kind, and chronic abscesses, are often so troublesome 
to the surgeon, and require to be laid open before they can be abolished. 

On the other hand, the mucous membranes, under peculiar circumstances, 
approximate to the skin in their physical aspect and qualities. When, for 
instance, a portion of the mucous lining of the rectum, or of the vagina, protrudes 
externally, is permanently exposed to the air, and subject to the friction of clothes 
or of neighbouring parts — that is to say, when it is placed under the same condi- 
tions as the skin — it assumes somewhat the characters of the skin: it gradually 
loses its red colour and approaches the tint of the skin, ceases to pour forth 
mucus, becomes dry, obtains even a sort of permanent cuticle, acquires firmness 
and densiiy, and is less sensible to the contact and pressure of foreign substances. 
It is impossible not to perceive the beneficial nature of this transformation. 

The greater number, then, of those interesting changes in the living body which 
have been classed under the head of transformations of tissue, have a restorative 
tendency. They exemplify the working of what the older pathologists discerned, 
and called the vis medicatrix natures. This is a phrase that has been much 
sneered at ; but (as I conceive) very unjustly, and sometimes ignorantly. It is 
simply a short formulary expressive of a great general truth, viz., that the animal 
frame is so constituted as to contain within itself the elements of repair, and of 
conservative adaptation. To a certain extent it is a self-mending machine. 
Surely this is an admirable provision, and clearly indicative both of wise con- 
trivance and of beneficent design. 

The intimate texture of parts may be further altered — not simply by some 
modification or reconstruction of the ordinary tissues, but — by an absolute dis- 
appearance or confusion of all regular structure. This is usually a consequence 
either of the effusion, in the natural interstices of the parts, of fluids, which after- 
wards pass into the solid state, or it is a consequence of the growth of solids 



LESIONS OF NUTRITION. 



39 



which do not belong to the healthy body. In this sketch of general pathology I 
must content myself with thus briefly alluding to this source of morbid change. 

I may as well observe here, that the alterations with which we have hitherto 
been occupied, of the solids of the body, fall, almost all of them, under the head 
of lesions of nutrition, as the French pathologists speak. That is to say, they 
commence, and have their primitive seat, in that process and place where the 
blood, having reached the capillary system of vessels, performs its special pur- 
poses. It is in or through the capillaries that the fluids and solids accomplish 
their vital union. Each solid receives from the blood, and assimilates with its 
proper substance, material particles, identical in their nature with those of which 
it already consists. Each solid gives up also to the blood, and so dismisses other 
particles, which before formed a portion of itself, but which have become unfit 
or superfluous. Now any departure from this continual building up and pulling 
down — any excess or defect of the particles added, or of the particles subtracted — 
any irregularity in the manner in which they are deposited — any variation from 
their right consistence, or in their kind and quality — in short any deviation from 
the regular process, as I have briefly described it — is called a lesion of nutrition. 

The few changes already spoken of, and not included among the lesions of 
nutrition, are: — 

The distension of the hollow organs by an undue accumulation of fluids within 
them ; 

The coagulation of the fluids in their proper vessels, excluding, however, the 
capillaries ; 

The escape of the fluids, as such, out of and beyond their containing vessels ; and 
The solution of tissues, after death, by the chemical agency of the gastric juice. 
None of these, properly speaking, constitute lesions of nutrition, although they 
sometimes lead to them. 

Lastly, let us take a glance at the changes of situation to which the solid parts 
of the body are liable. They are sometimes of very serious import. 

These changes of place — sometimes the consequence of disease, sometimes its 
cause, and not unfrequenily the cause of death — respect chiefly the viscera; and 
most especially the viscera of the chest, abdomen, and pelvis. I omit dislocations 
of joints, as belonging exclusively to surgery. 

In the chest, a whole lung may be displaced, and compressed against the ver- 
tebral column, by blood, or serum, or air, effused into the cavity of the pleura. 
An alteration of this kind, whereby one half of the respiratory apparatus is ren- 
dered incapable of its peculiar function, cannot be otherwise than full of peril. 

The very same causes operating on the left side of the thorax will dislocate the 
heart, thrust it over to the right of the sternum, where it may be felt, and heard, 
and seen, to pulsate. This again cannot happen without greatly disturbing the 
vital function of circulation, and putting life in jeopardy. 

Yet neither of these serious displacements is necessarily fatal. Both admit, 
under certain circumstances, of remedial treatment: as I hope to prove to you 
hereafter. 

In the abdomen and pelvis, the various forms of hernia may be adduced as 
involving very dangerous changes in the place and relative position of parts. 
Portions of the intestinal tube are apt to pass through accidental openings in the 
diaphragm — or between the edges of the linea alba surrounding the navel — or out 
at the abdominal ring — or through some other natural or accidental aperture. I 
need not tell you how fearfully life is compromised when, in consequence of such 
faulty position, the bowel becomes constricted — when its contents can no longer 
pass onwards, and inflammation, or gangrene, is present or impending. Even 
when there is no strangulation, the mere displacements to which the escape of 
the contents of the abdomen and pelvis from their natural limits gives rise, may be 
productive of much discomfort, deformity and hazard. Of this the historian Gib- 
bon presented a remarkable example. He had an immense scrotal hernia ; so 



40 



CHANGES IN THE BLOOD. 



large it was, that it hung down very nearly as low as his knees. After his death it 
was found that almost the whole of the omentum, and the greater part of the colon, 
had descended into the scrotum, and had dragged the stomach after them ; so that 
its pyloric orifice lay close to the abdominal ring. 

Akin to hernia is that partial displacement of the bowel in which a portion of * 
it passes, not through any natural or accidental opening, but into the bowel itself ; 
just as one portion of the finger of a glove is sometimes pulled into the remaining 
part, by the withdrawal of one's hand. The contained portion of intestine is 
liable to be nipped and strangulated by the containing portion — and all the peril 
of hernia results, with much less chance of relief by art. This state of things is 
called intussusception. 

Exactly of the same nature, though less alarming, is prolapsus of the rectum, 
or of the vagina. Here, also, a portion of the tube passes into the contiguous portion ; 
but being near the extremity of the canal, the inverted part protrudes externally, 
and becomes, in most cases, a source of distress and suffering, rather than of dan- 
ger. Inversion of the uterus is another example. 

Thus much, then, of the changes to which the solid parts of the body are sub- 
ject, in bulk, in form, in consistence, in texture, in situation. 

You cannot fail to perceive the injurious effects which many of these changes 
in the various solids are calculated to produce upon the movements and working 
of the living machine; how some of them must impede or derange its natural 
action ; some stop that action altogether. 

Now, the fluid parts of the body are liable also to alterations, which, if they 
are not always so obvious as those of the solids, are certainly not of less moment. 

You are probably aware that, for many centuries, the fluids were supposed to 
be the primary agents in every form of disease ; that all maladies were attributed 
to some acrimony or peccant state of the humours ; and that, however else the 
theories of medicine might vary and fluctuate, the humoral pathology, till a com- 
paratively recent period, ran through almost all of them. At length, the absurdity 
of the hypotheses, and still more the dangerous practice, which this doctrine 
generated, began to be manifest, and led to its total abandonment. Rather more 
than a century and a half ago, the foundation of the opposite doctrine appears to 
have been laid, by the writings of Glisson in this country, and by those of Baglivi 
in Italy ; and presently the notion came to prevail throughout the schools, that all 
the morbid conditions of the body had their exclusive origin in the solids. The 
pendulum of opinion swung at once, as is usual, into the opposite extreme of 
error. It promises, in our time, to settle at the proper medium. The old extra- 
vagances of the humoral doctrine still, indeed, find favour among the ignorant, 
and are commonly adopted by the quack : circumstances which illustrate the 
fact that the mischievous influence of unsound theories survives the duration of 
the theories themselves. The scientific physician of the present day can only 
wonder how exclusive solidism, or exclusive humoralism, should ever have found 
advocates. 



LECTURE IV. 

Morbid Alterations of the Fluids, especially of the Blood. Changes in its quan- 
tity and distribution. General and Local Plethora. Poverty of Blood. Active 
Congestion — its Phenomena — State of the Vessels, as seen by the Microscope. 
Mechanical Congestion. Passive Congestion. Relations of these forms of 
Congestion to Inflammations — to Hemorrhages — to Dropsies. 

After running over the principal alterations to which the solid parts of the 
body are liable, we were beginning to inquire into those no less important morbid 



CHANGES IN THE BLOOD. 



41 



changes which are apt to take place in its fluid constituents. I reminded you 
that, respecting the whole of this subject, pathologists had passed from one 
extreme of opinion to another ; that, for a very long period, the humoral patho- 
logy prevailed in the schools, and that in times not very remote from our own, 
it was entirely superseded by the opposite doctrine of exclusive solidism. It is 
strange that either misconception should have so long maintained its ground. 

If we consider the definite relation subsisting between the solids and the fluids 
of the body, and the unceasing agencies which they mutually exercise on each 
other — how, for instance, on the one hand, all the solids are originally built up, 
and are afterwards perpetually nourished and sustained by materials furnished 
from the blood — how, again, on the other hand, some of the solids are continually 
employed in the reciprocal office of feeding and renewing the blood, while others 
are as constantly at work in decompounding it by the various secretions — we 
cannot avoid perceiving that distinctions of the kind I have mentioned, founded 
upon mere differences of consistence, are futile. Flesh and blood are almost con- 
vertible terms: their composition, the chemists tell us, is identically the same. 
To use the strong expression of Bordeu, Le sang est de la chair coulante. You 
may be certain that no notable alteration can take place in the solids of the body 
which will not soon affect, in some way, its fluids ; and that every important 
change in its fluids must lead to, or proceed from, a corresponding and propor- 
tionate modification of its solids. The long dispute between the solidists and the 
humoralists was altogether baseless and unprofitable. 

The animal fluids are — the blood, the fluids that enter the blood, and the fluids 
that proceed from the blood. 

The fluids that enter the blood are of two kinds. 

1. Those by which it is renewed and enriched. 

2. Those which enter it in order that they may be conveyed out of the body. 
Now, although we cannot doubt that any considerable modification or defect of 

the fluids that feed and renovate the blood, and particularly of the chyle, must have 
a direct influence upon its composition and quality, we really know but little about 
them, except in their effects. We seldom have any means of procuring these, the 
first products of nutrition, so as to examine them, or to test their qualities; yet 
we can perceive causes that are likely to deteriorate or deprave those fluids (unfit 
aliment, impure air), and we know that, under the continued operation of such 
causes, the blood, replenished by these fluids, is actually and sensibly modified. 

Again, we cannot doubt that some of the matters derived from the body itself, 
and taken into the blood in order to be conveyed away, may, and often do, directly 
alter and contaminate the blood, and act as poisons upon the system: matters, for 
instance, absorbed from the parts of the body that are diseased, or dead and 
putrefying; in this way, doubtless, disorders which were at first strictly local, 
may come to affect the whole economy : — matters, again, which, though harm- 
less while merely transitory, and in minute quantity, become noxious when 
retained and accumulated in the blood, in consequence of faulty or deficient action 
of the organs destined to eliminate them from the circulating fluid. The injurious 
effects of some, of the substances which thus become deleterious, — as urea, of 
which the blood, during health, is continually purified by the kidneys; and bile, 
which is naturally separated therefrom by the liver; and carbonic acid, which it 
is the office of the lungs to excrete — will furnish topics of interesting inquiry 
hereafter. 

The fluids that leaveAhe blood may be considered under a threefold division. 

1. Those which are directly expended in the growth or maintenance of parts, 
some of them becoming fixed and solid, and others retaining their fluid condition. 
Of these, the principal alterations have been briefly pointed out among the lesions 
of nutrition. 

2. Those that are employed in aid of some definite function of the body : as 
the saliva, the gastric juice, the bile, the pancreatic secretion, the tears, the synovia 
of the joints, and so on. Now these may be secreted in excessive abundances ov 



42 



PLETHORA, 



in too scanty quantity, or of imperfect quality, or not at all: and all, or any, of 
these deviations from the healthy standard, may be the result of very serious 
disease, or may cause very serious disease ; and they will be spoken of hereafter 
when the disorders of the parts or functions connected with each shall be dis- 
cussed. 

3. Those which are separated from the blood merely to be excreted, as the 
urine, certain secretions from the bowels, and from the bronchi and skin. Some 
of these are extremely worthy of study, as furnishing, in their altered qualities, 
indications of disease; but they require no particular consideration in this part of 
the course. 

Dismissing, therefore, for the present, all further account, as well of the fluids 
that concur to form the blood, as of the fluids that issue from the blood, let us 
inquire what morbid changes the blood itself is liable to undergo. 

The blood, then, is subject, first, to remarkable variations in its quantity, both 
in respect to the whole system, and in respect to particular organs and tissues. 

2. Closely connected with these differences of quantity is the variety which is 
observable in regard to the proportions between the several proximate constituents 
of the blood. The changes that occur of this kind are sometimes strikingly 
evident to our senses. For example, we not unfrequently perceive that the blood 
drawn from a vein is thinner, manifestly more watery, less rich in fibrin, and in 
colouring matter, than blood of the standard quality. 

3. Again, independently of mere alterations in the relative proportions of its 
proximate constituent parts, the blood is liable to great change in its chemical 
composition, and, therefore, in its physical quality. This appears to be the case 
in sea-scurvy, and in the analogous disease called purpura, and it is doubtless so 
in many other complaints. 

The composition of the blood cannot fail to be affected by a deficient supply of 
the elements of nutrition from without ; by diseases of the digestive organs, inter- 
fering with the process of chylification ; by diseases of the organs of respiration, 
interfering with its change from venous to arterial ; by diseases of other channels 
of excretion — the bowels, the biliary apparatus, the skin — interfering (as I have 
already hinted) with its appointed purification ; by foreign contaminating matters, 
finding entrance (as they may when in solution, or in a gaseous form) through 
artery, vein, or any membranous substance, such as bladder and intestine: lastly, 
the composition of the blood may be altered, there is good reason to believe, by 
certain states of the nervous system. 

But contenting myself with having indicated these latter changes, or sources of 
change, I shall defer giving a more particular account of any except those that 
relate to the quantity and the distribution of the blood. 

I say the blood may undergo important alterations in its quantity. It may 
exist in too great abundance throughout the body ; and it may exist in too great 
abundance in certain parts only of the body. These states have been recognized 
for ages. Sometimes they are called respectively general and partial plethora: 
sometimes general and local congestions of blood ; people speak also of irregular 
determinations of blood to different organs; and, of late, the term hyperemia, 
first invented by M. Andral, in France, has been imported into this country, and 
much adopted here. All these words and phrases mean, in truth, the same thing; 
and their frequent recurrence in medical works, is, of itself, sufficient evidence of 
the frequency and importance of the conditions which they express. 

If we comprehend rightly this subject of plethora or congestion, we shall be 
prepared to understand some most important morbid states, of which it seems to 
be in many, if not in all cases, the earliest approach — the initial step. Inflam- 
mation, hemorrhage, dropsy, all acknowledge and imply a previous condition of 
congestion. " There is probably," says Dr. Alison, " no kind of diseased action of 
which any part of the living body is susceptible, which is not connected, sooner 
or later, with increased afflux of blood towards that part, either as its cause or its 



GENERAL PLETHORA. 



43 



effect ; and the immediate object of all our most powerful remedies is to act on 
these irregularities of the circulation." 

That the blood may be differently distributed in the capillaries at different times, 
we know by the variable colour of the surface, which depends upon the varying 
degrees of fullness of the cutaneous blood-vessels. The phenomenon of blushing, 
the red cheek of anger, the heightened colour of the skin under brisk exercise, 
are familiar facts illustrative of partial plethora of the capillaries, consistent with 
health. 

There are reasons (which I shall hereafter lay before you) for believing that a . 
similar sudden accumulation of blood, taking place in internal parts, may sensibly 
disturb their functions; causing transient fits of giddiness, insensibility, and some- 
times death itself, when the congestion affects the cerebral blood-vessels; and 
attacks of difficult breathing when the capillaries of the pulmonary tissue are 
concerned ; and even these attacks, for aught that I know, may end fatally. 

It often happens that when certain portions of the surface, as the cheeks, are 
visibly redder and fuller of blood than usual, or when such symptoms as I have 
just referred to denote the probability of some internal congestion, other parts of 
the surface, as in the extremities, are visibly paler: and there are, at the same 
time, corresponding and palpable differences of temperature. 

Perhaps it may not be so obvious that the whole quantity of blood, throughout 
the body, is sometimes in excess. 

That in the adult state, when the growth or increase of the body has been 
completed, blood may be made in greater abundance, and more rich in the mate- 
rials of nutrition than the wants of the body require, is not only conceivable, but 
true. We are able to assign circumstances in which this is likely to happen, and 
we find that under such circumstances it actually does happen. Full living, and 
a sedentary life, are causes likely to occasion general plethora — and they do occa- 
sion it. The full diet, so long as the digestive powers are perfect, provides more 
chyle, conducts into the blood a larger quantity of its proper pabulum. The 
sedentary life precludes that freer circulation of the blood, and that more libe- 
ral expenditure of it through the skin, and by means of the other organs of 
secretion, which would occur under more active habits. Persons thus circum- 
stanced are apt to grow fat ; the adipsoe tissue seeming, in these cases, to form a 
kind of safety valve for the diversion of the superfluous blood. Such persons 
have turgid and florid cheeks, red lips, red mucous membranes, and (not uncom- 
monly) ferrety eyes. Their entire vascular system is preternaturally distended. 
If you open a vein, you find that they bear a large abstraction of blood without 
fainting, and are even refreshed by it; and the blood drawn separates into a large 
and firm mass of coagulum, with but little serum. Keeping to the nomenclature 
we have already employed, we might say that there is here hypertrophy of the 
blood. 

When inflammation arises in the subjects of this general plethora, it runs high, 
and requires active treatment. But they are not, as you might naturally expect 
them to be, and as many writers state them to be, peculiarly prone to suffer 
inflammatory complaints. There is a general fullness of the vascular system, but 
no irregularity, nor any necessary tendency to irregularity, in the distribution of 
the blood. 

You will observe that the relative proportion of the more solid to the more 
fluid constituents of the blood is increased in these cases of general plethora : the 
blood is not only more abundant, but it is richer also in fibrin, and in red particles. 

The means to be adopted for redressing this unnatural and unsafe condition of 
the circulation, are those which common sense would suggest. The removal of 
a portion of the superfluous blood, a more restricted diet, a larger allowance of 
active exercise. 

It will be worth our while to contrast this state of general plethora with its 
opposite — that in which the blood is scanty and poor — what Andral calls (though 
with questionable propriety) ansemia, OHgasmia is the cacophonous but more 



44 



ANiEMIA. 



exact name assigned to it by Gendrin; but poverty of blood is the ordinary- 
English phrase for it, and the best of the three. This is a state which we can 
produce at will, by abstracting blood from the body in moderate quantity, but 
repeatedly, and at short intervals. It occurs, also, frequently, in spontaneous 
disease, and from various causes; from a privation of the materials destined to 
replenish the blood ; and in cases in which these materials appear to be tamed to 
little account, as in chlorotic girls. We see it in those who habitually and fre- 
quently lose a certain quantity of blood, in disease ; in persons, for example, 
who are subject to piles, and who bleed daily from the rectum ; still oftener in 
women who suffer repeated hemorrhages from the uterus. When the drain has 
been long-continued, these persons become very pale ; even those parts which 
are naturally most red, as the lips and tongue, become almost white ; their faces 
look like wax; and if still you draw blood from a vein, and allow it to coagulate, 
you will have a small clot floating in an abundance of serum, and that small clot 
will be of a light rosy colour; showing a great diminution in the proportion of 
fibrin ; and a still greater deficiency of the red particles. The blood, as they say, 
is 44 turned into water." It is a curious pathological fact, that the red particles 
require more time for their restoration than the other constituents of the blood. 
And I may mention to you now, what I shall have to repeat, that — in conjunction 
with the obvious curative measures comprised in arresting the habitual loss of the 
vital fluid, and in affording sufficient nutriment to the system, — the preparations 
of iron, and the respiration of pure air, have signal efficacy in renewing the red 
particles, and giving back again their native hue of redness to the cheek and lips. 

In general plethora every part is preternaturally full of blood, and the blood 
itself is full of the elements of nutrition. General plethora, therefore, implies, in 
one sense, local plethora of every organ and tissue. In strictness, however, local 
plethora is only predicable of a part that contains more than its share of red blood. 

Now the converse of this is not true, as it might be expected to be, of the 
opposite condition. A deficiency in the whole mass of blood contained in, and 
circulating through the body, does not protect the parts of the body from conges- 
tion — from having an undue quantity of blood sent to them. Far from it. Local 
determinations of blood are very common in persons in whom the mass of that 
fluid, and the proportion of its nutritive materials, have been considerably dimi- 
nished by disease, or by hemorrhage. 

This remarkable tendency, under such circumstances, to an unequal distribution 
of the blood in the capillaries, admits (I think) of this explanation. A due supply 
of healthy blood is requisite for the steady and equable performance of the functions 
of the brain and nerves. When this supply is defective, or uncertain, those functions 
become disordered and irregular, and, in their turn, influence the various solids, 
disturb their action, and derange the balance of the circulation. That the capil- 
lary blood-vessels may be filled to excess, or completely emptied, by causes ope- 
rating through the nervous system — by moral emotions, for example — we are 
sure from the phenomena just now adverted to, the blush of shame or anger, the 
paleness of fear; and there can be no doubt that morbid congestions, which 
sometimes are separated from those that are consistent with health by very slight 
shades of difference, are often determined through the agency of the same ner- 
vous system. And persons endowed with great sensibility or irritability of the 
nervous system are very liable to partial and irregular congestions of blood. 

But this is not the only way in which local congestion may arise. 

We can produce it, upon the surface of the body at least, at pleasure, and that 
in various ways ; by friction, by exposing the parts to a high temperature, by 
certain stimulating applications, mechanical (as a cupping-glass), or chemical (as 
a mustard poultice): we produce an injection of the small cutaneous blood-ves- 
sels ; there is, evidently, more than the usual quantity of blood attracted to the 
part, or detained in the part— a degree of redness, which soon subsides if the 
cause of it be withdrawn in time. 



LOCAL PLETHORA. 



45 



Congestion thus occasioned is not inflammation, but it is the first obvious step 
towards that complex process; and for this reason it deserves all your attention. 
Apply the exciting cause a little longer, or increase, in a slight degree, its inten- 
sity, and the phenomena of inflammation begin to manifest themselves. 

I said we can produce local congestion when we please upon the surface of 
the body ; but there can be no doubt that a similar state may be produced by 
analogous causes, in internal parts. Look at this representation of the stomach 
of a dog {one of Dr. RoupeWs plates). You see one portion of it of a bright red 
colour, actively and vividly congested. This was the consequence of a dose of 
alcohol. We may be certain that something of the same kind is the result of 
every visit to the gin shop. 

Local congestion thus produced, or of this kind, is said to be active. M. 
Andral, whose nomenclature has come much into fashion of late years, calls it 
sthenic, or active hyperemia. The arteries, perhaps, have more to do with it, 
in the first instance, than the veins. But it is in the capillary vessels, which are 
distinct from, and interposed between the minute arteries and veins, that further 
changes are wrought, when the process advances a stage beyond mere local ple- 
thora. What has been observed, by the aid of the microscope, with respect to 
the blood-vessels, I will endeavour to describe to you. 

I take the account I am about to give you chiefly from Kaltenbrunner, a Ger- 
man pathologist, who has recently investigated the subject experimentally, and 
whose observations are believed to have been most carefully and skilfully con- 
ducted, and their results no less faithfully narrated. His observations were made 
upon the circulation as it appeared in the web of a frog's foot, under a powerful 
microscope. It would be idle, and something like committing a fraud upon you, 
were I to lay any stress upon my own knowledge or experience in this matter, 
for I cannot pretend to any great skill in the use of that instrument, and my op- 
portunities of noticing, by its help, the phenomena of the circulation, have been 
too few to render their results of much value. Yet it may be in some degree 
satisfactory to you to know that I am not blindly repeating the remarks of others, 
and that what I have witnessed is perfectly in accordance with the statements of 
Kaltenbrunner, and affords me a strong assurance of his accuracy and fidelity. 
There is another reason, too, why I consider him the more trustworthy — he has 
no theories to which he might be disposed to bend or accommodate his facts. 

Before I detail to you his account of the phenomena of congestion, I may 
briefly describe the scene which presents itself when the web of a frog's foot is 
looked at through a good microscope. It is a most beautiful and wonderful spec- 
tacle, and particularly interesting to those who, like ourselves, are desirous of 
gaining some insight into the healthy and diseased states of the circulation. It is 
a sight which I hope and believe you also will have many opportunities of seeing 
in this place. You perceive, then, occupying the circular field of the instrument, 
a number of blood-vessels, through which the blood, with its globules, is in active 
motion : and you see at once that there are three different kinds of vessels before 
you. First, you notice the blood shooting with great velocity along tubes which 
divide and subdivide into smaller and smaller branches, each branch (speaking 
generally) going off at an obtuse angle : these are plainly arteries. Then, in an- 
other part of the field of view, you see the blood moving in the contrary direction, 
more slowly, in larger trunks, which are formed by the continual union and 
accession of smaller and tributary vessels of the same kind, that meet, for the 
most part, at acute angles : these you know to be veins ; and all the intermediate 
and surrounding surface in view is occupied with other vessels or channels, which 
connect themselves with the ultimate ramifications of the arteries on the one hand, 
and with the primary radicles of the veins on the other, but which differ from 
both arteries and veins in these particulars — that they interlace and anastomose in 
all parts, in a very irregular manner, and at all angles, and that they retain every- 
where the same uniform size ; they neither collect into larger and larger trunks, 
nor separate into smaller and smaller branches, but are disposed like the threads 



46 



ACTIVE CONGESTION. 



forming the meshes of a net, except that the interstices are irregular in size and 
shape. These are the true capillaries, intermediate between the arteries and the 
veins, and perfectly distinct in character from each, but communicating and con- 
tinuous with both. 

If now you press upon the animal's leg, so as to obstruct the circulation a lit- 
tle, the motion of the blood is retarded, especially in the capillaries. You see the 
red globules slowly following one another. These so-called globules are not 
really little spheres, but circular discs, or flat cells. You may sometimes see one 
of them sticking to the side of a capillary channel, and damming up the current; 
other globules accumulate behind it, till at last they all pass on again together. 

Now Kaltenbrunner irritates the web by pricking it, and soon afterwards the 
following appearances present themselves : — There is an increased afflux of blood 
to the part, so that arteries, veins and capillaries receive a column of blood two 
or three times as great as usual ; the velocity of the blood is accelerated ; the dis- 
tended sides of the vessels seem to tighten round the stream of blood which they 
contain. With this alteration of the circulation, the natural functions of the part 
begin to be modified. The change of the blood from arterial to venous is inter- 
rupted. The globules, passing with great rapidity through all the vessels, retain 
the characters of arterial globules even when they arrive at the veins ; they pre- 
sent a bright colour, show a tendency to stick together, and often form little clots, 
which pass through the capillaries and become visible in the veins. 

One of the natural functions of the web is the secretion of a kind of lymph ; 
but this secretion is now suspended. The parenchyma itself begins to be slightly 
tumid, and assumes a brighter tint than common. 

All these phenomena begin from a circumscribed spot, of which the circumfer- 
ence gradually expands as the affection increases ; and they cease insensibly at 
that circumference. 

This is active congestion. 

A certain period always intervenes between the first action of the irritant cause, 
and the commencement of true congestion. This period, the occurrence of which 
you will be good enough to bear in mind, Kaltenbrunner calls the period of incu- 
bation; the period in which the congestion is hatching. 

Active congestion, as such, does not continue long. It either passes on into 
inflammation, as I shall hereafter explain, or it begins to decrease. When it has 
been very slight, the quantity of blood, and the rapidity of its movement, diminish 
gradually from the circumference towards the centre; and in this way the conges- 
tion insensibly vanishes. 

But, in other cases, when it has not been so slight, the congestion terminates 
by an evident crisis, which Kaltenbrunner thus describes : — The blood, receding 
from the circumference of the congested part towards the centre, gives out, by 
exhalation, a liquid. The exhalation takes place by fits, and here and there, 
through the sides of the capillary tubes, and generally on the surface of the organ. 
The moment of exhalation is very transient; but it is repeated often, and in dif- 
ferent spots, until the congestion has disappeared. It is evidently critical, for the 
congestion is relieved and extinguished in proportion as the exhalation is repeated. 

I shall follow these consequences of active and continued local congestion no 
further at present; but merely remind you again that the changes I have last 
mentioned constitute the earliest appreciable modification of structure leading or 
belonging to inflammation. What we thus may see (and it is what I myself have 
had some opportunities of seeing) in the transparent textures of animals, we rea- 
sonably infer to take place, under analogous circumstances, in those parts of the 
body which are internal and opaque, and consequently hidden from our view. 

I will just observe, also, that as active congestion is the parent of inflammation, 
so it sometimes causes hemorrhage, and is relieved by it. But, comparing this 
form of congestion with another which I am about to meution, the connection of 
hemorrhage with it is, relatively, unfrequent. 

One obvious mode of remedying this congestion is the mechanical abstraction 



PASSIVE CONGESTION. 



47 



of blood from the loaded part. But it is seldom that this measure alone suffices ; 
and sometimes it would be ultimately hurtful to adopt it. The state of the con- 
stitution may be such, that the disposition to local plethora would be increased by 
the loss of blood. Undue susceptibility and disordered action of the nervous 
system are apt to be aggravated by bleeding; and in proportion as the nervous 
functions are irregularly performed, does the tendency to unequal distribution of 
blood in the capillary vessels augment. We have daily examples of this in 
hysterical young women. It is not, therefore, the mere congestion that we have 
to consider ; we must look deeper, for its cause. Leave a small thorn in the 
finger: the blood will be collected there in consequence of its irritation, and will 
continue to collect in spite of depletion. But extract the thorn, and your remedial 
measure of taking away blood is at once successful. So it is also with internal 
congestions of blood — of which the exciting and sustaining cause is not always so 
well known. 

Contrasted, in some important particulars, with active congestion such as I have 
been describing, is that morbid fullness of the capillary vessels which arises when 
the return of the blood from them towards the heart through the veins, is impeded 
by some mechanical obstacle. With this mechanical congestion the veins are 
exclusively concerned. 

Congestion of this kind may be strictly local. It may be confined to a single 
limb, when the principal venous trunk belonging to that limb is compressed, or 
otherwise diminished in size ; and when no collateral and compensatory channels 
for the returning blood have been established. If there be disease of the liver, of 
such a nature as to prevent a free passage of the blood through that organ, con- 
gestion will ensue in all those parts of the capillary system from which the blood 
is conveyed by the veins that ultimately concur to form the vena portae. The 
force of gravity alone is sufficient to produce venous congestion, and consequently 
congestion of the capillaries, in parts of the body in which, under ordinary cir- 
cumstances, the circulation through the veins is aided, instead of being opposed, 
by that force. If, for instance, the head be suffered to hang downwards for a 
certain time, we see the unequivocal signs of such congestion in the tumid condi- 
tion and the purplish red colour of the lips, cheeks, eyelids, and ears. When an 
impediment to the free transmission of blood exists in the heart itself, a tendency 
to stagnation is produced, first in the venae cavae, then in the smaller ramifications 
by which these veins are fed, and at length in the general system of capillary 
vessels ; and thus even general congestion may proceed from a fixed mechanical 
cause; the parts that are the most vascular being also the most readily and the 
most completely gorged. 

There is yet a third form of local congestion, differing, in some respects, both 
from active and from mechanical congestion. The capillaries become loaded, 
and the course of the blood in them is languid and sluggish, without any previous 
increased velocity of the blood in the arteries, and independently of any mechani- 
cal obstacle in the veins. To this form of congestion the term passive is applied. 
Andral denominates it passive or asthenic hyperaemia. I will tell you the class 
of facts from the observation of which the real existence of this passive plethora 
has been ascertained. 

In persons enfeebled by age, or by disease, the lower parts of the legs, the 
insteps and ankles, and the skin which forms the surface of old scars, are often 
habitually purplish, or violet coloured. There is congestion of dark blood in 
those parts. You may, perhaps, be ready to ascribe this to the mere influence 
of gravity upon the blood, but this cannot be the whole explanation, because the 
force of gravity is the same with all persons, and at all ages. A horizontal posi- 
tion of the limb will perhaps diminish the livid redness, or may even sometimes 
entirely remove it. But the depending position ought not to cause it, and would 
not cause it, if the blood-vessels were in a healthy condition. Neither can the 
difference of posture be any source of irritation to the congested part. The 
capillaries themselves appear to have lost, in a great degree, their natural elasti- 



48 



PASSIVE CONGESTION. 



city ; they easily dilate under the pressure of the blood, which, being thus retarded, 
accumulates in the part. The employment of friction, or some stimulating appli- 
cation, will often remove this congestion. 

I say all this is often to be noticed when there has been no cause of irritation 
operating upon the part, and no preceding state of active congestion. But it is 
important to mark the very frequent connection that exists between these con- 
trasted conditions. The one very often succeeds the other: the vessels become 
dilated under the force of the active hyperemia, and, the irritation ceasing, they 
do not at once recover their tone, but remain passively loaded and distended. 
They are frequently left in the same state upon the subsidence of inflammation. 

Take another illustration from what you may any day witness in respect to 
indolent ulcers. You will find that the large, flabby, and livid granulations which 
they present, may be made to contract, and to assume a more healthy and florid 
hue, by local stimulants: these evidently act by quickening the previously languid 
circulation, and unloading the congested capillaries. 

Observe, again, what not unfrequently happens in regard to the eye ; a little 
organ, indeed, but one that supplies us with more striking lessons in pathology 
and therapeutics than any other portion of the body. You know that the con- 
junctiva and sclerotica, through which, while healthy, colourless fluids alone 
circulate, are traversed, under various forms of disease, by innumerable vessels 
bearing red blood. Now it is notorious that, in certain cases, the application of 
any stimulating substance to the surface of the organ will increase the existing 
redness, multiply the number of visible vessels, and aggravate the complaint. 
These are cases of active congestion, dependent upon irritation that is still sub- 
sisting. But it is equally well known to practical men that the blood-vessels of 
the eye are liable to congestion of a very different kind. They are seen to be 
distended, somewhat tortuous, almost varicose, and the redness has a browner 
tinge, and is less vivid, than in the former case. In this kind of vascular fullness, 
— or in this stage of it, for it sometimes succeeds to active congestion, — emollient 
applications do harm rather than good, while strongly astringent and even irritant 
substances will often promptly dissipate the vascularity. These, again, are cases 
illustrative of congestion of the asthenic or passive character. The strong topical 
irritants restore to the feeble and relaxed vessels their natural elasticity, stimulate 
them to contract upon their contents, and to force onward the red blood, which 
they cease to admit from the arteries ; and the redness vanishes. 

In the production of active congestion the arteries appear to be principally con- 
cerned : in the production of mechanical congestion, the veins : in passive con- 
gestion, the capillaries — which, strictly, are neither arteries nor veins, but lie 
between the arteries and the veins — are the vessels chiefly in fault. 

If we turn our thoughts from the visible textures of the body to those which 
are hidden internally, we shall find reason to believe that these also are equally 
liable to similar conditions of passive congestion. Take those exceedingly vas- 
cular organs, the lungs, through which the whole of the blood circulating in the 
living body has to pass. The lungs, as might be expected, are very liable to 
congestion and engorgement of their capillary vessels. Oft-times this is clearly 
active, and the result of some irritating cause. But it is not always so. Many 
of you recollect the epidemic disorder called the influenza, which was so preva- 
lent here in the spring of 1831, and again in the early part of 1837. Among the 
most constant and striking characters of the disease were the symptoms of pulmo- 
nary catarrh ; and it was remarkable how long, in some persons, these symptoms 
persisted. After the pulse had regained its natural frequency of beat, and when 
all fever had ceased, the patient would continue to breathe with constraint and 
some labour, to wheeze a little, to cough, and to expectorate mucus. As all 
febrile disturbance had subsided, and no further benefit seemed to flow from 
adhering to what is called the antiphlogistic system, it was a reasonable conjec- 
ture that this disappointing obstinacy of some of the symptoms might depend 
upon a lingering but passive congestion of the pulmonary mucous membrane. 



PASSIVE CONGESTION. 



49 



And the nature of the juvantia showed the correctness of this conjecture. Tonics 
and stimulants, so far from aggravating the pectoral symptoms, speedily removed 
or abated them. 

You cannot fail, I think, to perceive the important bearing of these distinctions 
between active and passive congestion upon our notions of disease and our choice 
of remedies. These distinctions are not to be discovered by the knife of the 
anatomist. You must take care not to confound a knowledge of pathology, in 
the proper sense of that word, with a knowledge of morbid anatomy. Pathology 
comprehends not only the visible changes of structure which accompany disease, 
and are disclosed by death, but the processes by which those changes are effected 
in the living body, and the laws which govern those processes. 

There is one important law ascertained in respect to both active and passive 
congestion ; viz., that it is apt to recur; that those parts are most likely to suffer it 
(or inflammation, which implies itj that have suffered it before. We may often 
turn our knowledge of this general fact to good account, in what is termed the 
prophylaxis of disease — in devising means for warding off disorders. 

I have stated that active and passive congestion sometimes occur in succession, 
the latter being a sequel of the former. So, also, it may be said of passive and of 
mechanical congestion, that they often exist together. If the capillaries of a part 
or organ be much enfeebled, the mechanical effect of the gravity of the blood may 
suffice to bring them into a state of congestion. It is thus that Andral explains 
the occurrence of a gorged condition of the posterior portions of the lungs (evinced 
by symptoms during life, as well as by inspection of those parts after death), in 
persons who, having laboured under no previous pulmonary affection, have been 
confined to a supine position by long-continued disease or debility. This state 
of the capillaries is called by Lerminier the " engorgement of position ;" and by 
Laennec, " the pneumonia of the dying." It neither proceeds from irritation, 
nor has it the essential characters of inflammation ; although it is apt to be con- 
sidered an evidence of inflammation by the mere morbid anatomist. 

Again, as active congestion, when continued or intense, is antecedent and con- 
ducive to inflammation, so is mechanical congestion, when it reaches a certain 
point, the prolific source of hemorrhage, and the almost constant precursor and 
immediate cause of a large class of dropsical accumulations. 

I spoke a little while ago of general plethora, as a state in which the whole 
mass of blood circulating in the body is excessive in quantity, and rich in quality 
— full of fibrin and of colouring matter, thick with globules. But the blood, as a 
mass, may be in excessive quantity, yet poor in its materials, serous, deficient in 
globules, and fibrin, and colour; and in this condition of the blood, also, as we 
shall hereafter see, dropsies are apt to arise. 

We have now, therefore, laid the foundation for the better understanding of 
those three great classes of disease — Inflammations, Hemorrhages, and Dropsies. 

There is no region or organ of the body exempt from these diseased conditions 
and their consequences ; and of each of them some general account must be given, 
before we come to consider the special diseases incident to the several parts and 
organs. 

But previously to entering upon this general account of inflammation, of hemor- 
rhage, and of dropsy, we have still some other preliminary matters of importance 
to discuss. The causes and modes of death. The causes of disease. A sketch 
of the nature, classification, and import of symptoms. 

Our inquiries hitherto have related to the manner in which the physical con- 
ditions of the various parts of the body are capable of being altered, and their 
functions disturbed or suspended, in disease. But how it happens that some of 
these alterations of structure, or interruptions of function, are incompatible with 
the further continuance of life, and put a stop to the working of the whole 
machine, is an inquiry of no less interest, though of a somewhat different kind. 



4 



50 



CONDITIONS OF LIFE. 



LECTUREV. 

Different modes of dying. Pathology of Sudden Death. Death by Anxmia ; 
its Course, Phenomena, and Anatomical Characters. Death by Asthenia ; its 
Course, Phenomena, and Anatomical Characters. Syncope. Death by 
Inanition. Death by Apnoea: Death by Coma: their Course, and Phe- 
nomena, and the Anatomical Characters common to both. Application of the 
Principles obtained from- the investigation of the Phenomena of Sudden Death t 
in elucidating the Symptoms and Tendencies of Disease. 

I propose to devote the present lecture to the following inquiry : — Wherefore it 
is, and how it is, that some of the corporeal changes which we have been con- 
sidering, or the diseased conditions connected with those changes, come to be 
incompatible with the further continuance of life ? how it is that they put an end to 
the working of the living animal machine? why the machine should not continue 
to work, though perhaps imperfectly, notwithstanding such changes ? 

When our watches stop, we take them to a watchmaker to ascertain why they 
have stopped. The watchmaker knows that there are various ways in which the 
movements of the instrument may have been arrested. The main spring may 
have broken ; or the little chain that connects the barrel with the fusee may have 
parted ; or the teeth of some of the wheels may liave become inextricably entan- 
gled; or the watch may have ceased to go (as the saying is) simply because it 
has not been wound up. Now the examination which the watchmaker undertakes 
in respect to the watch, I am desirous of making in respect to the human body. 
I am going to inquire into the several processes and modes of dying — the steps, 
or ways, by which the vital functions of the body are extinguished. A very little 
experience in the sick chamber, or in the wards of a hospital, will suffice to teach 
you that, although all men must die, all do not die in the same manner. In one 
instance the thread of existence is suddenly snapped; the passage from life, and 
apparent health perhaps, to the condition of a corpse, is made in a moment: in 
another the process of dissolution is slow and tedious, and we scarcely know the 
precise instant in which the solemn change is completed. One man retains pos- 
session of his intellect up to his latest breath: another lies unconscious, and 
insensible to all outward impressions, for hours or days before the struggle is 
over. 

We seek to ascertain the laws and mechanism of these mysterious differences. 

The inquiry is not one of merely curious interest, but has a direct bearing upon 
the proper treatment of disease. It will teach us what we have to guard against, 
what we must strive to avert, in different cases. In speaking of particular dis- 
eases, I shall constantly refer to the facts and reasonings which I am now about 
to lay before you. 

In pursuing this inquiry, we need not go into any deep physiological disquisi- 
tion respecting the conditions that are essential to life. It is sufficient for our 
purpose to remark that life is inseparably connected with the continued circulation 
of the blood. So long as the circulation goes on, life, organic life at least, remains. 
When the blood no longer circulates, life is presently extinct: and our investigation 
of the different modes of dying resolves itself into an investigation of the different 
ways in which the circulation of the blood may be brought to a stand. 

Observe the ample provision that is made, in the construction of the body, for 
carrying on and maintaining this essential function. First, there is an extensive 
hydraulie apparatus distributed throughout the frame, and consisting of the heart 
and other blood-vessels. Next, there is a large pneumatic machine, forming a 
considerable part of the whole body, and composed of the lungs, and the case in 
which they are lodged. Lastly, the power by which this machine is to be worked 



PATHOLOGY OF SUDDEN DEATH. 



51 



and regulated is vested in the nervous system. Each of these systems must con- 
tinue in action, or the circulation will stop, and life will come to an end. The 
functions they respectively perform are, consequently, called vital functions: and 
their main organs — the heart, the lungs, the brain (by which I understand the 
intercranial nervous mass) — are denominated vital organs. The functions of any 
one of the three being arrested, the functions of the other two are also speedily 
extinguished. But the phenomena of dying vary remarkably according as the 
interruption beains in the one or the other organ. Hence Bichat, who in his 
Recherches sur la vie et la mort, laid the foundation of the distinctions I am about 
to describe, spoke of death beginning at the head, death beginning at the heart, 
and death beginning at the lungs. This nomenclature is, however, unsatisfactory 
and insufficient, as you will presently perceive. 

That the heart may continue to propel the current of the blood two things are 
necessary : first, a certain power or faculty of contraction ; and, secondly, a suffi- 
cient quantity of blood in its chambers, to be moved, and also to stimulate them 
to contract. If this, the proper stimulus to the internal surfaces of the heart, be 
•withheld, or much deficient, it will soon cease to beat. There are plainly, there- 
fore, two ways in which death might be said to begin at the heart; and these require 
to be distinguished. 

The respiration is entirely subservient to the circulation of the blood. The 
two organs, the heart and lungs, respond intimately to each other. The whole 
of the blood is sent by the right heart to the lungs, simply that it may there be 
submitted to the chemical action of the atmosphere. The respiratory apparatus 
is added to the body for the sole purpose of thus repeatedly ventilating the blood. 

To this purpose also (setting aside all accidental impediments) two things are 
requisite ; first, circumfused air to enter and depart at short intervals; and, se- 
condly, alternating movements of the chest to cause its entrance and exit. 

Now these movements, although they admit of being regulated by the will, are 
essentially involuntary. The ordinary acts of respiration depend upon a certain 
condition of the medulla oblongata. If this condition fails, the mechanical part 
of the respiratory process, and, consequently, the chemical part also, ceases. 

The respiration hangs, therefore, directly upon the nervous system. 

On the other hand, the action of the heart is not directly or necessarily depend- 
ent upon any constant nervous influence conveyed to it. The circulation goes on 
in an acephalous foetus; it may be kept up, by maintaining artificial respiration, 
in a decapitated animal : nay, even when both brain and spinal cord have been 
abstracted from the body. 

But though the nervous influence is not necessary to the movements of the 
heart — further than as it is necessary to the respiration, and to the introduction of 
nutriment — it has been clearly ascertained that very sudden and extensive injury 
or shock to the nervous system may instantly paralyze the heart, and so stop its 
action. 

There are certain states, then, of the brain and nerves which, without directly 
affecting the heart, bring the motions of respiration to a pause : and there are 
certain states of the brain and nerves which act directly on the heart and arrest 
its play. That is, there are two different ways in which death might be said to 
begin at the head. 

Hence, I say, the nomenclature employed by Bichat is defective and inaccurate. 

In order to see clearly the steps by which the circulation, and with it life, 
finally terminates, in the various forms of dying, we must study the problem 
under its simplest forms. We must examine the cases in which the vital func- 
tions are, each in their turn, suddenly stopped, by some known cause, operating 
upon this or that vital organ. We must take advantage of the experiment (if I 
may so call it) which is performed before our eyes whenever a healthy man is 
cut off at once by external violence, or by poison, acting directly upon a par- 
ticular organ or system of organs. The inquiry might be assisted, and, indeed, 
it has been mainly carried on, by experiments made upon living animals of a 



52 



DEATH BY ASTHENIA. 



similar conformation with man. But the pathology of sudden death is happily 
now too well understood to require any further recurrence to that painful mode 
of " interrogating nature." 

Death, as it takes place in disease, is usually complicated. Many parts are 
affected, and different functions languish, and various disturbing causes are in 
operation, at the same time. Occasionally, however, the process of dissolution 
is as simple and obvious as in death produced by violence ; and in most cases 
some primary and predominant derangement may be traced of this or that vital 
function ; and a tendency is more or less clearly manifest to one or the other of 
the modes of dying, which we may now proceed to consider in succession. 

And first let us examine that form of death which is caused by a want of the 
due supply of blood to the heart. This is called, with much propriety, death by 
anaemia. 

The best examples of death taking place in this way are those in which it is 
the consequence of sudden and profuse hemorrhage. The circulation fails, not 
because the heart has lost its power of contraction, but because blood does not 
arrive in its chambers in sufficient quantity. 

We assure ourselves of this in two ways. In the first place, when the body of 
an animal is examined immediately after death from sudden and copious loss of 
blood, the heart is not found dilated and full of blood, as it would be if it had 
ceased to act from a want of power to contract upon its contents ; but it is found 
empty, or nearly so, and contracted. Secondly: this conclusion is confirmed by 
the reverse experiment: by the effect, I mean, of the transfusion of blood. It is 
a fact well ascertained, first by experiments made upon animals, and afterwards 
by most happy trials upon the human subject, that in cases of apparent death 
• from violent hemorrhage the suspended functions may be restored by conveying 
a timely supply of blood into the vessels of the seemingly dead animal from the 
veins of a living animal of the same species. Now it is quite clear that this intro- 
duction of fresh blood could be of no avail in a case where the heart was unable 
to act upon the blood which had already reached it. 

The phenomena which attend this mode of dying are paleness of the counte- 
nance and lips, cold sweats, dimness of vision, dilated pupils, vertigo, a slow 
weak irregular pulse, and speedy insensibility. With these symptoms are fre- 
quently conjoined nausea, and even vomiting, restlessness and tossing of the 
limbs, transient delirium: the breathing is irregular, sighing, and, at last, gasping; 
and convulsions generally occur, and are once or twice repeated, before the scene 
closes. 

It is thus that women often die, in whom " flooding" happens after childbirth. 
Sometimes the sudden bursting of an aneurism occasions this form of death. It 
is common on the field of battle, and in accidental injuries whereby large blood- 
vessels are wounded. Internal hemorrhage, depending upon diseases to be here- 
after described, may also prove fatal in the same manner. 

This, then, is one form of death beginning at the heart. Another form, the 
converse of this, but spoken of also as death beginning at the heart, is that in 
which there is no deficiency of the proper stimulus to the heart's action, but a 
total failure of contractile power in that organ. This is well denominated death 
by asthenia. \ 

Death occurring in this way is not uncommon. The effects of some kinds of 
poison furnish a good illustration of it. There are certain substances which, ap- 
plied to some part or other of the body, speedily extinguish life : and when, after 
their fatal operation, the thorax is opened, each chamber of the heart is found to 
be filled with its proper stimulus, upon which it has been unable to contract. 

This was distinctly made out by Sir Benjamin Brodie, in his able and scientific 
investigation of the effects of different poisons. You may read with advantage 
his papers on this subject in the Philosophical Transactions for 1811 and 1812. 
He ascertained upon examining the chest after death occasioned by the upas an- 
tiar, that the heart was not empty, but full, there being purple blood in its right, 



DEATH BY INANITION. 



53 



and scarlet blood in its left cavities. These are the anatomical characters of this 
kind of death ; and they prove that the action of the heart does not cease from a 
defect of stimulus, but from a loss of its contractile power. 

The state of suspended animation common to both these forms of dying — (the 
ultimate external phenomena being nearly the same in each, and the result in 
each being the simple failure of the circulation) — is often expressed by the term 
syncope. 

Besides the essential distinctions between them already mentioned, there is 
this further point of difference. In death by anaemia, the suspension of the func- 
tions of the nervous system arises from a lack of blood which should be sent to 
the brain from the heart. Hence the well-known effect of mere position. Syn- 
cope is sooner produced by venesection when the person bled is sitting up than 
when he is recumbent : and the first remedy for the fainting state is to lay the 
patient flat upon the ground, or even to place his head a little lower than the trunk 
of his body. Tn the one posture the current of the blood towards the head is 
impeded by the force of gravity ; in the other it is not. In sudden death by 
asthenia this order is reversed; the nervous system is the part first affected, and 
through it, consecutively, the heart. This appears from the fact that sudden 
death by asthenia is sometimes produced by causes which we know to act pri- 
marily upon and through the nervous system ; by strong mental emotion — as 
intense grief, joy, terror. Cases of fatal concussion, where the brain is jarred by 
some bodily shock — and death occurring almost instantly from blows on the 
epigastrium — are of this kind. Lightning and electricity kill too, when they kill 
at all, in the same way. And we shall hereafter see that certain varieties of 
apoplexy, and several other diseased conditions, destroy life by suddenly arresting 
the contractile power of the heart. 

When death by asthenia occurs more slowly, from disease, the phenomena 
are somewhat different. The pulse becomes very feeble and frequent, and the 
muscular debility extreme ; but the senses are perfect, the hearing is sometimes 
even painfully acute, and the intellect remains clear to the last. The tendency 
to death of this form is remarkably manifest in acute inflammation of the perito- 
neum., in what is called malignant cholera, and in cases of extensive mortification. 

Akin to this form of dying is that in which the living powers are slowly ex- 
hausted by lingering and wasting disorders, as in many cases of phthisis, in dia- 
betes, and in dysentery; or by hemorrhages moderate in amount, but frequently 
repeated; or by any other long-continued drain upon the system. The death is 
partly, however, to be ascribed to a deficient supply of the natural stimulus to 
the heart's action. The type of these mixed modes of dying is seen in death by 
starvation, which may be considered intermediate between death by anaemia, and 
death by asthenia. Death from inanition can never be sudden. The blood, 
renewed no longer from without, and fed only by absorption from the system 
itself, diminishes gradually in quantity, while its quality deteriorates. Gradually 
also the contractile power of the heart, as well as of the muscles generally, is 
weakened ; and from these combined causes its movements at length cease. Ac- 
cordingly after death by starvation the heart is not found to be so much contracted, 
nor so nearly empty, as after death by sudden and copious hemorrhage. 

Certain diseases of the throat or the oesophagus, prohibiting the introduction 
of food ; of the stomach, preventing its retention ; of the digestive organs gene- 
rally, hindering its assimilation, are fatal in this manner. 

We have yet to consider how death is produced by the suspension of the 
respiratory function — in other words, by a want of the due arterialization of the 
blood. 

There are two perfectly distinct modes in which this cause of death may 
happen ; distinct, i. e., in regard to the steps of the process, although identical in 
regard to the ultimate result. 

1. When the access of air to the lungs is suddenly denied by some direct 
obstacle to its entrance. 



54 



DEATH BY APNCEA. 



2. When the muscular actions required for breathing cease in consequence of 
insensibility, caused by disease or injury of the brain. 

The first of these two forms of dying is commonly called death by asphyxia. 
The second is conveniently termed death by coma. Bichat spoke of them respect- 
ively as death beginning at the lungs, and at the head. 

It is of much importance to get rid, when we can, of improper names. They 
are very apt to warp our notions concerning the real nature of the things they are 
intended to express. This term asphyxia, which is in every body's month, is 
very inappropriate, if we look to its etymology, to the kind of death which it has 
come to denote. It signifies, you know, literally, pulselessness, the want of pulse ; 
and therefore it might express any kind of death whatever; or if applied to any 
particular mode of dying, it would seem to belong to that we have just been con- 
sidering, namely, death beginning at the heart. And you will presently see that 
it is peculiarly inapplicable to all those cases where death results from the non- 
arterialization of the venous blood. Its current signification has, I am afraid, been 
too long established by custom, to allow of its being restored to its proper mean- 
ing without much confusion. But, at any rate, I can and shall avoid its use, and 
adopt in preference the generic term apncea (privation of breath) as justly expres- 
sive of the mode of death to which the word asphyxia is commonly given by 
authors. The generic English term is suffocation. 

The entrance of air into the lungs may be prevented in various ways : by 
stoppage of the mouth and nostrils [smothering): — by submersion of the same 
inlets in some liquid (drowning) ; or in gases which, though not in themselves 
poisonous, contain no oxygen; such are hydrogen and azote: — by mechanical 
obstruction of the larynx or trachea from within, as by a morsel of food (choking), 
or from without, as by the bowstring (strangulation ; both these varieties are 
included in the term throttling): — by forcible pressure made at once upon the 
chest and abdomen, preventing all movement of the ribs and of the diaphragm ; 
this happens sometimes to workmen employed in excavating, who are buried, 
their heads excepted, by the falling of a mass of earth ; it was near happening, 
Dr. Roget tells us, to an athletic black man, of whose body a cast was attempted to 
be taken, as an academic model, by one operation, and in one entire piece. " As 
soon as the plaster began to set, he felt on a sudden, deprived of the power of 
respiration, and to add to his misfortune, was cut off from the means of expressing 
his distress; his situation was perceived just in time to save his life;" in this 
way the victims of Burke and Hare were stifled; and the same immovable state 
of the lung-case is sometimes produced in tetanus, or by the poisonous influence 
of strychnine, all the respiratory muscles being fixed in rigid spasm : — by para- 
lysis of the same muscles, from injury or disease of the spinal cord above the 
origin of the nerves that give off the phrenic nerve, and therefore above the origin 
af the intercostal nerves also; or from section of the phrenic and intercostal nerves: 
— lastly, by such breaches in the walls of the thorax as admit air freely to the 
surface of both lungs, and spoil the pneumatic machine, as a pair of bellows is 
spoiled when deprived of its valve. Of course the same consequences ensue when 
both pleurae become filled with liquid of any kind. 

Whenever the privation of air is sudden and complete, the following external 
phenomena present themselves. — Strong but vain contractions occur of all the 
muscles concerned in breathing, and struggling efforts to respire are made, 
prompted by that uneasy sensation which every one has experienced who has 
tried how long he can hold his breath, and which, when unappeased, soon rises 
to agony: this extreme distress is transient, being almost immediately succeeded 
by sensations, not unpleasant, of vertigo, and then by loss of consciousness, and 
convulsions: at length all effort ceases, a few irregular twichings or tremors of 
the limbs alone perhaps remaining; the muscles relax, and the sphincters yield; 
but still the movements of the heart, and even the pulse at the wrist, continue for 
a short time after all other signs of life are over; there is no asphyxia (properly 
so called) till the very last 



DEATH BY APNCEA. 



55 



During this process, which does not occupy more than two or three minutes, 
the face at first becomes flushed and turgid, ihen livid and purplish, the veins of 
the head and neck swell, and the eyeballs seem to protrude from their sockets; at 
length the heart ceases to palpitate, and life is extinct. 

The internal changes which correspond with, and cause these outward symp- 
toms, have been carefully studied, and accurately, though slowly and lately ascer- 
tained. They all proceed from the prevention of the chemical alteration naturally 
produced in the blood, within the capillary vessels of the lungs. The blood, 
continuing venous, passes at first in considerable quantity through the pulmonary 
veins, into the left side of the heart, and thence through the arteries, to all parts 
of the body. This venous blood, however, is inadequate to sustain, or sufficiently 
to excite, the functions of the parts it thus reaches. In the brain the effect of the 
unnatural circulation is felt at once ; and shown by the convulsions and insensi- 
bility that ensue. The motion of the blood in the pulmonary capillaries is also, 
from the first, impeded, and its current gradually retarded, until it stagnates alto- 
gether ; the lungs remaining full, the right chambers of the heart distended, and 
therefore less capable of contracting. Meanwhile the black blood, flowing more 
and more tardily and scantily into the left chambers, leads, by its unnatural quality, 
as well as its deficient supply, to feeble contractions ; and this side of the heart 
is comparatively empty. 

In this state, even after the heart has ceased to beat, but not long after, if the 
cause which has excluded the air be withdrawn, and fresh air readmitted — in 
other words, if artificial respiration be instituted — the blood in the pulmonary 
capillaries undergoes the required change, becomes arterial, begins again to pass 
onwards, and by degrees the circulation is restored, and the patient saved. 

In this mode of death the circulation is first arrested, and death truly begins, 
in the lungs. 

When the carcass of an animal, that has thus perished of apnoea, is immedi- 
ately afterwards examined (so speedy an inspection of the human body being, 
for obvious reasons, seldom practicable or proper), the left side of the heart is 
found to contain a small quantity of dark blood, while its right cavities are greatly 
distended, and the lungs, the cavae, and the whole venous system, are gorged with 
blood of the same character. These are, in few words, the anatomical characters 
of sudden death by apnoea. 

The pathology of this mode of dying has, I say, been thoroughly understood 
only of late. It will not be uninteresting, and may, I think, be useful, to trace 
briefly the successive steps by which the true explanation has been attained. 
Haller was of opinion that the quiescence of the lungs, consequent upon the 
cessation of the alternate movements of the thorax, formed a mechanical impedi- 
ment to the further transit of blood through them ; and that death resulted from 
obstruction of the circulation in the lungs. He was partly right ; but he erred in 
supposing that the stream of blood was arrested absolutely, and at once, and by a 
a mechanical obstacle. Apnoea, with all its peculiar phenomena, occurs, when 
atmospheric air is excluded, although the lungs continue to play ; as in persons 
who breathe azote or hydrogen gas. It was clearly shown by Dr. Goodwyn, in 
his Essay upon the Connection of Life with Respiration, that the unaerated blood 
passed through the lungs and entered the left auricle and ventricle of the heart ; but 
he thought that it went no further. His notion was that arterial blood is the only 
stimulus which can excite the contraction of the left cavities of the heart, and that, 
when venous blood arrives in them, the organ becomes motionless; and no blood 
being sent to the brain, the person dies. Had this theory been true, the left 
chambers would be found full of blood after death (which they are not), and the 
mode of dying would not have differed essentially from that which we have already 
considered as death by asthenia. The well-devised experiments of Bichat carried 
the investigation a step further, and proved that the unaerated blood not only reached 
the heart, but was propelled by the contractions of that organ to every part of the 
body, through the arteries. Having applied a ligature upon the trachea of a living 



56 



DEATH BY APN(EA. 



animal, he made a small opening in one of its carotid arteries. Presently the 
slender stream of blood that issued began to lose its florid tint, and to assume the 
dark colour of venous blood ; but it continued to flow, and the afflux of this dark 
blood upon the brain was marked by convulsions and insensibility. Bichat con- 
ceived, therefore, the erroneous belief that the blood underwent no obstruction in 
its passage through the lungs, but that, remaining unpurified and venous, it acted 
as a poison upon every part to which it was carried by the arteries — first upon the 
nervous system, and ultimately (passing through the coronary arteries) upon the 
muscular substance of the heart itself. There are, however, two well-known 
facts, which, upon this theory, would be inexplicable — the comparative empti- 
ness of the left chambers of the heart, and the restoration of the suspended 
functions by the timely performance of artificial respiration. The air could never 
reach and revivify or depurate the venous blood, stagnating in the capillaries of 
the heart. It was reserved for Dr. Kay to correct the unsound parts of Bichat's 
doctrine, and to show that the blood begins to stagnate in the capillaries of the 
lungs, in consequence of its failing to undergo the change from venous to arterial ; 
and that the movements of the left heart are brought to an end, principally by the 
deficient supply of blood from the lungs. His experiments tend, moreover, to 
prove that venous blood circulating through the arteries has no directly poisonous 
operation, but is capable, though much less effectually than arterial blood, to sup- 
port, in some degree, the irritability of the muscles. A muscle will continue to 
contract longer when supplied with venous blood by its arteries, than when sup- 
plied with no blood at all. Doubtless, in death by apnoea, the movements of the 
heart are weakened, partly in consequence of the imperfect stimulus afforded by 
the venous blood that penetrates its substance ; but the main cause of the failure 
of the circulation seems to be the difficulty with which the non-arterialized blood 
finds its way through the capillaries of the lungs. This theory is consistent 
with all the phenomena observed. For a detailed account of the experiments and 
reasonings upon which Dr. Kay's conclusions are founded, I must refer you to his 
work on Asphyxia. 

Sudden death by apncea is not very often witnessed as the result of disease. It 
sometimes is caused by a spasmodic closure of the rima glottidis. It is no 
uncommon consequence of accidents, in which the upper cervical vertebras are 
broken or displaced. I have seen several instances of death rapidly produced, 
with all the symptoms of sudden suffocation, generally in intoxicated persons, in 
whom the chink of the glottis has been found closely plugged by a fragment of 
meat, which " had gone the wrong way." 

But there are numerous forms of more chronic disease, in which the tendency 
to death by apncea is plainly discernible, sometimes for a long while before their 
fatal termination arrives. And the phenomena are similar in character to those 
which are noticed when the struggle is short. We hear the patients complain of 
the " want of breath;" we see how they labour to satisfy this want, when it 
becomes urgent, by the elevated shoulders, the dilating nostrils, the energetic 
action of all the muscles that are auxiliary to the respiration ; we perceive by the 
dusky and loaded countenance, the livid lips, and ears, and eyelids, that the blood 
is but imperfectly arterialized. The diminished capability of such blood to support 
the functions of the brain is made evident by the vertiginous sensations, and the 
delirious thoughts of the gasping sufferers ; and after death we find the same 
distension of the right chambers of the heart, while the left are nearly empty — the 
same gorged condition of the pulmonary arteries and venous system generally, 
which constitute the anatomical characters of this mode of dying. These appear- 
ances are even more constantly visible in the dead body, when apncea has been 
gradually produced, than after sudden suffocation ; simply, I believe, because they 
are more permanent. After sudden death, however caused, the blood seldom 
coagulates ; and the venous turgescence consequent upon rapid apncea, although 
great at first, has time to subside and disappear before the body is examined. 

In protracted cases, death does not take place purely in the way of apncea ; the 



DEATH BY APNCEA. 



57 



heart is weakened, and the nervous influence impaired by the continued circula- 
tion of imperfectly arterialized blood; but the symptoms belonging to apncea are 
plainly predominant. 

When (as is most common) the privation of air is incomplete, and a scanty and 
insufficient supply is admitted, morbid changes take place in the lungs themselves ; 
the air-tubes and cells become charged with serous fluid, which operates as an 
additional cause of suffocation. The same phenomenon is observed when the 
par vagum is divided on both sides. 

Death by apncea in disease is extremely common. It maybe produced by any 
thing which narrows the chink of the glottis ; by warts that sometimes grow there, 
by oedema of the submucous tissue of the larynx, by inflammatory tumefaction of 
its lining membrane: it may result from the presence of what are called false 
membranes in the windpipe and bronchi, such as are formed in the distemper 
named croup: it may be the consequence of disease situate in the substance of the 
lungs themselves, rendering them incapable of receiving the requisite quantity of 
air; of this we have examples in pneumonia, and in pulmonary apoplexy: or it 
may proceed from disorders of the pulmonary mucous membrane, the air passages 
becoming blocked up with excessive and unnatural secretions, as in bronchitis. 
Phthisis is sometimes fatal in the way of apncea; more commonly it tends to 
death by asthenia. Diseases of the pleurae attended with effusion, and causing 
pressure upon the lungs ; diseases of the heart and great thoracic blood-vessels, 
affecting the quantity of blood in those organs ; even certain abdominal maladies, 
accompanied by swelling, and thrusting the diaphragm upwards — terminate by the 
same mode of dissolution. 

Death by coma, although common enough, and of much importance to be 
understood, need not detain us long. Certain morbid states of the brain (it is 
unnecessary at present to inquire into their nature and origin) produce stupor, 
more or less profound; the sensibility to outward impressions is destroyed, some- 
times wholly and at once, much oftener gradually; the respiration becomes slow, 
irregular, stertorous ; all voluntary attention to the act of breathing is lost, but the 
instinctive motions continue; the stimulus conveyed by the pulmonary branches 
of the eighth pair of nerves, and probably by certain branches too of the fifth, 
still excites, though perhaps imperfectly, the reflex power of the medulla oblongata, 
which sustains the involuntary movements of the thorax. At length this function 
fails also — the chest ceases to expand — the blood is no longer aerated — and 
thenceforward precisely the same internal changes occur as in death by apncea. 

You will observe that the extinction of organic life takes place in exactly the 
same manner in both cases: the difference between the two forms of dying being 
this — that in death by apncea, the chemical functions of the lungs cease first, and 
then the circulation of venous blood through the arteries suspends the sensibility; 
whereas, in death by coma, the sensibility ceases first, and in consequence of this 
the movements of the thorax, and the chemical functions of the lungs, cease also. 
So that the circulation of venous blood through the arteries is in the one case the 
cause, and in the other the effect, of the cessation of animal life. 

The causes that destroy the sensibility leave no constant or necessary traces of 
their operation. The essential anatomical characters of death by coma, and of 
death by apncea, are therefore the same. 

Death occurring in the way of coma has this peculiar kind of interest belonging 
to it, that it may sometimes be effectually obviated by a mechanical expedient. 
The circulation ceases because the actions of respiration cease — and the failure of 
the acts of respiration arises from a suspension of the nervous power. If it be 
merely a suspension — if the nervous functions are within the verge of recovery — • 
organic life may be sustained by the performance of artificial respiration, until 
the insensibility has passed away ; and thus the danger to life, which depended 
on that insensible state, may be escaped. 

Many years ago, in the course of those researches to which I have already 
referred, Sir Benjamin, then Mr. Brodie, was led to think that by continuing the 



58 



APPLICATION OF PRINCIPLES. 



respiration artificially in animals labouring under the influence of narcotic poisons, 
the heart might be kept in action until the stupefying but transitory effect of the 
poison upon the brain had gone off. This idea he soon brought to the test of 
experiment, and the result was such as to justify his ingenious reasoning. He 
inserted some woorara into a wound which he had made in a young cat. After a 
certain time the respiration had entirely ceased, and the animal appeared to be 
dead, but the heart could be still felt beating. The lungs were then artificially 
inflated about forty times in a minute. The heart continued to beat regularly. 
When the artificial breathing had been kept up for forty minutes, the pupils of 
the cat's eyes were observed to contract and dilate upon the increase or diminu- 
tion of light, but the animal remained perfectly motionless and insensible. At the 
end of an hour and forty minutes there were slight involuntary contractions of the 
muscles, and every now and then there was an effort to breathe. At the end of 
another hour the animal, for the first time, showed some signs of sensibility when 
roused, and made spontaneous efforts to breathe twenty-two times in a minute. 
The artificial breathing was, therefore, now discontinued. She lay, as in a state 
of profound sleep, for forty minutes longer, when she suddenly awoke, and began 
to walk about. 

Sir Benjamin Brodie had indeed been anticipated in this happy proposition for 
recovering persons apparently dead after taking narcotic poison, after submersion, 
and the like, — although he does not seem to have been aware of it. The experi- 
ment had once been tried before, and on the human subject, and with success, 
though not upon such scientific principles. The case is given by Mr. Whately, 
in the Medical Observations and Inquiries, vol. vi. A man who had swallowed 
an immense quantity of solid opium, and who seemed to be dead, was restored 
by the patient continuance, on the part of his medical attendants, in a process of 
artificial breathing. 

It is seldom that we can hope for success from this expedient in the treatment 
of disease ; simply because, in most cases, the injury of the nervous system which 
has produced the insensibility is irretrievable. 

In most forms of apoplexy, and of hydrocephalus, death occurs in the way of 
coma. Sometimes, however, as I mentioned before, the lesion of the nervous 
substance is so extensive and sudden, as to operate like a shock, and cause death 
by asthenia. The tendency to death by coma is also strongly pronounced in 
sundry affections of the brain, both acute and chronic. These will form subjects 
for our consideration hereafter. 

The several modes of dying, then, in cases of sudden death, are clearly enough 
made out. Let me briefly sum up the conclusions at which we have arrived. Life 
cannot be maintained without the circulation of arterial blood : and whenever a 
person dies, he dies either because no blood circulates through his arteries, or 
because venous blood circulates through them. 

When it comes to pass that no blood is circulated through the arteries, we say 
that death occurs in the way of syncope ; and this is of two kinds. In the one 
there is not blood enough received by the left side of the heart to stimulate its 
chambers to contract, or to be sent onwards by their contraction ; in the other, 
there may be blood enough, but the heart has not sufficient power to contract 
upon it. 

Also there are two ways in which death may be brought about in consequence 
of the circulation of the venous blood through the arteries. In one of these, the 
first step is the sudden shutting out of air from the lungs ; the blood which arrives 
in those organs is not aerated, or rendered arterial, but circulates again as venous 
blood, producing a failure of the animal functions, and weakening the muscles, 
till it finally stagnates in the capillaries of the lungs themselves. In the other, 
the animal functions are the first to suffer — -insensibility occurs — the power which 
governs the movements of respiration is withheld—the breathing ceases— and 
organic life is extinguished as in the former case. 



CAUSE OF DISEASE. 



59 



I trust you even already perceive that a right understanding of these matters is 
calculated to throw both light and interest upon our study of the symptoms and 
of the tendencies of disease. It will enable us to aim with more precision at 
fulfilling the indication so often inculcated by Cullen, of " obviating the tendency 
to death." In this sketch I have merely been able to hint at the important bear- 
ings of such views upon our practice. My attention was first called to them by 
the lectures of my respected instructor, Dr. Alison, who was accustomed to illus- 
trate them by reference to the phenomena of one large class of disorders. All 
the modes of dying that I have described are apt to take place in fevers. Some- 
times we have to combat the one, sometimes the other tendency. The disease 
often proves fatal in the way of coma; this happens principally when the brain 
has been a good deal affected, when there have been much headache, delirium, 
and stupor; sometimes, when the lungs have been seriously implicated, life is 
extinguished in the way of suffocation or apnoea : and occasionally fever seems 
to terminate fatally in the way of syncope, especially when the stress of the dis- 
order has fallen upon the bowels, when there has been continued diarrhc&a, and 
ulceration of the intestinal glands. Or if death does not occur precisely in these 
ways, at least it resembles more in different cases, sometimes one form of dying, 
sometimes another. 

It is notorious that very different remedies, and even different plans of treat- 
ment, have been strongly recommended, in fever, by different practitioners. One 
probable reason of this is, that one plan has been found the most proper to avert 
the fatal event in one form of the disease, and one in another. The tendency to a 
particular mode of death will prevail in, and characterize, a whole epidemic. We 
shall resume these considerations hereafter: in the mean time the facts we have 
been reviewing may teach us the danger of applying, with too much confidence, 
the experience we may have gained of one epidemic to the treatment of another; 
and the risk we are sometimes liable to, of misjudging, and criticising unjustly, 
the practice recommended by other physicians, because it does not appear to 
accord with the results of our own observation. 



LECTURE VI. 

Causes of Disease: distinction between predisposing and exciting causes. Enu- 
meration of causes, as connected with the Atmosphere — Food and Drink — 
Poisons — Exercise — Sleep — Menial and Moral Conditions — Hereditary Ten- 
dencies — Malformations. Temperature. Effects of Heat and of Cold. 

The causes of disease are commonly arranged under three heads — as predis- 
posing, exciting, or proximate. 

Of these three, the last mentioned, or the proximate cause, is nothing else than 
the actual disease itself — the actual condition of that part of the body from which 
the whole train of morbid phenomena essentially flows. When we know that 
part, and that condition, we name the disease accordingly. It may be inflamma- 
tion of the lungs; or softening of the brain. When we do not, we call the com- 
plaint after the group of symptoms by which it is characterized: intermittent 
fever, perhaps; or marasmus. The term "proximate cause" is, therefore, an 
unnecessary term: it is, moreover, to learners, a puzzling term, and tends to give 
to the study of the disease a scholastic and repulsive aspect. I wish you to get 
into the habit of contemplating the whole science of medicine under its simplest 
and plainest form. I am sure we may very well abolish the term "proximate 
cause" altogether; and having now given an explanation of its meaning, for your 
guidance when you meet with it in books, I shall never employ it, in these lec- 
tures, except perhaps in a quotation, again. 



60 



CAUSE OF DISEASE. 



In strictness of language, one event is held to be the cause of another event 
which follows it, when the first being absent, the second never occurs; and the 
first being present, the second never fails to occur, unless some other event inter- 
vene to prevent it. But the causes of disease will not bear to be spoken of after 
so strict a fashion. We perceive that certain external circumstances (quse nos 
circumstant) often precede such and such diseases ; and that the diseases seldom 
happen when the same circumstances are not previously observable ; and we 
begin to regard those circumstances as exciting causes of those diseases. We 
find that the diseases are much more frequent among persons known to have been 
exposed to the agency of the presumed causes than among persons who are not 
known to have been so exposed. The evidence at first is presumptive only. But 
the more uniform their conjunction, and the more rare their disjunction, the more 
confidently do we assign to the two consecutive events the relation of cause and 
effect. By this kind of observation a number of exciting causes of disease have 
been clearly established to be such. 

But recollect, certain circumstances being present, such and such diseases do 
often, not always, follow. Some persons are more liable to be affected by the 
operation of many of these ascertained causes than others are ; and the same 
persons are more liable to be influenced by the same cause at one time than at 
another. And special circumstances, existing in particular cases, will be found 
to account for this variable operation of known exciting causes upon the bodily 
health. These special circumstances may properly be called predisposing causes. 
Thus, of twenty persons exposed to the same noxious influence — to the combined 
agency of wet and cold during a shipwreck, for example — one shall have catarrh, 
another rheumatism, a third pleurisy, a fourth ophthalmia, a fifth inflammation of 
the bowels, and fifteen shall escape without any illness at all. A man does that 
with impunity to-day, which shall put his life in jeopardy when he repeats it next 
week. It is not, therefore, the exciting cause alone that in all cases determines 
the disease. Something — nay much, or all— will frequently depend upon the 
condition of the body at the time when the exciting cause is applied; and this con- 
dition of the body, which we call predisposition, will depend upon circumstances 
then or previously in operation ; and these circumstances are, in our language, 
predisposing causes. 

Do not confound, as many seem to do, the predisposition with the circumstances 
creating it. The predisposition is a certain state of the body — the predisposing 
cause is what produces that state. The cause of the predisposition is the predis- 
posing cause of the disease. A predisposing cause may therefore be defined to 
be any thing whatever which has had such a previous influence upon the body 
as to have rendered it unusually susceptible to the exciting cause of the particular 
disease. 

It is sometimes difficult, or impossible, to say of a given cause whether it ought 
to be ranked among the exciting or among the predisposing causes ; whether it 
has prepared the system for being affected by some other agent, or whether it 
has itself produced the disease ; but for the most part the distinction is real, and 
sufficiently well marked, and of great importance to be attended to. 

Disease may sometimes be averted, even in despite of strong and fixed predis- 
position to it, if we know, and can guard against, the agencies by which it is 
capable of being excited. A man may inherit a proclivity to consumption, yet 
fortunately escape that fatal complaint by timely removal to a warm and equable 
climate, and by other suitable precautions ; that is, by avoiding whatever tends to 
rouse the dormant tendency into action. On the other hand, disease may often 
be warded off, notwithstanding the presence and application of its exciting cause, 
when its predisposing causes are ascertained and can be prevented. In proportion 
as the body is weakened or exhausted, it yields more readily to the pernicious 
influence of contagion, or of malaria; but by obviating all causes of debility, and 
fortifying the system, we walk with comparative security amid surrounding 
pestilence. 



CAUSE OF DISEASE. 



61 



Diseases sometimes occur when no exciting cause, when no cause at all, has 
been apparent. All that we can say of such cases (which are not, however, very- 
frequent) is, that the causes have not hitherto been discovered. 

Now the ascertained causes of disease are many and various. Whatever mi- 
nisters to life, health, or enjoyment, may become the medium, under changing 
circumstances, of pain, disease, or death. The atmosphere, in which we are 
constantly immersed, is full of dangers. Both the organic and the inorganic 
world of matter around us abound in poisons ; they lurk in our very food, which 
becomes pernicious when taken in excess, or when it consists of certain sub- 
stances, or certain admixtures of substances ; so that there really was much truth, 
as well as some humour, in the startling motto to Mr. Cecum's book on adulter- 
ations — " There is death in the pot." Our passions and emotions also, nay, even 
some of our better impulses, when strained or perverted, tend to our physical 
destruction. The seeds of our decay are within as well as around us. 

Let us enumerate, however, a little more particularly, the various known 
sources of disease, with the view of making, afterwards, a few practical comments 
upon some of them. 

I shall pass over, in this enumeration, nearly all chemical and mechanical 
injuries ; inasmuch as these belong to surgery. 

If we look to atmospherical causes, we shall find that those varieties in the state 
of the air which proceed from mere differences of degree in its natural qualities 
may be productive of disease. Such are, extremes of heat and of cold ; sudden 
variations of temperature ; excessive moisture or excessive dryness ; different 
electric conditions; differences of pressure, as measured by the barometer ; a de- 
ficiency of light. 

Again, the atmosphere may be a source of disease in consequence of its being 
loaded with impurities. Malaria, contagions of various kinds, and noxious gases 
in general, may be considered as so many poisons. 

Under the head of nutriment we may place the use of food of which the quality 
is bad and hurtful; this cause also strictly belongs to the class of poisons. Again, 
an insufficient supply of healthy food; and still more common causes are excess 
in eating, and intemperance in drinking. 

The numerous poisons which are not comprehended under either of the fore- 
going heads are also prolific sources of disease. 

Another great class among the causes of disease might be formed by consider- 
ing together the influence of various trades and avocations which are directly 
injurious to the health of those who pursue them. 

We know, by ample experience, that a certain amount of bodily exercise is 
essential to good health. We see the evil consequences of much overstepping 
that amount, in the deformities and disorders which result from labour too severe, 
or too long continued. But a much more numerous train of complaints follow 
the opposite state — that in which, from indolence, or from necessity, but little 
exercise is used. 

Excessive indulgence in sleep on the one hand, and long-continued want or 
interruption of repose on the other, are apt to give rise to serious maladies. 

Very many diseases have a mental origin. Excessive intellectual toil — the 
domination of violent passions — the frequent recurrence of strong mental emo- 
tions — vicious and exhausting indulgences, — each and all will sap the strength, 
and grievously impair the health of the body : and perhaps there is no cause of 
corporeal disease more clearly made out, or more certainly effective, than pro- 
tracted anxiety and distress of mind. 

When we add to this catalogue of the sources of disease all those morbid tend- 
encies which are hereditary — and those which flow from original malformation, 
and are congenital — we shall have a tolerably complete list of the manifold dan- 
gers to which our mortal frames are continually liable. 

There are several points of view under which the consideration of these causes 
of disease might be shown to be interesting. We might inquire, for example, 



62 



CAUSE OF DISEASE. 



which of them are commonly predisposing, which exciting causes ; and what are 
the circumstances which are found to rentier the same agent at one time merely a 
predisposing, and at another time an exciting cause. 

We might also separate, with some advantage, those causes of disease to which 
the human body is often and necessarily exposed, from those which consist in 
agencies that are of local or temporary existence only. But without multiplying 
these artificial distinctions, I shall take occasion to advert to them either when 
speaking more in detail of particular causes, or when speaking of the disorders 
they have produced. 

In our investigations into the causes of disease, great caution is necessary in 
order to avoid being misled by individual cases. The circumstances capable of 
influencing the bodily health are so various — so many of them are apt to be in 
operation at the same time — and so little power have we of excluding them, one 
after the other, so as to ascertain the exact efficacy of each — that our observations 
respecting their relative or their actual effects are open to much fallacy. We 
endeavour to escape this source of mistake by repeating and multiplying our ob- 
servations. But it is by tracing diseases as they affect considerable masses of 
men, placed as nearly as possible under the same external circumstances, that we 
gain the surest and most satisfactory evidence in respect to the causes of disease. 
And hence it is that the experience of the medical officers of our fleets and armies 
is so valuable. Dr. Alison has well remarked, that all the circumstances of the 
whole number of men whose diseases fall under the notice of military and naval 
practitioners are, in many respects, exactly alike : the men are generally healthy 
adults in the first instance — the circumstances in which they are placed are tho- 
roughly known to the observer — and, indeed, are often to a certain degree at his 
disposal; they are often suddenly changed also ; and changed sometimes as to 
one portion of the whole mass of individuals, while they remain unchanged as to 
another portion; so that his opportunities of observation partake in some measure 
of the nature of experiments, and being made upon a large scale, ihey are espe- 
cially interesting and conclusive. In point of fact a great deal has been learned, 
with absolute certainty, upon this subject. 

Hitherto I have simply enumerated the principal causes of disease: — but con- 
ceiving a bare enumeration of this kind to be of but little use, I shall inquire 
somewhat more nearly into the nature and mode of operation of several of them 
now; of others I prefer to speak in connection with the particular diseases to 
which they give rise. 

You will not consider the inquiry superfluous. To know the cause of a disease 
is sometimes to be able to cure, often to be able to prevent it. In some cases the 
cause is beyond our power, but an acquaintance with its nature may teach us 
how to moderate or to remedy its consequences. There are many diseases also 
over which medicine has very little control, but the causes of which, when ascer- 
tained, may be avoided, or extinguished. Such causes, when they do not happen 
to be removable by individual efforts, are often susceptible of extinction by the 
united measures of a community. And for this reason it is very desirable that 
correct opinions respecting the causes of disease should be widely diffused among 
the public; — and there is now no way in which information of this kind is so 
likely to be made generally known, as by communicating it to medical students 
who are about to scatter themselves in all directions over the face of the land. 

I shall proceed, then, in the first place, to the consideration of heat and cold, 
as external agencies capable of producing disease. 

The range of atmospheric temperature compatible with human life is very con- 
siderable. Its limits are probably just those extremes of heat and cold that belong 
to the lower strata of the air in the different parts of the planet on which man is 
destined to exist. Under the burning sunshine of the tropics, and amid the pro- 
found frost of the polar regions, we alike find human dwellers. These different 
degrees of external temperature impress indeed peculiar physical characters upon 



CAUSE OF DISEASE. 



63 



those who are subjected to them, but they do not, of necessity, extinguish life, or 
even cause disease. It requires more care, however, to preserve life under intense 
cold than under intense heat. In some parts of India the temperature ranges for 
a long time together from 80 to 100, and even 110° of Fahrenheit's thermometer: 
I believe it sometimes reaches 120°. We can form some estimate of this heat by 
remembering the oppressive effect of the lowest of these temperatures — that of 
80° — to which the thermometer sometimes rises in this country in the hot weather 
of summer. But these tropical climates are very thickly peopled. In the arctic 
countries, on the other hand — in the northernmost parts of America, for example — 
where the sun appears above the horizon for a short part of the year only, and 
where the thermometer sinks to 40 or 50° below zero — we still find inhabitants, 
indeed, but they are few,*and thinly scattered. This mainly depends, no doubt, 
upon the scanty supply of human food in those parts of the world; but something 
also is to be ascribed to the depressing influence of extreme cold upon the vital 
powers. Indeed, the deficiency of human food is itself owing to the restraining 
effect of a low temperature upon organic life. Under a degree of temperature a 
little greater than that at the equator — or a little less than the lowest around the 
poles — it seems probable that man would soon perish. And in this fact we have 
one striking instance of the adaptation of external nature to the physical constitu- 
tion of the human race. 

But for a short time — and under certain circumstances — man is capable of 
enduring a very much higher degree of heat than the open and general atmo- 
sphere ever attains even in the hottest portions of the earth. Whether he could 
continue to exist, even for a litde while, under a much more intense cold than 
ever occurs naturally on the surface of the globe, is more questionable. 

It was long believed that the human body could not be safely exposed, even 
for a short time, to a degree of heat much exceeding that which is met with in 
hot climates. This opinion, which we now know to have been erroneous, was 
strengthened by the result of some experiments made by the celebrated Fahren- 
heit himself, and related by Boerhaave in his Chemistry. Some animals were 
shut up in a sugar-baker's stove, where the mercury stood at 146°. A sparrow 
died in less than seven minutes, a cat in rather more than a quarter of an hour, 
and a dog in about twenty-eight minutes. The noxious air of the stove had 
probably more to do with the speedy deaths of these animals than the heat. 
The truth, upon this subject, may be said to have been discovered by accident. 
In the year 1760 and 1761, MM. Duhamel and Tillet were appointed to devise 
some means of destroying an insect which consumed the grain in the province of 
Angoumais in France. They found that this could be done by subjecting the 
corn, and the insects contained in it, in an oven, to a degree of heat great enough 
to kill the insect, but not so great as to hurt the grain. In order to ascertain the 
precise heat of the oven, they introduced into it a thermometer placed upon the 
end of a long shovel. The mercury, when the thermometer was withdrawn, was 
found to indicate a degree of heat considerably above that of boiling water. But 
M. Tillet was aware that the thermometer had sunk several degrees as it was 
drawn towards the mouth of the oven. While he was puzzled to invent some 
way of determining more exactly the actual degree of heat, a girl, who was one 
of the attendants on the oven, offered to go in, and to mark with a pencil the 
height at which the mercury stood. And she did enter the oven, and remained 
there two or three minutes, and then marked the thermometer at 100° of Reau- 
mur, which nearly equaled 260° of Fahrenheit. M. Tillet then began to express 
some anxiety for the safety of the girl, but she assured him that she felt no in- 
convenience, and remained in the oven ten minutes longer, during which time 
the mercury reached the 288th degree of Fahrenheit's scale — denoting 76° of 
heat above that of water when it boils. When she came out her complexion was 
considerably heightened, but her respiration was by no means quick or laborious. 
This experiment was afterwards repeated. Another girl remained in the oven as 
long as the 'former had done, at the same temperature, and with the same im- 



64 



CAUSE OF DISEASE. 



punity. Nay, she even breathed, for the space of five minutes, air heated to 
about 325° of Fahrenheit — or 113° above that of boiling water. 

The publication of these facts naturally excited the curiosity of scientific men, 
and other experiments were soon instituted. Dr. Dobson, of Liverpool, and 
several other persons with him, shut themselves up in the sweating room of the 
public hospital there, the air having been heated till the quicksilver stood at 224° 
of Fahrenheit. They did not experience any oppressive or painful sensation of 
heat. Dr. Fordyce and Dr. Blagden made some remarkable trials of the same 
kind. They entered rooms artificially heated to a very high degree, sometimes 
naked, and sometimes with their clothes on, and bore the extraordinary tempera- 
ture of 240°, and even 260°, for a considerable time, with very little inconveni- 
ence. In all these experiments it was found that the animal heat, as ascertained 
by thermometers placed under the tongue, or grasped in the hand, was scarcely 
increased at all ; and the respiration but little affected ; but the pulse was very 
much quickened. The frequency of Dr. Blagden's pulse in one instance was 
doubled. You may read a detailed account of these experiments in the Philo- 
sophical Transactions ; but to give you a more lively notion of the degree of 
heat to which the bodies of these gentlemen were exposed, I may tell you that 
their watch-chains, and other pieces of metal about them, became so hot that they 
could scarcely be touched ; when they breathed upon the thermometer, the mer- 
cury immediately sank several degrees; each act of expiration produced a plea- 
sant feeling of coolness in the nostrils, and they cooled their fingers by breathing 
upon them. In and by the same healed air which they respired, eggs were 
roasted quite hard in twenty minutes, and beef-steaks were dressed in thirty-three 
minutes ; and when the air was blown upon the meat by means of bellows, it 
was sufficiently cooked in thirteen minutes. 

It is ascertained, then, beyond all doubt, that the human body is capable of 
sustaining these very high degrees of temperature, for a short time, without 
detriment. 

Facts of this kind may, perhaps, appear to you rather curious than useful. 
Man is never submitted to any natural heat of the air even approaching towards 
that to which the authors of the experiments I have been describing voluntarily 
exposed themselves. But a knowledge of extreme cases always tends to throw 
light upon those that lie between the extremes ; and the direct results arrived at 
in these philosophic inquiries are not barren of practical utility to members of our 
profession. It is not long ago that a man was found almost dead in an oven ; he 
expired a quarter of an hour after he was taken to one of the borough hospitals ; 
and an inquest was held upon his body. The newspaper report of the case 
(which is the only one I have seen) states the temperature of the oven to have 
been about 120° — a candle was melted by it in half a minute. Now prior to the 
trials just mentioned, exposure to such a degree of heat would have been held a 
sufficient cause of death. We now know (and it would be discreditable if we 
could not support our opinion in a court of law, or before a coroner, by a refer- 
ence to authentic facts) that something else must have concurred in extinguishing 
life ; and, in fact, it turned out that the man was drunk when he went into the 
oven. 

But what are the effects, upon the human frame, of a high, yet less excessive, 
temperature of the air ? 

One very constant effect of heat is that of stimulating the organic functions of 
the body. We have seen that the temporary application of great heat accelerates 
remarkably the action of the heart : the pulse was uniformly found to be much 
increased in frequency in the persons who made trials of their powers of endur- 
ance in heated rooms. We have evidence to the same purpose in the annual 
changes that take place in the vegetable kingdom at a given place, the summer 
renewing its foliage, the winter checking and repressing it ; and still more in the 
superior luxuriance of vegetation in warm climates as compared with cold. And 
the same observation applies to those functions which animals possess in com- 



CAUSES OF DISEASE. 



65 



mon with plants. Towards the poles both man and the lower animals are smaller 
than at the equator. Linnaeus remarks that the hares, partridges, and other ani- 
mals which inhabit the northern climes, are considerably smaller in size than the 
same species in more southern countries. And Mr. Tooke, in his View of Rus- 
sia, observes, "As we approach nearer to the north pole, both the animal and 
vegetable productions of nature become more and more stunted. The ordinary 
stature of the Samoyedes seldom exceeds four or five feet, and their whole exte- 
rior corresponds with their dwarfish size." The stature of the native inhabitants 
of hot climates does not, I believe, exceed that which is proper to the temperate 
zone; but if, as is generally believed, the human body, like plants and fruits, 
grows faster, and ripens sooner, in proportion as we approach the equator, this 
must be attributed to the stimulus of heat acting upon the organic life. 

On the other hand, and in some sort as a contrast with this, we may observe 
that considerable heat, when applied for some time together, has a sedative or 
depressing influence upon the animal functions, i. c, upon the nervous system ; 
causing languor and lassitude, want of energy, a disinclination to exertion both 
bodily and mental. 

Under favourable circumstances, and where due precaution is exercised, it is 
probable that a very high degree of natural temperature of the atmosphere may be 
borne with impunity. Sir James M'Grigor informs us (in his account of the 
passage of the army in 1801 from India to Egypt), that during the march over 
the sandy desert of Thebes, where the heat was uniform, though the thermome- 
ter in the soldiers' tents was as high as 118°, the health of the troops was equal 
to that which they had enjoyed in any former period in India. 

But there are some forms of disease which are distinctly traceable to heat as 
their cause. 

The effect of hot weather in promoting the cutaneous perspiration is notorious. 
By the same influence the hepatic function is rendered more active. Dr. James 
Johnson first, I think, distinctly pointed out the sympathy or consent that obtains 
between the liver and the skin, under varying conditions of external warmth. 
Whatever may be the explanation of the fact, experience has taught us that a 
high atmospheric temperature, when its operation is continued for some time, has 
a marked influence upon the liver, increasing the quantity of bile that is secreted, 
and altering its sensible qualities; and this disturbance of function is not unfre- 
quently followed by inflammation of the gland itself. In this country we wit- 
ness, almost annually, the effects of a succession of sultry weather, in those 
attacks of vomiting and diarrhoea which are so common towards the latter end of 
summer, and in the autumn, especially when the season happens to have been 
unusually hot ; and which result, apparently, from the excessive quantity or a 
morbid state of the bile. The English cholera (a totally different disorder from 
that which has of late years been called, most improperly, the cholera), is, as you 
know, so frequent and general in some years, as to be fairly considered and 
termed an epidemic disease. In tropical climates the same morbific operation of 
external heat is still more conspicuous ; leading not only to violent disorder of the 
stomach and intestines, with the evacuation of large quantities of vitiated and 
acrid bile, but also to acute inflammation of the liver going on to suppuration, and 
the formation of large abscesses. These last diseased conditions are extremely 
rare in this latitude. The yellow complexions of those who return to England 
after a long residence in India, are to be attributed to that disordered state of the 
liver, and of its functions, to which such persons are proverbially subject, and 
which has in them been brought on by the influence of a hot atmosphere, ope- 
rating for a long space of time together. Hepatic affections, acute or chronic, 
are among the chief diseases to which Europeans, at least, are liable in that 
climate. 

We have here an example of the distinction I wish you to notice between pre- 
disposing and exciting causes. The heated atmosphere stimulates unduly the 
secreting function of the liver. Now a secreting organ is never so apt to be 



66 



CAUSES OF DISEASE. 



affected by any exciting cause of inflammation as when the process of secretion 
is going on. This law, which I mention by anticipation, depends, no doubt, 
upon the increased afflux of blood that accompanies the act of secretion. The 
excessive activity of the hepatic function constitutes thus a predisposition to in- 
flammation of the liver. The hot atmosphere, which creates this predisposition, 
holds the place of a predisposing cause in respect to the inflammation that ensues ; 
but the exciting cause is exposure to cold : one of the most common and best ascer- 
tained exciting causes of inflammation in general. You are not to imagine that 
there can be no such thing as exposure to cold in a climate where the temperature 
of the air is habitually above 80°. Dr. James Johnson, in his book on Tropical 
Climates, observes that on the coast of Coromandel the temperature is steady by 
day, and the nights are hot: but yet, he says, nothing is more common than 
exposure to cold in this place. The European soldier or sailor, after the heat 
occasioned by his employments in the day, strips off his clothes, and lies oppo- 
site a window or port, his shirt wet with perspiration, to enjoy the sea breeze at 
night. And the same author tells us that the application of cold after or during 
perspiration, commonly produces an attack of hepatitis in some one of its various 
forms. Now the effect of that kind of exposure here described does not depend 
upon the actual temperature, but upon the sensation that is produced, and the 
sensation depends upon the relative temperature; and there can be no doubt that, 
under the circumstances mentioned by Dr. Johnson, a strong sensation of cold 
would be occasioned, even by a Seabreeze as warm as 80°, or warmer. Changes 
of temperature seem to be as readily felt at one part of the thermornetric scale, as 
at another, and in whichever direction they take place. Dr. Walsh states, that 
while sailing along the coast of Brazil, after having been long accustomed to a 
temperature of 72°, a strong breeze set in from the sea, and the thermometer fell 
to 61° ; (i. e., to a point which we should here call temperate ;) "but," he says, 
44 the sense of cold from the sudden transition of temperature was quite painful. 
After bearing it for some time, shivering on deck, it became intolerable, and we 
all went below, put on warm clothing, and dreadnoughts — and again appeared 
with thick woolen jackets and trovvsers, as if we had been entering Baffin's Bay, 
and not a harbour under one of the tropics." 

It is interesting to compare this statement with Capt. Parry's account of a change 
of temperature at the opposite extreme of the scale, and in the other direction. 
Having previously said that the thermometer had fallen to 13° below zero in the 
night of the 21st of October, he goes on thus: — " The wind veering to the south- 
east on the 24th and 25th, the thermometer gradually rose to 23°. I may possi- 
bly incur the charge of affectation in stating that this temperature was much too 
high to be agreeable to us; but it was nevertheless the fact, that everybody felt 
and complained of the change. We had often before remarked that considerable 
alterations of the temperature of the atmosphere are as sensibly felt by the human 
frame at a very low part Qf the scale as in the higher. The difference consists 
only in this, that a change from 40° upwards to about zero, is usually a very wel- 
come one; while from zero upwards to the freezing point, as in the instance just 
alluded to, it becomes, to persons in our situation, rather an inconvenience than 
otherwise." 

Besides the more gradual effects of great heat, direct or indirect, upon the 
human body, it sometimes operates distinctly as an exciting cause, and gives rise 
to more sudden attacks of illness. Persons who are exposed to the direct beams 
of a hot sun, especially during any labour or active exercise, are apt to be affected 
by what is called the sun-stroke, the coup cle soleil, insolation : they fall down 
insensible, and often die in a very short time. This disorder is common among 
troops in long marches in India. It is a complaint of which the cause has long 
been known by the inhabitants of hot climates. There is a case of it related in 
the Bible. 44 And Manasses was her husband, of her tribe and kindred, who died 
in the barley harvest. For, as he stood overseeing them, and bound sheaves in 



CAUSES OF DISEA.SE. 



67 



the field, the heat came upon his head, and he fell on his bed, and died in the city 
of Bethulia." 

Pathologists are not agreed respecting the intimate nature of this distemper; 
nor about the manner in which it destroys life. Some regard it as a sort of 
apoplexy : and hold that death takes place in the way of coma. But the most 
approved remedies of apoplexy — bleeding and other evacuations — have not proved 
successful in relieving it. The natives of India prefer the pouring of cold water 
upon the head to every other curative measure. Our army sergeants also found 
that stimulants — rum and water, for instance — answered better than depletion. I 
have never seen this affection, but I should conjecture that it is more akin to the 
state we call concussion than to true apoplexy. It would appear that the sun's 
rays act upon the brain like a shock. The nervous system is suddenly and exten- 
sively influenced, and the heart's movements arrested, as in syncope. One of Sir 
Benjamin Brodie's experiments is in favour of this opinion. He placed a rabbit 
in a basket in an oven, the temperature of which was not more than 150°, and it 
died in a few minutes, without any apparent sufTering. The heart was afterwards 
found distended with blood, on both sides, as after death by asthenia. 

Great heat tends also to the production of certain cutaneous diseases : it is said 
that few Europeans escape, on their first settling in tropical climates, an eruption 
of pimples, attended with almost intolerable itching and pricking, and lasting for 
some weeks. It is called in India the prickly heat. 

Before considering that most prolific source of disease which is familiar to the 
commonest observation in sudden transitions of temperature, let us inquire what 
are the ascertained effects of extreme cold upon the human frame. Of course I 
use the term cold in its popular acceptation, as if it were something positive, 
instead of signifying the mere privation of heat. It is much more convenient to 
speak of it in this way, and there is no risk of your being misled by my doing so. 

Now this inquiry is of more practical interest to us than that which is concerned 
with the immediate effects of extreme heat. Even in this climate medical men 
are not unfrequently called upon, in cases of injury or death produced by intense 
cold, either to remedy fhe morbid conditions it has caused, or to explain the mode 
and probability of its operation in extinguishing life. 

The effects of cold, as might well be imagined, are in many respects the direct 
opposites of the effects of heat. When its application is continued, it acts as a 
sedative upon the organic functions both of animals and of plants. This appears 
from the shrinking of the external parts : the superficial arteries become unable to 
transmit the blood in the usual quantity through the integuments. Hence the 
skin becomes pale, and contracting round the sebaceous glands and the hair-bulbs, 
exhibits a roughness which is compared to that of the skin of a plucked goose, 
and is technically called cutis anserina. By the same contraction of the smaller 
vessels, and repressed circulation, the extreme and projecting parts are diminished 
in size. Thus, rings which are tight on the fingers while the body is warm, 
drop off in cold weather — and even the shoes fall from the feet during extreme 
exposure. The heart with the whole arterial system becomes weak. I have 
already, when speaking of the contrasted operation of heat, illustrated the wither- 
ing influence of a continued low atmospheric temperature upon the organic func- 
tions, by referring to the dwarfish size of both men and the lower animals, as 
well as of plants, in cold regions. We have evidence of the same fact in the tardy 
development of the functions, and particularly, as many travelers affirm, of the 
sexual functions, in cold climates as compared with hot; and in the winter torpor 
of certain animals, which is very analogous with the state of trees and shrubs in 
that season. 

I need not tell you that to judge of the effects of mere coldness of the atmo- 
sphere we must take the case of the atmosphere at rest. The air is a bad con- 
ductor of caloric, and for that reason, a much lower, as well as a much higher 
degree of temperature, can be borne when it is in a state of quiescence, than when 



68 



CAUSES OF DISEASE. 



fresh portions of it are perpetually brought into contact with the surface of the 
body by currents of air. " With the thermometer," says Captain Parry, " at -55°," 
(a most fearful degree of cold, you will observe, 55° below zero, i.e., 87° below 
the freezing point,) " with the thermometer at -55°, and no wind stirring, the 
hands may remain uncovered for ten minutes or a quarter of an hour without 
inconvenience; while with a fresh breeze, and the thermometer nearly as high as 
zero, few people can keep them exposed so long without considerable pain." 
And speaking in another place of the cold, when the thermometer was 49° below 
zero ; 9 or 10°, that is, below the point at which mercury freezes, he says, "The 
weather being quite calm, we walked on shore for an hour without inconvenience, 
the sensation of cold depending much more on the degree of wind at the time, 
than on the absolute, temperature of the atmosphere as indicated by the ther- 
mometer. In several of the accounts given of those countries, in which an intense 
degree of natural cold is experienced, some effects are attributed to which it cer- 
tainly did not come under our observation in the course of this winter. The first 
of these is the dreadful sensation said to be produced in the lungs, causing them 
to feel as if torn asunder when the air is inhaled at a very low temperature. No 
such sensation was ever experienced by us, though in going from the cabin into 
the open air, and vice versa, we were constantly in the habit, for some months, 
of undergoing a change of from 80° to 100°, and in several instances 120° of 
temperature, in less than one minute : and what is still more extraordinary, not a 
single inflammatory complaint (beyond a slight cold, which was cured by common 
care in a day or two), occurred during this particular period." 

But when the cold air is in motion, in other words, when there is wind, so 
that fresh portions of cold air are brought, successively, in contact with the surface ; 
or when it is accompanied with moisture, or occurs under other circumstances 
favourable to its operation, and to be spoken of more particularly presently ; then 
cold of a much inferior degree of intensity may very speedily occasion partial or 
total death. By partial death I mean the loss of vitality in certain parts of the 
body only — the ears, nose, fingers, toes, and feet. The parts thus affected are 
said to be frost-bitten : and the mode of managing such accidents falling within 
the province of surgery, I shall confine my remarks almost entirely to the case 
where general death — death in its full and ordinary meaning — is either brought 
about, or impending, in consequence of exposure to cold. 

One of the earliest effects of extreme cold upon the system at large has been 
said to be a remarkable and overpowering drowsiness. But I believe you will 
find that most or all of the persons in whom this torpor has been noticed had not 
only been exposed to severe cold, but had been using also a great deal of exer- 
cise: and perhaps the drowsiness ought to be ascribed, in some measure at least, 
to that exercise. They who attribute it to the cold alone explain the comatose 
state in this way. They say that the chilling of the surface and extremities drives 
the blood inwards, causes it to accumulate internally, and increases the flow of 
blood towards the head. One thing, however, is certain, viz., that drowsiness is 
not a necessary consequence of exposure to severe cold, although it is a very 
common consequence. Dr. 'Currie, in his Medical Reports, gives a very inte- 
resting account of the shipwreck of an American vessel on the coast of Ireland. 
Most of the crew, fourteen in all, were immersed, to a considerable depth, for 
twenty-three hours, in water of which the temperature was believed not to exceed 
33 or 34° of Fahrenheit: and he states expressly that none of the men were 
drowsy, and that in no one of the three that perished was death preceded by 
sleep. 

The overpowering tendency of cold when combined with fatigue (and perhaps, 
under certain circumstances, of intense cold alone), to induce sleep, was strikingly 
exemplified in what befell Dr. Solander among the hills of Terra del Fuego. The 
story, as given in Captain Cook's Voyages, is well known. Sir Joseph Banks 
and Dr. Solander had been out botanizing. On their return towards the ship, 
after various hardships, and after having traveled through swamps for a con- 



CAUSES OF DISEASE. 



69 



siderable way, the weather, which had been very fine, became gloomy and cold, 
with sudden blasts of piercing wind, accompanied by snow. Finding it impos- 
sible to get back to the ship before the morning, they resolved to push on through 
another swamp that lay in their way, into the shelter of a wood, where they might 
build a wigwam and kindle a fire. Mr. Banks (as he was then) undertook to 
bring up the rear. Dr. Solander, who had more than once crossed the mountains 
that divide Sweden from Norway, and who well knew that extreme cold, especi- 
ally when joined with fatigue, produces a torpor and sleepiness that are almost 
irresistible, conjured the company to keep moving, whatever pain it might cost 
them, and whatever relief they might be promised by an inclination to rest. 
" Whoever sits down" said he, " will sleep, and whoever sleeps will wake no 
more." Thus at once admonished and alarmed, they set forwards ; but they had 
not gone far before the cold became suddenly so intense as to produce the effects 
that had been most dreaded. Dr. Solander was the first who found the inclina- 
tion, against which he had warned others, invincible, and he insisted on being 
suffered to lie down. Mr. Banks entreated and remonstrated with him in vain: 
down he lay upon the ground, although it was covered with snow, and it was 
with much difficulty that his friend kept him from sleeping. Richmond, also, one 
of the black servants, began to linger in the same manner. When he was told 
that if he did not go on he would in a short time be frozen to death, his answer 
was that he desired nothing but to lie down and die. The doctor said he was 
willing to go on, but that he must first take some sleep; although but a short time 
before he had told the company that to sleep was to perish. Mr. Banks and the 
rest found it impossible to carry them, and there being no remedy, they were 
both at length suffered to lie down, being partly supported by some bushes ; and 
in a few minutes they fell into a profound sleep. Soon after some of the people 
who had been sent forward returned with the welcome news, that a fire was 
kindled about a quarter of a mile on the way. Mr. Banks then endeavoured to 
wake Dr. Solander, and happily succeeded; but, though he had not slept five 
minutes, he had almost lost the use of his limbs, and the flesh was so shrunk, 
that his shoes fell from his feet. He consented to go forward with such assist- 
ance as could be given him ; but no attempts to relieve poor Richmond were suc- 
cessful. He, together with another black left with him, died. 

In many instances, before this complete torpor comes on, intense cold has a 
curious effect upon the nervous system, blunting the sensations, and confusing 
the intellect, and giving to the person exposed to it the appearance of one intoxi- 
cated. It is very necessary that you should be aware of this, for there is too 
much reason to believe that poor wretches who have been picked up by the con- 
stables in the streets at night, during periods of hard frost, have been supposed to 
be drunk, when, in truth, they were only stupefied by the cold. Such a mistake 
is most likely to be fatal to them : instead of receiving the attention and treatment 
proper for persons in their condition, they are liable to be laid aside, by them- 
selves, to sleep off their supposed debauch, and the morning finds them corpses. 
It is not at all improbable that-some of you may be called upon to investigate 
such cases: and as actual instances are more readily impressed upon the memory 
than any general description, I will read you a short history illustrative of what I 
have just been saying, from Captain Parry's Journal. 

" John Pearson *** had his hands severely frost-bitten, having unfortunately 
gone without mittens, and with a musket in his hand. A party of our people 
most providentially found him, although the night was very dark, just as he had 
fallen down a steep bank of snow, and was beginning to feel that degree of torpor 
andtlrowsiness which, if indulged, inevitably proves fatal. When he was brought 
on board his fingers were quite stiff, and bent into the shape of that part of the 
musket which he had been carrying: and the frost had so far destroyed the ani- 
mation in his fingers on one hand, that it was necessary fo amputate three of 
them a short time after." 



70 



CAUSES OF DISEASE. 



It is what immediately follows this, that I was desirous of pointing out to your 
attention. 

"The effect which exposure to severe frost has in benumbing the mental as 
well as the corporeal faculties, was very striking in this man, as well as in two of 
the young gentlemen who returned after dark, and of whom we were anxious to 
make inquiries respecting Pearson. When I sent for them into my cabin, they 
looked wild, and spoke thick and indistinctly, and it was impossible to draw from 
them a rational answer to any of our questions. After being on board for a short 
time, the mental faculties appeared gradually to return with the returning circula- 
tion ; and it was not till then that a looker-on could easily persuade himself that 
they had not been drinking too freely. To those who have been much accus- 
tomed to cold countries, this will be no new remark, but I cannot help thinking 
(and it is with this view that I speak of it) that many a man may have been 
punished for intoxication, who was only suffering from the benumbing effects of 
frost: for I have 'more than once seen our people in a stale so exactly resembling 
that of the most stupid intoxication, that I should certainly have charged them 
with that offence, had I not been quite sure that no possible means were afforded 
them on Melville Island to procure any thing stronger than snow-water." 

When persons in this state are suffered to sleep, and the operation of the cold 
continues, they become less and less sensible to external impressions, until death 
closes the scene. 



LECTURE VII. 

Causes of Disease, continued. Laivs by ivhich the operation of Cold upon the 
Bodily Health is regulated. Circumstances that favour its injurious Effects, 
and respect, first, the Body itself; secondly, the manner in which the Cold is 
applied. Modifying influence of certain states of the Mind — of Sleep — of 
Habit. Means of protection. Influence of the different Seasons. Impurity 
of the Mr. Hereditary tendencies to Disease. 

In the last lecture I commenced the consideration of some of the causes of 
disease. 

We learned, by the evidence of authentic facts, that the human body is capable 
of bearing a very high degree of external temperature, for a short time, without 
detriment — and even without much inconvenience; and we learned — also by the 
testimony of facts — that the body is equally well calculated to endure, under 
favourable circumstances, a very low degree of atmospheric temperature — or, to 
speak in popular language, a very intense degree of cold. 

It appears also that a high, but not extreme, atmospheric temperature, when 
long continued, has a stimulating effect upon the organic functions, and a de- 
pressing or sedative effect upon the animal functions of the body. Long-con- 
tinued heat predisposes the body to be injuriously influenced by exposure to cold : 
the diseases apt to follow such exposure, under such circumstances, being de- 
rangement of the hepatic functions — violent disturbances of the stomach and 
bowels, with a copious discharge of vitiated and acrid bile — and acute inflamma- 
tion of the liver itself. As more direct consequences of exposure to extreme heat 
— in other words, as examples of disorders of which extreme heat sometimes 
proves an exciting cause — I mentioned the coup de soleil, and the eruption called 
the prickly heat. 

With respect to external cold, I pointed out to you its depressing effects upon 
the organic functions of the body — and, when it becomes very intense, indeed, its 
directly sedative influence upon the animal functions also — producing a state 



CAUSES OF DISEASE. 



71 



resembling intoxication, overpowering drowsiness, and coma, especially when 
the cold has had an auxiliary in fatigue; and, ultimately, death itself. 

I hardly need say that the effect of external cold upon the body, within certain 
limits of intensity and duration, is totally different from all this. When it is not 
intense — or when, though intense, it is applied for a short time only — or when 
its refrigerating and sedative properties can be sufficiently counteracted by exer- 
cise and warm clothing — cold becomes a tonic; stimulating, refreshing, and in- 
vigorating both mind and body. Instead of benumbing, it heightens the sensi- 
bility ; instead of stupefying, it clears and sharpens the faculties, and bestows 
alacrity and cheerfulness of spirit ; and in this way, among others, cold becomes 
a very important curative agent. 

Here also, therefore, the contrast obtains; a high external temperature relaxes 
and depresses — a low one, under the circumstances just mentioned, braces and 
enlivens. 

Nevertheless, exposure to cold is one of the most common causes of various 
complaints. Many or most of the internal inflammations acknowledge cold as 
their ordinary exciting cause. Acute rheumatism has, perhaps, no other external 
origin. Apoplexy and palsy, and dropsy, are its frequent consequences. " With 
the exception," says Dr. Bateman, in his Observations on the Diseases of London, 
" with the exception of a small number of diseases occasioned by unwholesome 
occupations, and by the contagions, the great mass of human malady in this 
metropolis is referable to the climate or state of the seasons, and to intemperance: 
but, of these two causes, the vicissitudes of the weather, especially its cold, are 
by far the most prolific sources of mischief." 

It must, therefore, to every one who is engaged, or likely to be engaged, in the 
practice of physic, be a matter of first-rate importance, and of great interest, to 
ascertain the circumstances under which the application of cold is the most pre- 
judicial, or has the greatest influence upon the body — as well as the means by 
which the bad effects of exposure to cold may often, in a great degree, be pre- 
vented. 

There are some short but valuable hints upon this subject in Cullen's First 
Lines. The late Dr. Currie, of Liverpool, was, however, the first person who 
distinctly pointed out the laws that regulate the operation of cold as a cause of 
health and disease. 

Of the circumstances which favour the morbific effects of cold, some relate to 
the condition of the body itself, some to the particular manner in which the cold 
is applied. The former are predisposing circumstances; the latter accessory. 
We will glance at these in succession. 

It has long been a popular, as well as a professional axiom, that sudden vicis- 
situdes of temperature are dangerous; that a previous hot state of the body 
augments the hurtful effect of cold, whether applied externally or internally. But 
the proposition thus broadly stated is not universally true. It is well known that 
the inhabitants of Russia are in the habit, while reeking from their vapour baths, 
of rolling immediately in the snow, or plunging into cold water, without suffering 
from the change. Sir Charles Blagden, describing some of the experiments which 
I mentioned in the last lecture, says, ''During the whole day we passed out of 
the heated room (of which the temperature ranged from 240° to 260°), after every 
experiment, immediately into the cold air without any precaution. After exposing 
our naked bodies to the heat, and sweating most violently, we instantly went into 
a cold room, and stayed there even some minutes before we began to dress, yet no 
one received the least injury." And Captain Scoresby, speaking of the arctic 
regions, tells us that he has often gone from the breakfast-room of the vessel, 
where the temperature was 50° or 60°, to the mast-head, where it was only 10°, 
without any additional clothing, except a cap — "yet," says he, " I never received 
any injury, and seldom much inconvenience from the uncommon transition." 

It is plain, therefore, that the proposition which assigns danger to sudden 
vicissitudes of temperature requires limitation. The effects of a sudden descent 



72 



CAUSES OF DISEASE. 



from one point to another in the scale of atmospheric temperature vary according 
to the state of the body at the time. Without going into any physiological dis- 
cussion respecting the source of animal heat, I may just remind you of the faculty 
of evolving heat possessed by man and the warm-blooded animals ; by which 
faculty very nearly the same degree of inward temperature is steadily maintained 
under very different degrees of outward temperature. If the external temperature 
be lower than that of the body, the caloric thereby carried off is speedily replaced, 
in a healthy adult, by this evolution of heat from within, aided by clothing, or by 
exercise. When the external temperature approaches the standard heat of the 
body, sweat soon breaks forth, and the superfluous heat is removed by evapora- 
tion : for so constant is the internal evolution of caloric, that an atmosphere which 
does not as constantly abstract any of it is excessively incommoding: an external 
temperature of 98°, which is about the average heat of the blood in man, is, as 
you know, extremely oppressive. The terms hot, warm, cool, cold, as applied 
to the surrounding air, are regulated by the sensations that it produces upon the 
average of persons. If the heat be carried off as fast as it is generated, and no 
faster, no particular sensation is felt, and the bodily powers are neither stimulated 
nor exhausted. This equilibrium is maintained (supposing that no extraordinary 
exertions are made), when the thermometer stands at 62°, or thereabouts. We 
call that point in the scale temperate. All degrees above that point, up to 70, are 
reckoned warm; all above 70, hot. Descending in the scale, we speak of the 
temperature denoted by any degree between the 60th and the 50th, as being cool; 
and every lower degree of temperature is cold. I am speaking of the average of 
healthy men : for remarkable diversities occur among individuals in respect to the 
epithets which they assign, under the guidance of their sensations, to particular 
degrees of the thermometric scale ; their sensations differing according to the 
power which their constitutions respectively possess of evolving heat. Now if 
this power of evolving heat, thus inherent in the system, be entire, and active, 
and persistent — if it have not been weakened by any of those circumstances which 
are known to have the effect of weakening it— no peril need attend even violent 
alterations of external temperature. Unusual heat of the body at the time when 
the cold is applied, so far from implying danger, is really the condition of safety, 
provided the heat is steady and permanent. You may read, in Dr. Currie's book, 
numerous instances of the cold affusion being employed in the hot stage of fever, 
and particularly in cases of scarlet fever, not only with impunity, but with great 
benefit to the patient. The same holds true of the application of cold when the 
body has been heated by exercise — and, indeed, whatever may have been the 
cause of the increased heat — provided always that that cause remains steadily in 
action, that there is no local disease, and that the body is not fatigued, and fast 
losing its heat. But if a person be already exhausted and weakened by exercise 
— if he be sweating and rapidly parting with his heat — and especially if the exer- 
cise be over, and he remain at rest immediately after and during the application 
of the cold — then it becomes highly perilous, and likely to produce internal mis- 
chief. 

The more correct statement, therefore, respecting the application of cold is, 
that it is dangerous— not when the body is hot — but when the body is cooling 
after having been healed. 

This principle obtains alike, I say, whether the cold be applied externally or 
internally ; to the surface of the body, or to the mucous membrane of the stomach. 
Very many instances are recorded of death taking place immediately after a copious 
draught of cold water. I believe it will be found that in all these cases, the body, 
after having been much heated and enfeebled by severe exertion, was losing its 
preternatural heat from profuse perspiration, and, in general, from the cessation 
also of the exertion by which this heat was accumulated. Celsus was aware of 
the danger: "ex labore sudanti frigida potio perniciosissima est." The fatal 
influence of cold water thus applied was experienced, on a large scale, among the 
troops of Alexander the Gireat, upon their reaching the banks of the River Oxus, 



CAUSES OF DISEASE. 



73 



thirsty, fatigued, and perspiring from their toilsome march of forty-six miles across 
the scorching sands of the desert. According to Quintus Curtius, Alexander lost 
more of his soldiers on that occasion than in any one of his battles. " Sed qui 
intemperantius hauserant intercluso spiritu extincti sunt; niultoque major horum 
numerus fuit, quam ullo amiserat prcelio." Dr. Currie relates a striking example, 
which fell under his own observation, of sudden death thus produced. A young 
man had been playing a severe match at fives, and had violently heated himself. 
When it was over he sat down on the ground panting for breath, and covered 
with profuse perspiration. In this state he called to a servant to bring him a 
pitcher of cold water just drawn from a neighbouring pump. After holding it in 
his hand a little while, till he recovered his breath, he put it to his mouth, and 
drank a large quantity at once. He laid his head on his shoulder, and bent for- 
wards ; his countenance became pale, his breath laborious, and in a few minutes 
he expired. 

I may take the opportunity of telling you that the remedies to be administered, 
when life is in jeopardy from this cause, are warmth to the epigastrium ; and 
laudanum in free doses. 

If death does not speedily follow the external or internal application of cold fo 
the body under the untoward circumstances I have described, inflammation of 
some internal part is very apt to arise. 

By attending to the principles now laid down, you will be enabled to furnish 
those whom it may be your business to advise with many useful suggestions, and 
to caution them against some common mistakes : mistakes which have had their 
origin in the unqualified credit given to the maxim, that sudden vicissitudes of 
external temperature, and exposure to cold while the body is hot, are dangerous ; 
whereas these things are dangerous under certain circumstances only. Thus, you 
may tell the sportsman- that wet feet, or a wet skin, need cause him no appre- 
hension, so that he continues in active exercise; and changes his clothes, and 
avoids all further application of cold, as soon as his exercise ends. You may 
admonish the bather that after walking in a hot day to the river's side, he had 
better not wait to cool himself a little, before he plunges into the stream ; and in 
like manner you may venture to counsel the young lady who has heated herself 
with dancing, not to linger in the entrance hall till the glow has somewhat sub- 
sided, but to make the best of her way to her carriage, and thence to her bed ; and 
you may tell your male friends, who happen to be similarly circumstanced, that 
the best thing they can do is to walk briskly home in their great-coats. The main 
points to be remembered are, that " the heat which is preternaturally accumulated 
by exercise is held with little tenacity, is dissipated by profuse perspiration, and is 
speedily lost when to this perspiration is added a state of rest after fatigue ;" and 
that, in these circumstances, the application of cold is most apt to be prejudicial. 

Among the circumstances which favour the morbific effects of cold, and relate 
to the condition of the body itself, is to be included — for reasons that must now 
be obvious to you — whatever has the effect of weakening the system, and so 
diminishing its capability of evolving heat. The most common of these debili- 
tating circumstances are enumerated by Cullen — " fasting, evacuations, fatigue, a 
last night's debauch, excess in venery, long watching, much study, rest imme- 
diately after great exercise, sleep, and preceding disease." All these, you will 
observe, tend to lessen the vigour of the circulation, and to depress the power of 
generating heat. Consistent with the same principle is the fact ascertained by 
Dr. M. Edwards, that the faculty of evolving heat is very feeble in old persons, 
and in the newly born; it being in these classes that we find the greatest number 
of victims to the power of cold. 

The bad effects of cold upon the system depend partly upon the intensity of 
the sensation it produces — -but still more upon the duration of that sensation. 
We are seldom the worse for a momentary sensation of cold, however lively it 
may have been ; whereas even slight feelings of chillness, if long protracted, are 
apt to terminate in some form of disease. 



74 



CAUSES OF DISEASE. 



By the help of this principle we may explain most of the circumstances which, 
relating to the manner in which the cold is applied, have been found by experience 
to aggravate its hurtful influence. 

Cold is more likely, cseteris paribus, to prove injurious when it is applied by a 
wind, or current of air. The sensation of cold is sustained by the continual 
accession of fresh particles of frigid air to the surface of the body. Some striking 
facts in illustration of the refrigerating and depressing effects of a stream of cold 
air were mentioned in the last lecture. 

Again, the injurious operation of cold is augmented, when it is accompanied 
with moisture. Wetness is notoriously the worst way in which cold can be 
applied. The contact of wet or damp clothes with the skin both increases and 
prolongs the sensation of cold. For the same reason, a cold foggy atmosphere 
is more prejudicial than a clear, and therefore drier one, of the same temperature. 
The heat of the body is abstracted more rapidly than it is generated from within, 
and if it be not replaced by exercise, or cordials, the balance of the circulation is 
deranged, and internal mischief often follows. 

The same principles serve to illustrate the effect of certain other circumstances, 
adverted to by Cullen, as being counteractive of the morbific tendency of expo- 
sure to cold : "passions engaging a close attention to one object," — " that state 
of the body in which sensibility is greatly diminished, as in maniacs," — and "the 
power of habit." These circumstances are worthy of a moment's notice. 

Impressions which are unheeded are unfelt and inoperative. As it is scarcely 
possible, when the attention is engrossed by bodily pain, to carry on any con- 
nected train of thought — so on the other hand the senses become impassive in 
proportion as the mind is fixed upon some absorbing subject of reflection, or 
enchained by some powerful emotion: impressions made upon the organs of 
sense are no longer taken notice of; the corresponding sensations, if they are 
excited at all, are not remembered, and the effect of such impressions is as if they 
had never been ; they are not followed by the usual consequences. Persons 
gasping for breath in spasmodic asthma will remain for hours at an open window, 
with scarcely any clothing, during severe frost, and without suffering from the 
cold; their attention is so anxiously and exclusively bestowed upon the distress in 
their breathing, that the coldness of the air is unnoticed and unperceived, and has 
no sensible effect. 

For where. the greater malady is fixed, 
The lesser is scarce felt. 

The morbific effect of cold upon the system is certainly modified by the degree of 
attention that is paid to the sensation it excites. 

Upon the very same principle may be explained the impunity with which sonje 
maniacs undergo exposure to cold — even when suffering no fever which might 
regenerate the lost heat. "I have seen," says Dr. Currie, "a young woman, 
once of the greatest delicacy of frame, struck with madness, lie all night on a cold 
floor, with hardly the covering that decency requires, when the water was frozen 
on the table by her, and the milk that she was to feed on was a mass of ice." 

Sleep is enumerated by Dr. Cullen among those conditions of the body which 
diminish its power of resisting cold. And certainly cold is very readily caught 
(as the phrase is), when its causes are present, during sleep. But while we sleep 
sensation is in a great measure suspended. This would seem, therefore, to fur- 
nish a contradiction to the principle that the effect of cold upon the bodily health 
depends upon the strength and the duration of the sensation excited by it. Dr. 
Alison— I speak from recollection of his observations heard many years ago — 
disposes of this difficulty by affirming that the sleeper who thus suffers, does 
really feel, and is conscious of, the sensation of cold, and that it mingles with and 
probably suggests his dreams. Lord Brougham, in his Discourse of Natural 
Theology, gives a very lively picture of dreams so excited — drawn, as I should 
guess, from his own experience. Probably something of the same kind has 
occurred to most of us. " Every one knows (he says) the effect of a bottle of 



CAUSES OF DISEASE. 



75 



hot water, applied during sleep, to the soles of the feet: you instantly dream of 
walking over hot mould, or ashes, or a stream of lava, or having your feet burnt 
by coming too near the fire. But the effect of falling asleep in a stream of cold 
air, as in an open carriage, varies this experiment in a very interesting, and in- 
deed instructive manner: you will, instantly that the wind begins to blow, dream 
of being upon some exposed point, and anxious for shelter, but unable to reach 
it; then you are on the deck of a ship, suffering from the gale — you run behind 
a sail for shelter, and the wind changes, so that it still blows upon you ; you are 
driven to the cabin, but the ladder is removed, or the door locked. Presently 
you are on shore in a house with all the windows open, and endeavour to shut 
them in vain ; or, seeing a smith's forge, you are attracted by the fire, and sud- 
denly a hundred bellows play upon it, and extinguish it in an instant, but fill the 
whole smithy with their blast, till you are as cold as on the road/' 

Certain it is, that though while sleeping we are not sensible of, or (what per- 
haps is the same thing) do not remember, ordinary impressions, we are neverthe- 
less conscious of unusual sensations; so that the facility with which we take cold 
during sleep is no real exception to the general law, that the sensation produced 
by cold is concerned in its injurious effects. 

The last of the accessory circumstances mentioned by Cullen is « the power of 
habit." No one can doubt the effect of custom in enabling the body to resist the 
operation of cold, who has had opportunities of observing how differently an 
inclement temperature is borne by persons whose employments oblige them to 
live much under the open sky, as shepherds, sailors, stage-coachmen; and by 
such as pursue in-door occupations — mechanics, tailors, shopmen, and the like. 
Probably the sensibility of the surface is blunted by habitual exposure. We may 
believe too that the purer air breathed by the out-door labourer, and his more 
active life, confer a more vigorous state of health, and endow him with an ampler 
faculty of evolving animal heat. The fact is unquestionable; and we may some- 
times turn our knowledge of it to good account, in gradually fortifying the system 
against the influence of cold that cannot be avoided. An ill-directed application 
of this principle has led, however, to grave errors, and cost many lives. You will 
now and then hear parents talk of hardening their children, by causing them to 
brave all sorts of weather, by teaching them to be indifferent about variations of 
temperature, to sit in winter time without a fire in the room, and to despise great 
coats, flannel, and other additions to their usual dress. Fearing to render them 
effeminate by over care and cockering, they run into the opposite and more dan- 
gerous extreme. 

This process is often attempted with children originally delicate, and to such it 
is doubly hazardous. During the early periods of life the inherent protective 
power of evolving heat is comparatively feeble; and in this climate it requires to 
be carefully cherished. 

The experiment of hardening should never be tried on any child or person who 
is ailing or unsound; who shows any sign of present disease; or any marked 
disposition to future, and especially to scrofulous, disease. Whenever it is tried 
it must be conducted in conformity with the principles already laid down. The 
subject of the experiment must be sufficiently clothed, and he must not fail to use 
such exercise during the exposure as may be requisite to excite and sustain the 
adequate generation of animal heat. An abiding sense even of chilliness must 
never be aimed at nor permitted. 

The most direct and certain mode of fortifying the body against injury from 
accidental exposure to cold, is afforded by the use of the cold bath, and especially 
of the shower bath. When this is regularly taken in the morning, the surface of 
the body becomes inured to a degree of cold greater than it is likely to encounter 
during the remainder of the day. It is fortunate that we have an easy criterion of the 
propriety of continuing this expedient. When the sense of cold does not remain 
long, and is followed by a glow of warmth, the cold shower bath is sure to do 
good, If, however, after the bath, the person suffers headache, and continues to 



76 



CAUSES OF DISEASE. 



be chilly, languid, and uncomfortable, it should at once be given up as useless, 
and even hazardous. 

By observing these simple rules, a healthy child may be made hardy also, 
without the risk which their neglect would impose, of damage to his bodily fabric, 
and of abbreviating, by what was meant to prolong, his mortal span. 

Closely connected with the effects of temperature upon the health is the influ- 
ence of the different seasons of the year. A few remarks upon that influence, as 
it is witnessed in our own climate and country, may properly conclude our pre- 
sent subject. 

It is open to the commonest observation that the general health of the commu- 
nity fluctuates with the changing seasons. Catarrhs, and coughs, and pectoral 
complaints of all kinds, are most apt to commence, or to grow worse, in the win- 
ter and spring months ; while bowel-complaints are more numerous and distress- 
ing in the summer and autumn. The mucous membranes of the air-passages 
sympathize with the skin under the agency of external cold ; those of the stomach 
and intestines under that of continued atmospheric heat. 

The thoracic disorders are more serious and fatal than the abdominal. Various 
other maladies are likewise aggravated by cold, or by vicissitudes of temperature. 
Hence the mortality of the winter is always larger than that of the summer ; un- 
less, indeed, this rule happens to be disturbed by the intervention of some widely- 
spread epidemic. I am not sure that the superior salubrity of the hotter over the 
colder portion of the year is generally acknowledged, even in this age of enlight- 
ment. 

It is the cold that, more than any other element of the weather, occasions the 
difference. 

There are two small publications by the present Dr. Heberden, to which I 
would direct your attention, as being singularly instructive upon these points. 
One you will find in the eighty-sixth volume of the Philosophical Transactions : 
Of the influence of Cold upon the Health of the inhabitants of London. The 
other is a separate pamphlet. Observations on the Increase and Decrease of dif- 
ferent Diseases. 

From a number of tables, framed chiefly upon the weekly bills of mortality, 
Dr. Heberden (in the last-named paper) draws the conclusion that the whole 
number of deaths is greatest in January, February, and March, and least in June, 
July, and August. This is contrary to the notions of the ancients, and perhaps 
of many of the moderns also. Celsus says, " Igitur saluberrimum ver est ; prox- 
ime deinde ab hoc, hiems ; periculosior aestas ; autumnus longe periculosissimus." 

The difference of place may perhaps account for this difference of opinion. 
Celsus lived in Rome. That city, and the surrounding district, abound in mala- 
ria; a cause of disease which, happily, is now scarcely known in London, but 
which, wherever it exists, operates most powerfully and most extensively during 
the autumn. The comparative healthiness of the several seasons may doubtless 
be disturbed, and even reversed, by endemic peculiarities of this kind. 

In his paper in the Philosophical Transactions, Dr. Heberden compares the 
number of deaths that took place in London in January, 1795, which was an un- 
usually severe month, with the number that occurred in January, 1796, which 
was an uncommonly mild month. Of those two successive winters one was the 
coldest, and the other the warmest, of which any regular account had been kept 
in this country. In the month of January, 1795, the thermometer, upon an ave- 
rage, stood at 23° in the morning, and 29 0, 4 in the afternoon ; always, you will 
observe, below the freezing point. In the same month in 1796, it stood at 43°-5 
in the morning, and at 50° in the afternoon ; always much above the freezing 
point. The average difference in the two months was more than 20°. 

In the five weeks beginning upon January 1st, 1795, there were 2823 deaths : 
in the five weeks beginning upon January 1st, 1796, there were only 1471. The 



CAUSES OF DISEASE. 



77 



difference, 1352, is enormous. The mortality in the former year was nearly 
double of that in the latter. 

One object which Dr. Heberden had in view in making this comparison, was 
to disabuse his countrymen of the notion that, in winter, frosty weather is more 
favourable to health than mild weather; a notion which has been embodied in the 
proverb, that " a green Christmas makes a fat churchyard." 

It is very instructive to remark in what classes of persons the injurious effects 
of the severe weather of winter is most felt. The increased mortality was found 
to be chiefly among the very young, and the very old ; in other words, among 
those in whom the recuperative power of generating heat is the feeblest. 

In January, 1795, there were in London 717 deaths of persons above sixty 
years old, while in January, 1796, there were only 153 such deaths ; or scarcely 
more than one-fifth of the former number. 

I have often been struck by the unusual length of the newspaper obituaries dur- 
ing periods of hard frost; and by observing how many of the individuals whose 
deaths they record were far advanced in years. Dr. Heberden remarks that 
among persons older than sixty, the tide of mortality, as measured by the weekly 
bills, follows regularly the degree of coldness of the weather ; so that any one 
accustomed to examine these lists may form a tolerably accurate judgment of the 
severity of any of our winter months, by noting the ratio of the mortality in per- 
sons above sixty. 

The deaths from asthma (under which vague term all kinds of pectoral disorder 
attended with shortness of breath appear to have been included) were 249 in Janu- 
ary, 1795; only 29 in January, 1796. In the former of these months there 
were 825 deaths attributed to consumption; in the latter, 342. 

All this accords with what I mentioned before of the effect of cold weather in 
producing or exasperating diseases of the respiratory organs. 

One of the conclusions deduced by Dr. Heberden from his examination of the 
bills of mortality is, that " the number of deaths by palsies and apoplexies is in 
this country always greatest in winter." There are intelligible reasons for this. 
When the surface is chilled, and the blood driven out of the superficial vessels by 
the cold, it must accumulate in internal parts, and so press with increased force 
towards the head. And there is another reason for the frequency of these affec- 
tions in the winter season : it is, as we have seen, the season of pectoral com- 
plaints, and of embarrassed respiration. Dyspnoea and fits of coughing greatly 
impede the return of the blood from the head through the veins : and cerebral 
congestion tends to the production of cerebral hemorrage, especially when the 
arteries of the brain are diseased ; and they often are' so. Accordingly we find 
that in January, 1795, there were fifty-two deaths from apoplexy and palsy ; 
while in January, 1796, the number was only thirty-one. 

Since these lectures were first delivered, three Annual Reports of the Regis- 
trar-General of Births, Marriages, and Deaths in England, have been printed, 
and liberally circulated, by the obliging attention of Mr. Lister, among the mem- 
bers of our profession. Much of the practical information afforded by these in- 
teresting volumes is rendered accessible, even to a cursory reader, by Mr. Farr's 
able analysis of the registered facts ; which amply illustrate and confirm most of 
the inferences drawn by Dr. Heberden from the old tables of mortality. 

For example, under the head of " Influence of the Seasons," Mr. Farr shows, 
by numerical statements, especially in the third Annual Report, that in London 
the degree to which the mean monthly temperature descends in December, Janu- 
ary, or February, determines, to a great extent, the mortality of the winter. 

Again, ** The causes of death which prove most fatal in the cold months belong 
principally to the pulmonary class, and the cerebral diseases of the aged : those 
which prove most fatal in summer belong to diseases of the bowels." 

The mean temperature of the external atmosphere in London is 50|°. In pro- 
portion as the mean temperature of the day and nightfalls beneath that point, the 
mortality progressively increases. 



78 



CAUSES OF DISEASE. 



" The rise in the mortality," says Mr. Farr, " is immediate ; but the effects of 
the low temperature go on accumulating, and continue to be felt thirty or forty 
days after the extremities of the cold have passed away. The cold destroys a 
certain number of persons rapidly ; and in others occasions diseases which prove 
fatal in a month or six weeks. The practical lesson taught by these facts is obvious. 
A great number of the aged, and of those afflicted with difficulty of breathing, 
cannot resist cold sunk so low as 32°. The temperature of the atmosphere in 
which they sleep can never safely descend lower than 40°: for if the cold that 
freezes water in their chamber does not freeze their blood, it impedes respiration, 
and life ceases when the blood heat has sunk a few degrees below the standard." 

The immense body of authentic facts thus yearly accumulating in these Reports 
constitute most valuable contributions to the science of vital statistics; and cannot 
fail to throw light upon the sources, and to point towards the prevention, of many 
very dangerous and destructive disorders. To ascertain the causes of any disease, 
and to display them before the public mind, are, I repeat, large steps towards the 
ultimate removal of such as human endeavours are competent to remove. 

You may trace the influence of the seasons, not only in the prevalence of par- 
ticular diseases in certain portions of the year, but also in the character of other 
disorders that are liable to occur in all periods of the year alike ; in the character, 
for example, of fevers. In the majority of cases of continued fever, you will find 
that the pectoral symptoms are most troublesome in the spring, and the abdominal 
symptoms in the autumn. It is said, also, but I do not know that this is so gene- 
rally true, that affections of the head, in continued fever, are more frequent and 
severe in the winter than at other periods of the year. 

Mere impurity of the air — by which I mean impurity that does not result from 
the admixture of any specific poison, such as the marsh poison, and the various 
contagions — is a powerful predisposing cause of disease. The prejudicial effect 
of impure air is seen, on a large scale, by comparing the inhabitants of great 
towns, in respect of health and longevity, with those who live in the country. 
If we again refer to Mr. Farr's calculations, founded upon the returns made to the 
Registrar-General, we find it staled, in the third Annual Report, that in cities, as 
contrasted with rural districts, the deaths from consumption are increased 24 per 
cent.; those from typhus 55 per cent.; those from childbirth 59 per cent.; and 
so of several other disorders. ".The diseases chiefly incidental to childhood are 
twice as fatal in the town districts as they are in the country." The mean dura- 
tion of life in the two classes of districts differs nearly 17 years; being in the 
proportion of 55 years [country) to 38 years (towns). 

These differences we can explain only by attributing them to the weakening 
influence of impure air, and the want of sufficient exercise : for, as Dr. Alison 
has remarked, " it is hardly possible to observe separately the effect on the animal 
economy of deficiency of exercise, and deficiency of fresh air, these two causes 
being very generally applied together. But it is perfectly ascertained on an 
extensive scale, in regard to the inhabitants of large and crowded cities as com- 
pared with the rural population of the same climate, that their mortality is very 
much greater, especially in early life — and the probability of life very much less." 
There is one circumstance which shows that impure air is the more noxious agent 
of the two, namely, the great comparative mortality, in towns, of children under 
two years of age, even although they get as much exercise as their time of life 
would allow of anywhere. 

The noxious and depressing influence of vitiated air is made strikingly manifest 
by the effect of removal to a purer atmosphere. "We are continually obliged to 
recommend " change of air" to our patients. We advise them to go out of Lon- 
don, that their recovery from acute disorders may be accelerated, and that they 
may regain the degree of general strength which is necessary to the cure of many 
chronic complaints ; of all .those especially that require the use of tonic medicines, 
among which class of remedies no one is so effectual, in constitutions that have 



CAUSES OF DISEASE. 



79 



been weakened by a town life, as migration to the clear and pure air of the 
country. 

It is necessary, however, to remember that although impure air has most un- 
questionably a very hurtful effect upon the general health, there is no specific 
disease which can be distinctly traced to it as an exciting cause. It is as a pre- 
disposing influence that the impurity operates. For instance, it never generates 
(as I believe) continued fever, yet it will most certainly aggravate the symptoms, 
and favour the propagation, and augment the mortality, of that, and of other dis- 
eases, in a great degree. If there be any diseased condition that is strictly the 
product of impure air, it is scrofula. Scrofula (as I shall presently show you) 
depends in part upon hereditary constitution ; it partly arises also from exposure 
to cold and wet; but there is much reason for believing that impure air is a very 
powerful agent in calling scrofula into action, and in aggravating the strumous 
diathesis. 

I have entered the more fully into the consideration of certain states of the 
atmosphere, its extremes and its variations of temperature, and its impurity, as 
causes of disease, because there is no part of the course in which I could more 
conveniently introduce them. Most of the other causes of disease, enumerated 
in my last lecture, will be discussed in connection with the disorders to which 
they give birth: malaria, for example, when I speak of ague; contagions, when 
we come to the exanthemata and to continued fever; epidemic influences, with 
epidemic distempers; improper or insufficient diet, and intemperance generally, 
w ith indigestion, and the disorders of the alimentary canal ; and so on. There is, 
however, one remarkable predisposing cause of disease, a few observations upon 
which may serve to fill up the little that remains of the present hour. I mean, 
that disposition to certain diseases which is apt to descend from parents to chil- 
dren : hereditary tendencies to disease. 

We must distinguish between stisceptibility of disease, and a tendency to disease. 
In one sense all persons are born with a predisposition to most forms of disorder. 
No one is protected by nature against inflammation when the causes of inflamma- 
tion come into play. Poisons of various kinds, and specific contagions, which 
indeed are poisons, operate with tolerable uniformity upon all men alike. 

But there are certain complaints which we may separate in this respect from the 
others: which complaints some persons have a tendency to, and some have not. 
The tendency is sometimes strong and evident, sometimes feeble and faintly 
marked; sometimes it displays itself in the midst of circumstances the most 
favourable to health, sometimes it requires for its development conditions the 
most adverse and trying. To mention some of these diseases: scrofula, which I 
soon shall describe more particularly, gout, mania, and (I believe I may add) 
spasmodic asthma. 

Not only is a disposition to these complaints strikingly pronounced in some 
persons, but other persons appear wholly free from such a tendency — nay, even 
devoid of the susceptibility of them. Gout, in those capable of it, may be acquired 
by habits, as it may be repressed and prevented by the opposite habits. The 
habits that, in certain persons, bring it on, are the intemperate use of the luxuries 
of the table, and an indolent or sedentary manner of life: but there are many 
people in whom no amount of rich living or idleness will generate gout. So 
there are some in whom no exposure to impure air, cold, and wet, and no priva- 
tions — in other words, no appliance of the influences calculated to bring the 
strumous diathesis into play — will ever produce any form of scrofula; will ever 
render them consumptive, for instance, consumption being one of the most common 
and fatal shapes of scrofulous disease. There are many who endure the utmost 
distress and excitement of mind, yet never become insane. There are many who 
never become afflicted with asthma, although surrounded by the most powerful 
exciting causes of that complaint. 

Now with respect to these diseases, and perhaps a few others, it is matter of 
fact that they occur much more frequently in persons, some one or more of whose 



80 



CAUSES OF DISEASE. 



ancestors have suffered from them, than in other persons : the tendency is trans- 
mitted, is hereditary. 

That the circumstances of the parents do influence the physical characters* of 
the children, no one can doubt: it is matter of daily observation; and one of the 
best possible illustrations of the fact is to be found in what are called family like- 
nesses. We see children resembling their father, or their mother; or both parents 
at once, as mulattoes. 

It has been suggested that the similarity in features and expression, and even 
in moral character, which cannot be denied to exist, may be ascribed to training 
and imitation. But allowing something to that cause, it cannot be all. It was, I 
remember, a common remark when I was at Cambridge, that the followers and 
admirers of a very good man, the late Mr. Simeon, appeared to come at last to 
resemble him. So man and wife are sometimes fancied to grow like each other. 
That is, the same prevailing cast of thought and feeling, the idem sentire et idem 
velle, may give such an habitual expression and character to the countenance, as 
shall constitute, to superficial observers, a likeness. But there are family-likenesses 
which will not admit of such an explanation as this: similarities in the shape or 
size, or disposition of peculiar features. Every one has heard of, or may remark 
in portraits, the hereditary thick lip of the imperial house of Austria. Many 
persons now living have had the opportunity of tracing the lineaments of our own 
royal family through at least three generations. The sisters of one of our 
English dukes are remarkably handsome young women, and bear, to this day, a 
striking resemblance to the portraits of their beautiful ancestress, the celebrated 
Nell Gwyn. And independently of the general cast of features, we. trace these 
family-likenesses in minute or unequivocal particulars, as the colour of the hair 
and eyes, the shape of the limbs, the stature of the body, and so on : nay, in more 
decided peculiarities than these, in points of unusual formation. You have heard, 
probably, of the American calculating boy, Zerah Colburn. A great number of 
individuals of his family, descended from a common ancestor, had six fingers and 
six toes instead of five. The peculiarity was transmitted through four successive 
generations ; and probably, could his pedigree have been further traced, through 
many more. I am myself acquainted with a gentleman who had the misfortune 
some years ago to have a bastard child laid to his charge. At first he had some 
misgivings on the subject, and suspected that he might have no title to the credit 
(or I should rather say to the discredit) of the imputed paternity; but all his 
scruples were satisfied when he found that the child had six fingers on each hand, 
for he had himself possessed two small supernumerary fingers, which had been 
amputated when he was an infant. Haller gives an account of a web-footed 
family, descended from a mother in whom that configuration existed. There is now 
living ki London a musical composer of some celebrity, in whose person nature 
has played a similar freak ; and whose father, grandfather, and great-grandfather, 
were all web-footed before him. Beyond this point his information does not 
reach. I am indebted for the knowledge of this instance to one of my former 
pupils, Mr. Cooper, of Grafton-street. 

Now there is one very curious circumstance observable in regard to these 
family-likenesses, namely, that they may fail to appear in the child, and yet appear 
in the grandchild ; may skip over a generation or two ; may, after lying dormant, 
break out, as it were, in some collateral branch of the family tree. 

This not only proves that certain physical peculiarities may be transmitted, but 
it discloses this remarkable property, that peculiarities not possessed by the parent 
may nevertheless be transmitted by him. And this evidently opens a wide field 
for the operation of hereditary tendencies. A person is not to consider himself 
as necessarily free from a disposition to consumption or gout, because his parents 
have never shown any symptoms of those disorders. 

When one parent only bears the transmissible tendency, the disease appears to 
be most apt to break out in the children who most resemble that parent in their 
physical conformation and appearance. Yet this is not a universal rule. I am 



SYMPTOMS. 



81 



acquainted with a gentleman who had lost several brothers or sisters by phthisis. 
The fatal disposition is known to exist on his mother's side, while his father's 
pedigree is believed to be quite free from it. All the children that have hitherto 
become consumptive have resembled the mother in bodily configuration and fea- 
tures, except this gentleman, who is like his father's family, but who, neverthe- 
less, labours under unequivocal consumption.* 

It becomes a very interesting, and a very important question, whether acquired 
peculiarities can be transmitted. I have been told, by a gentleman attending the 
class, that he knew a man who, having been accidentally deprived of sight, after- 
wards propagated blind children. I believe, however, such an event to be 
uncommon. Dr. Prichard is of opinion that all original or connate bodily peculi- 
arities tend to become hereditary, while changes in the organic structure of the 
individual from external causes during life, end with him, and have no obvious 
influence on his progeny. Although this general law is probably true, I doubt 
whether it be yet sufficiently established by a reference to actual facts. 

I need scarcely say a word respecting the importance to medical men, and 
indeed to all men, of a knowledge of these hereditary dispositions. Such know- 
ledge ought to regulate, in some degree, the choice of persons wishing to marry. 
Where both parents have a decided tendency to any complaint, there will be a 
double probability of a diseased offspring. Lawful intermarriages between mem- 
bers of the same family are often highly objectionable on the same sttore. Any 
inherent defect or morbid propensity is aggravated by what cattle-dealers call 
" breeding in and in." 

Again, if it be known that in any family an hereditary proclivity exists — to gout 
and gravel, for instance, or to consumption — this knowledge ought to warn every 
individual of that family sedulously to avoid the causes which foster and develop 
these diseases; and medical men, possessed of the requisite information, may 
give most valuable advice and instruction on these points. 



LECTURE VIII. 

Symptoms. Their Uses in relation to the Diagnosis, the Prognosis and the 
Treatment of Diseases. Signs, as distinguished from Symptoms. Pathog- 
nomonic^ Commemorative, Direct nd Indirect Symptoms. Examples of 
Symptoms as they consist of uneasy Sensations, disordered Functions, or 
changes of Sensible Qualities. 

We are perpetually reading and talking about symptoms ; and no wonder, for 
symptoms are the signals by which we learn that disease is present; the evidence 
upon which our whole art proceeds. We are always, therefore, observing symp- 
toms, analyzing them, striving to interpret their meaning, to ascertain what they 
signify. Without a knowledge of symptoms we can have no knowledge of the 
art of physic. Sagacity in penetrating the import of symptoms constitutes a great 
part of the skill of an able physician. We shall find it useful to take a cursory 
view of semeiology, and to familiarize our thoughts with some of the cardinal 
symptoms themselves, before we speak of them in connection with particular 
diseases. 

What do we mean by a symptom ? 'Zv/xriTf^/xa — "Something that happens con- 
currently with something else." Symptoms, they say, are coincidences, but this 
is merely translating the word cvimt^fxata into English through the Latin-. 
Symptoms are sometimes defined to be morbid phenomena — "anything observed 
in a patient out of the course of health." But in forming our estimate of disease 

* This gentleman, an eminent London physician, has died since this lecture was given. 
6 



82 



SYMPTOMS. 



we must often take into account functions that are regular and undisturbed : these 
have been said to furnish negative symptoms. For my own part, if I were called 
upon to define a symptom, 1 should say, " Every thing or circumstance happen- 
ing in the body of a sick person, and capable of being perceived by himself or by 
others, which can be made to assist our judgment concerning the seat or the 
nature of his disease, its probable course and termination, or its proper treatment: 
every such thing or circumstance is a symptom" 

And I wish you to take notice at once, that it is for the three purposes just 
adverted to, that we cultivate the study of symptoms, viz.: — 

First, To ascertain the seat and the nature of the disease under which our 
patient is labouring: in technical language to form the diagnosis. I am no great 
friend to technical phrases where they can be avoided without inconvenience; 
but in some cases short terms of art save us a great deal of tiresome periphrasis 
and circumlocution. 

A second object of the study of symptoms is to enable us to foresee and foretell 
the probable course and issue of the disease ; in other words, to frame the 
prognosis. 

And a third, and paramount use of a knowledge of symptoms, is to direct our 
treatment of the disease. 

I suspect that the immense importance of the first mentioned of these three 
objects — the diagnosis or recognition of disease, is not always clearly seen, either 
by students or practitioners of medicine. Sometimes we are obliged to prescribe 
for a malady, although we are in great uncertainty, perhaps in total ignorance, 
respecting its nature or its situation. But this is always unsatisfactory. On the 
other hand, when we have ascertained where and what ihe disease is, we apply 
with much more confidence, precision and comfort, those rules for its relief which 
we have picked up by our own observation, or have been taught by others. This, 
how r ever, is a very limited view of the importance of an exact and true diagnosis. 
Diagnosis forms the indispensable basis of all advances in physic as a practical 
art. There is a common saying, that the knowledge of what a disease is, is half 
its cure. In one sense this may sometimes be true, but in another sense it is not 
so. Almost all that we know concerning the proper treatment of the sick is 
origiymlly derived from observation, not of the nature of diseases, but of the 
effects of remedies. That rhubarb will purge, and opium lull to sleep, and loss 
of blood occasion faintness, are truths which experience alone could suggest, and 
successive trials alone confirm. They are purely empirical truths. No one could 
guess them beforehand. No skill in the discrimination of disease has even a 
tendency to teach them. In some few cases, indeed, we see that certain mechani- 
cal derangements exist, which are manifestly capable of mechanical relief. When 
parts of the body are displaced, as in hernia and dislocations ; or when distension 
and pressure are evidently produced by accumulated fluids ; the mechanical reme- 
dies are at once suggested by the physical and obvious faults. But with such 
exceptions, diagnosis does not, of itself, afford us any direct information as to the 
cure of diseases ; but it does this — it defines and fixes the objects about which 
observation is to be exercised, and experience collected. When we can once 
identify a given diseased condition, we obtain the privilege of watching the 
behaviour of that diseased condition, again and again, under the operation of 
therapeutic measures; and from that time the increase of our knowledge concern- 
ing the appropriate management of that particular disease becomes progressive 
and sure. The term experience is obviously misapplied, and the results of all 
observation are vitiated, when any doubt exists about the sameness of the objects 
contemplated. It is mainly to this imperfection in the diagnostic part of medi- 
cine that we must attribute the uncertainty and variation, both of doctrine and 
practice, which have brought so much suspicion, and reproach, and ridicule upon 
the science we profess. False experience, if I may use such a term, has greatly 
hindered the progress of the healing art ; and false experience springs from false 
diagnosis. A man will tell you that he has cured a score of cases of advanced 



SYMPTOMS. 



phthisis ; but he has deceived himself : they were not cases of true phthisis, but 
simply cases of chronic inflammation, with puriform discharge of the mucous 
membrane of the bronchi. He publishes an account of his success, and of his 
plan of treatment; and thus he deceives others also: and thus he retards the sci- 
ence which he fondly and conscientiously believes he is promoting. Accuracy of 
diagnosis, then, cannot be too highly estimated, nor too diligently sought after. 
It has been wonderfully improved within the last twenty years. 

The prognosis, or foreknowledge of the course and event of diseases, has but 
little connection with the promotion of the art of healing; but it is not on that 
account less worthy of our attention. Both physician and patient find their 
advantage in the capability of the former to determine whether a disease be reme- 
diable — to foresee the changes that may be expected in its progress — to predict 
the manner in which it will terminate. Knowledge of this kind opens to us a fair 
and honourable source of credit and reputation ; and it begets a degree of confi- 
dence towards us, which is beneficial, not merely to ourselves, but to our clients. 
Our influence over a sick person, and the efficacy of many of our remedial mea- 
sures, are remarkably increased by the reliance he places on our skill, and by our 
apparent acquaintance with the nature of his complaint. It is often of material 
consequence, in another point of view, that the fatal character of a disease should 
be plainly perceived. A sick man, made aware of his danger, is furnished with 
a motive and an opportunity for arranging his worldly affairs, in the settlement of 
which the future comfort and happiness of his family may be very deeply con- 
cerned ; for making his will ; and also for more solemn preparation for the awful 
change that awaits him. For these reasons medical men have, in all periods, 
endeavoured to read, in the phenomena presented to them by diseases, the event 
to which those diseases severally tend. To form an accurate opinion on this 
head is, however, one thing — to divulge it, another. There is always some risk 
of losing, instead of gaining credit, by strong statements, and confident predic- 
tions of the death or the recovery of a patient. If you give an unfavourable 
prognosis, you have a good chance of losing your patient altogether; his friends 
argue very naturally, that you are not infallible, that you may be wrong, that if 
you know of no means of safety for him, some other practitioner may, and they 
will grasp at whatever straw comes near them. Do not suppose that this is 
merely a selfish view of the matter : it is often of much moment to the patient 
himself, that he should not be tempted to put his life under the charge of impos- 
tors, who will feed his hopes, and promise largely, and torture him perhaps with 
their discipline, and have no mercy upon his pocket. Many an instance have I 
known of persons dying of consumption, who, when given over by their regular 
attendants, have been brought to London at considerable expense, exchanging the 
many comforts of home for the inconveniences cf a hired lodging, that they might 
be cured by that ignorant and cruel and rapacious quack, Mr. St. John Long. 
There are other reasons, too, why we must sometimes conceal the truth from our 
patients. It often happens that a person is extremely ill, and in great danger, 
but may yet recover if he is not informed of his peril. To agitate a person in 
these circumstances by telling him that he is likely to die, is to lessen, perhaps 
to destroy, his chance of recovery. You kill him if you take away his hope of 
living. It must be confessed that the duty of the medical man in these cases is 
very painful and embarrassing : the patient and the patient's friends are urgently 
inquisitive to know whether there is any danger ; or whether he is not yet out of 
danger. The rule which I have always adopted in circumstances of this dis- 
tressing kind, when I see clearly that the case is hopeless of cure, is to fix as well 
as I can upon that person among the family or friends of the patient to whose 
prudence the real state of the matter may be the most safely confided. If I think 
that there is a possible chance of recovery, and that a knowledge of his danger by 
the patient would diminish that chance, of course I urge the necessity of speaking 
to him with assumed cheerfulness and confidence ; if I see that the case is abso- 
lutely and inevitably mortal, either soon or at some little distance of time, I leave 



84 



SYMPTOMS. 



it to the discretion of the person with whom I communicate to disclose or conceal 
my opinion as he or she may think best. There are, I believe, practitioners, 
who make it a point, on principles of worldly policy, never to speak despairingly 
of a patient; but I cannot regard such a rule of conduct as honest, or justifiable, 
or consistent with one's Christian duty. 

Now I would have you observe that symptoms do not serve equally or indif- 
ferently the three several purposes that I have spoken of. The same symptom 
or set of symptoms may indeed at once reveal the nature of the disease, and fore- 
show its result, and indicate its treatment. When we have discovered what the 
disease is, we may want no further information to tell us how it will terminate, 
or how we are to prescribe for it. A man previously sound and well, shivers, 
then becomes hot, and afterwards sweats, and then reverts to his natural state of 
comfort and good health : and the same series of phenomena recur every other 
day. We pronounce the disease to be ague; we predict that, in this climate at 
least, the patient will recover; and we give him quina; all upon the strength of 
the same set of symptoms. But this is not necessarily the case: certain symp- 
toms may disclose to us what the malady is, and where it is situated; other 
symptoms teach us whether our patient is likely to survive or not; and a still dif- 
ferent set instruct us what is the proper method of cure to be attempted. We see 
a number of little pustules scattered over his skin, and we know that our patient 
is labouring under small-pox. His chance of recovery will be singularly differ- 
ent, according as the spots upon his face run together, or remain separate and 
distinct from each other; and we investigate the state of his pulse, and his breath- 
ing, of his bowels and his brain, before we can venture to prescribe for him. 
Those symptoms, or combinations of symptoms, which disclose the place and 
nature of the disease, we call signs of disease; those which teach us what to do, 
we call indications of treatment. We speak also of prognostic signs. By 
keeping these distinct ends of the study of symptoms in mind, we shall be enabled 
to group them to advantage, and to avoid huddling confusedly together symptoms 
that speak, not indeed a different language, but upon a different topic. The 
ancients, who knew but little of the intimate nature of diseases, but who paid 
great attention to symptoms, have laid down most admirable rules in respect to 
prognosis : which shows not only that the prognostic signs are more easily made 
out, in many cases, than the diagnostic, but also that they may be independent of 
them. 

I have just spoken of symptoms as being signs. These words are not, how- 
ever, exactly synonymous, although they are frequently employed as if they 
were so. Even those medical writers who admit a distinction between them, 
have not always succeeded in clearly pointing out the difference. Signs are 
deduced from symptoms, by arranging and comparing them, and noticing the 
circumstances under which they occur. Symptoms are obvious to all persons 
alike — to the nurse as well as to the physician : signs, for the most part, are such 
to medical eyes alone. Let me try to make this plainer by the help of an illus- 
tration. Symptoms may be considered as resembling so many words. When 
taken separately, or when put together at random, the words have no force or 
signification. Arrange them in due order, reduce them into a sentence, and they 
convey a meaning. The sentence is a sign or expression of something which is 
thus revealed. Symptoms become signs when their import can be interpreted. 

A certain crackling sound, of which I shall have much to say hereafter, is heard 
(we will suppose) in some part of a patient's lung, by the ear applied outside his 
thorax. The sound is a symptom; any one who listens may perceive it. It is 
even so far a sign that it denotes the unnatural presence of a liquid in the lung, 
and the passage of air through that liquid. But the liquid may be one of several 
— mucus, or serum, or pus, or blood: we cannot tell by the sound alone which 
of these it is. But if we learn that the person in whose lung the sound is audible 
has been ill for a day or two only, that he has pain in his chest, cough, embar- 
rassed breathing, and fever, we conclude that he is labouring under that serious 



SYMPTOMS. 



85 



disease, inflammation of the lung. The crackling sound alone could not assure 
us of this ; nor without the addition of this sound could the pain, the laboured 
breathing, the cough, or the fever. Taken collectively, the symptoms constitute 
a diagnostic sign, and bespeak the existence of pneumonia. 

Sometimes a symptom, or set of symptoms, becomes a sign, by its relation to 
what has gone before and what follows it. To adhere to our illustration, the 
meaning becomes evident from the context. By comparing, at short intervals, in 
the supposed case of pneumonia, the extent and character of the sounds heard 
during respiration, we ascertain whether the disease be advancing or receding ; and 
thus convert the sounds, or their variations from day to day, into a prognostic sign. 

We always strive,- then, to penetrate beyond the symptoms to the disease of 
which they are significant. But we do not always succeed in this, and when we 
do not (as in the case of ague), we are driven to the necessity of regarding the 
combination of symptoms as the disease. 

You will often hear of pathognomonic symptoms. A pathognomonic symptom 
is one which, when it occurs, settles infallibly the nature of the malady ; becomes 
a positive sign or token of a particular morbid condition. But there are very few 
symptoms, if there be any, which, taken singly, can ever be said to be strictly 
pathognomonic signs ; yet a symptom which in itself possesses little or no value 
may become very significant when conjoined with others. 

Much light is often thrown upon symptoms by what the French call commemo- 
rative circumstances — that is, by a knowledge of the previous history and condi- 
tion of the patient. For example, a person may have palpitation and other marks 
of disordered action of the heart, and doubts may exist whether these symptoms 
depend or not upon organic disease of that organ. The question is often deter- 
mined in the affirmative, by our learning that the patient has had one or more 
attacks of acute rheumatism of the joints. 

There are some other general division of symptoms, which it is useful to attend 
to. Thus some symptoms are said to be direct, and others to be indirect symp- 
toms. Direct symptoms relate to the very part which is affected; indirect symp- 
toms are such as " declare themselves through the medium of some other parts, 
or through the medium of the constitution at large." There are some cases in 
which the direct symptoms are of much more value than the indirect ; and there 
are other cases in which those which are indirect are the most important; and 
there are yet many more which require for their elucidation a knowledge of both 
the direct and the indirect symptoms. 

Again, there are many symptoms of which we receive no information, except 
through the statements made by the patient himself; and there are many others 
of which we learn the existence by means of our own observation, by the exer- 
cise of our several senses. The relative importance of these varies too in differ- 
ent cases. Of course those symptoms which we are able to ascertain for ourselves 
are the most trustworthy ; but both sorts of symptoms shed mutual light upon 
each other. We should constantly be making mistakes if we relied solely upon 
what our patients tell us. On the other hand, the value of the information we 
derive from their statements is made apparent by the difficulty we are apt to 
experience in investigating the diseases of children ; of those who are dumb; or, 
what is much the same thing, who speak no language that we understand. 

Now, setting aside that notice of the healthy functions which is sometimes 
necessary in order to determine the relative value and meaning of other symp- 
toms, and regarding those symptoms only which consist of morbid changes, they 
may all be classed under three heads : 1. Uneasy, unnatural, or impaired sensa- 
tions : 2. Disordered or impeded functions: and 3. Alterations of structure or of 
appearance; changes of sensible qualities. When these last come within the 
direct cognizance of our senses, they are called, usually, physical signs. 

Uneasy or altered sensations we can only be aware of through the testimony 
of the patients themselves. The symptoms belonging to the other classes fall, 
generally, under our own notice. 



86 



SYMPTOMS. 



Uneasy or altered sensations comprehend a large class of morbid symptoms. 
By their occurrence persons sometimes become conscious that they are unwell 
before any other symptoms are observable. Of all the uneasy sensations pain is 
the most common and the most important. It rarely happens that it is not felt, 
at one period or another, in inflammatory disorders; and it very often occurs, and 
is very acute too, when there is no inflammation at all. I shall have occasion, in 
a subsequent lecture, to lay before you the criteria between pains that accompany 
inflammation, and pains that are independent of it. Upon that point of distinction 
the whole question of treatment commonly depends ; and it is often a most diffi- 
cult point to determine. 

There are many different kinds and degrees of pain. Different kinds of morbid 
action are accompanied by different kinds of pain ; and the same kind of morbid 
action—inflammation, for example — produces different modifications of pain, 
according as it affects different parts. The pain that belongs to inflammation of 
the lungs differs from that which is felt in inflammation of the bowels. Bones, 
muscles, tendons, ligaments — the bladder, the kidney, the uterus — all modify, in 
a manner peculiar to themselves, the pain that is produced in them by injury or 
disease. Different epithets are given to the different varieties of pain — i. e., per- 
sons endeavour to explain how they feel by likening their sensations to something 
which they have felt before, or fancy they have felt. Thus we hear of sharp 
pain — shooting pain — dull pain— gnawing pain — burning pain — tearing pain; 
and so on. 

If pain be felt in a part only when it is touched, i. e. t when pressure is made 
upon it, the heightened sensibility is called tenderness:— the part is said to be 
tender. This is a very important kind of pain, as we shall see hereafter. A 
part may be both painful and tender: or painful without being tender: or tender 
without being otherwise painful. 

Pain often takes place, not in the part really affected by disease, but in some 
distant part. Inflammation of the liver or diaphragm will cause pain of the right 
shoulder: the mechanical irritation of a stone in the bladder produces pain at the 
extremity of the urethra: inflammation of the hip-joint occasions pain in the knee: 
disease of the heart is often attended with pain running down the left arm : many 
headaches result from irritation of the stomach. We call these instances of indi- 
rect or sympathetic pain. Some of them admit of no very obvious explanation : 
• — others have been ascribed to connections between the sentient nerves of the 
two parts ; " especially when the part really injured is internal, and that to which 
the feeling is referred is external, and both derive their sentient nerves from the 
same larger branches." You will perceive that a due estimation of these sympa- 
thetic pains is of no small importance. 

I may observe of pain in general, that it is differently felt — or at any rate differ- 
ently complained of — by persons of different constitutions and temperaments. 
There are even, I fancy, national differences in this respect. I have been present, 
as you may believe, at a great number of surgical operations, and I have been 
struck with the different degrees of patience with which the same operation has 
been borne by Irishmen and by Scotchmen. The Irishmen, generally speaking, 
either feels more acutely, or gives more free vent to his feelings in cries and 
exclamations : the Scotchman, on the contrary, most commonly preserves a reso- 
lute silence. In complaints that are attended with low spirits, and hypochon- 
driacal symptoms, there is reason to believe that the pain spoken of often depends, 
in a great degree, upon the eager attention that is paid to it. The accounts given 
by such patients of their sufferings are always to be received with a grain of 
allowance; and this is often an embarrassing circumstance in practice. Patients 
tafte it ill if they do not seem to be implicitly credited; and yet if they are not 
convinced that much of what they suffer depends on their great attention to it, 
they will never get well. You will often find that they cease to feel pain — i. e., 
they forget to attend to their complaints— when their attention is otherwise 



UNEASY SENSATIONS. 



87 



strongly arrested ; as by conversation, or music. I adverted to this principle iu 
my last lecture. 

Besides pain, in all its modifications, there are many other, and very interest- 
ing, uneasy sensations. Itching is an uneasy sensation nearly allied to pain. As 
severe mechanical irritation will cause pain, so a slighter degree of it will cause 
itching. Itching occurs in many cutaneous diseases, and it gives a name to one 
of them, which is emphatically called the itch. And the Latin word signifying 
the same sensation, prurigo, is made use of to denote other forms of disease of 
which itching is the most prominent symptom. It often affects some one of the 
natural outlets of the body. It occurs about the rectum, from the motions of little 
worms that nestle in the lower part of that gut. This prurigo podicis, which 
does not always depend on the cause just mentioned — and the prurigo pudendi in 
the female — are sometimes most distressing complaints; harassing the patienls 
continually, preventing sleep, excluding them from society, and requiring medical 
treatment. Acrid matters in the intestines will sometimes produce a kind of itch- 
ing there; and the call to void the faeces is perhaps more akin to itching than to 
any other sensation: sometimes, indeed, it amounts to pain. The tickling often 
felt in the windpipe, and provoking the person to cough, appears to be of the 
same nature. Tingling and pricking are sensations which have also some analogy 
with itching. 

Nausea is another uneasy sensation. It is sometimes a direct symptom of 
disease or disorder of the stomach, to which the sensation is referred. Sometimes 
it is a very important indirect symptom, taken in conjunction with others, of disease 
in some part at a distance from the stomach — in the kidney, for example, or in 
the brain. The nausea which is so troublesome to pregnant women is another 
instance of a morbid sensation sympathetic of irritation in a distant organ. 

Another example of an uneasy sensation we have in giddiness, or dizziness — 
technically, vertigo. It sometimes results from disease within the head ; some- 
times it is an indirect consequence of disorder of the stomach ; or of mere debility 
and an approach to syncope. 

Patients will also complain of an undefinable sensation which they usually call 
sinking — a sensation which is referred to the epigastric region. This is frequently 
a source of much distress to hysterical women; and it is occasionally the fore- 
runner of death at the close of severe diseases which have a tendency to end 
fatally in the way of syncope. 

Many other symptoms might be mentioned which belong to this class of uneasy 
sensations, and for our knowledge of the existence of which we must depend 
upon the accounts given us by the patients themselves. Sensations of weight; 
and of tightness and fullness ; drowsiness, tenesmus, strangury, heartburn ; and 
various depraved conditions of the special senses. In the majority of diseases 
the appetite is lost or impaired ; but sometimes excessive hunger accompanies and 
denotes disease. We sometimes derive the first suspicion of the existence of 
diabetes from the preternatural keenness of the appetite. Thirst is a very constant 
and striking symptom in all febrile and inflammatory disorders ; and in the disease 
just now mentioned, diabetes, it frequently constitutes the whole distress of which 
the patient is sensible. The appetite may be perverted, as well as deficient or 
excessive. Chlorotic girls will eat cinders, sealing-wax, slate pencil, and such 
trash. So women who are pregnant either have or pretend to have inordinate 
longings for particular kinds of food — longings which are evidently fostered by 
encouragement. They are not, I believe, common at present in this country; 
and they are less frequently heard of among the poor, who have not the means 
of gratifying them, than in the higher classes of society. 

The class of uneasy sensations you see then is a very large one, and some of 
the morbid feelings are of very great moment. However, there are not many 
diseases which consist altogether of uneasy sensations; and when we find that 
pain or uneasiness is complained of in any part or organ, we next proceed to 
inquire whether the functions of that part or organ are disturbed or suspended. 



88 



SYMPTOMS. 



If we discover any interruption or derangement of function, we have additional 
reason for concluding that the part so affected in its sensations and in its functions 
is actually the seat of disease. This is an inquiry which we can prosecute with 
much less assistance from the patient himself; and mostly with no assistance at 
all; and even in spite of any erroneous opinions which he may have formed, and 
is anxious to state upon the subject. The study of disordered functions is of 
great practical value. 

The functions of the brain and nerves — of the heart and blood-vessels — of the 
respiratory apparatus — and of the digestive organs — are all of vital consequence. 

Some of the impeded or disordered functions which relate to the brain and 
nerves are in fact identical with the last class of symptoms, and consist of altered 
or morbid sensations : sensation being one of the natural functions of those parts. 
Depravations, for instance, of the sense of touch ; numbness; the total absence of 
sensation, which we call anaesthesia. Symptoms of this kind do not constitute 
primary diseases, but they often portend or accompany very serious alterations in 
the brain, or in some part of the nervous system: and it is from that circumstance 
that they derive the great interest and importance which belong to them. The 
same may be said of perverted conditions of the other senses. The sense of 
vision is often impaired, and in various ways and degrees, from mere dimness or 
imperfection of sight, to total blindness. And this total blindness may occur 
without any other apparent disease, the humours and fabric of the eye itself being 
in all evident respects healthy and right; it may come on, too, so gradually, and 
increase so slowly, as not to be discovered for a long time, even by the patient 
himself. Mr. Day, the great blacking man, of the firm of Day and Martin, who 
died not long since, was almost entirely blind. He told me he first discovered 
that the sight of one eye was gone, one day when he attempted to look at a distant 
object through a telescope. He could see nothing, and he imagined that the little 
brass plate which slides over the eye-glass had not been withdrawn. There was, 
however, no such obstacle ; and he too soon found that when the other eye alone 
was closed, he was in total darkness. This state of blindness is called amaurosis, 
and it may depend upon pressure made upon the retina, or upon the optic nerves, 
or upon the brain at the origin of those nerves. There are other causes also, to 
be mentioned hereafter, of amaurosis. Its approach is sometimes marked by the 
fallacious appearance of black spots upon the objects the patient is looking at, or 
floating before him in the air — muscae volitantes. Some of the other deprava- 
tions of sight are still more extraordinary, and except that they are not uncommon, 
might almost be considered fabulous. Thus persons sometimes see things around 
them apparently in motion, when in truth they are not so. This is, in fact, a 
symptom I have mentioned before — vertigo. If the patient shuts his eyes, and 
consequently can see nothing, he feels as if he were himself turning round, while 
in reality he is at rest. Persons in this state fancy sometimes that the bed on 
which they lie is sinking rapidly down with them into some abyss. A still 
stranger depravation of the sense of vision is that in which a person sees only one 
half of an object at which he is steadfastly looking. One man, in passing along 
the street, imagined that every body he met had only one eye. The late Dr. 
Wollaston was subject to this optical delusion : he frequently found that only one 
half of the object he looked at was visible: and he wrote an ingenious paper in 
the Philosophical Transactions to explain this. After his death a tumour was 
found in his brain, interfering with the optic nerves. The celebrated Mr. Aber- 
nethy had once a temporary affection of the same kind, dependent no doubt upon 
some slight and transient injury of the brain. He was thrown, I believe, from 
his horse — at any rate he received a violent blow on his head, which stunned 
him ; and when he had recovered a little, he was taken home in a hackney-coach. 
On his way he amused himself with reading the names of the tradespeople placed 
in front of the shops, and he was greatly surprised to find that one half of each 
name — the last half—seemed blotted out. He described this in his lectures, in 



DISORDERED FUNCTIONS. 



89 



his whimsical way, by taking his own name as an example : " I could see as far 
as the ne (said he), but I could not see a bit of the thy." 

Those very wonderful cases of spectral illusion which sometimes occur, come 
within the class of symptoms we are now considering; they throw a strong light 
upon many of the well-authenticated ghost-stories — which were in fact merely 
instances of disease or derangement in the brains of the ghost-seers. It would 
be out of place to go into any detail upon this interesting subject here. You will 
find some excellent examples of these spectral illusions in Dr. Hibbert's book on 
Apparitions, in Sir David Brewster's Natural Magic, and in Sir Walter Scott's 
Letters on Demonology. 

The sense of hearing is liable to analogous disorders. Sometimes it becomes 
preternaturally acute; and this is a bad symptom when it does occur. I was 
called, a year or two ago, to see a gentleman in the Temple ; he had been taken 
ill only a few hours before, but I found him dying; the pulse was gone from his 
wrist, and his skin was cold, but his intellect was entire, and he complained of 
nothing but the distress he felt from the loud noises that were made by those 
around him, in moving about and in speaking, although, in fact, all noise was as 
much as possible suppressed, and conversation was carried on in whispers : but 
his hearing was painfully acute. He died the same evening; I believe of an 
irregular form of cholera. It is always right that patients should be protected 
from the irritation which might arise from this source ; for that degree of noise 
which would not interfere with the sleep of a healthy person will often not only 
prevent it in a sick man, but bring on delirium, and aggravate greatly the disease 
under which he labours. The custom of strewing the streets with straw before 
the houses of those who are seriously ill, is, in many cases, a very proper pre- 
cautionary measure. 

The opposite fault, obtuseness of hearing, is much more common. Deafness 
is frequently attributable to some physical imperfection in the organ of hearing. 
But it is with cases in which it has a deeper origin, that the physician is chiefly 
concerned. It often occurs in fever, and is not then thought a bad symptom : it 
certainly is a much less unfavourable circumstance than morbid acuteness of 
hearing; and it probably depends upon a disordered state of the brain, which is 
not in itself very dangerous. 

What is called tinnitus aurium, is an instance of the depravation of the sense 
of hearing. It seems sometimes to result from the too strong throbbing of the 
arteries. It occurs in many disorders, and is not unfrequently a symptom of dis- 
eased cerebral vessels, and a precursor of apoplexy or palsy. It is sometimes in 
itself extremely annoying. Curious and undeflnable sounds are heard by some 
patients — sounds like a rushing wind, like the falling of a cataract, the ringing of 
a bell, or the beat of a drum. A female patient of mine, in the Middlesex Hos- 
pital, last year, who had disease of the bones of the ear, with symptoms that 
threatened some implication of the brain, affirmed that she heard a perpetual 
noise in her ear like the singing of a tea-kettle. I have lately been consulted by 
a gentleman from the country, who had no other complaint than a constant hissing, 
which worried him greatly, in one ear. Another had watched with curious anx- 
iety, and described to me very graphically, the successive variations which this 
troublesome symptom underwent in his own person. It began suddenly, with 
some headache, and had lasted six weeks. At first it was a loud roaring, like 
that of the sea ; in a few days it came to resemble exactly the whistling of the 
wind among the trees in winter ; afterwards he could have believed that the room 
was filled with humming gnats ; and finally the noise settled down into the gentle 
sound of a distant waterfall. It haunted him incessantly. Sir David Brewster 
relates the case of a lady, subject to spectral illusions, whose ear was mocked by 
unreal sounds, as her eye by unreal visions. Being in her right mind, and per- 
fectly aware of the infidelity of her senses, she repeatedly heard, not vague noises 
merely, but voices and sentences, when none were uttered. 

Affections of the intellect — of what are sometimes called the internal senses, 



90 



SYMPTOMS. 



are very common and very important symptoms of disease. Incoherence of the 
trains of thought — palpably false belief — extravagant perversions of the judgment. 
These affections are sometimes considered as primary diseases themselves ; they 
very frequently accompany certain febrile diseases ; and they are not uncommon 
in diseases that are unattended with fever. There is more or less derangement of 
the internal senses from the very beginning of continued fever. The power of 
attention is impaired. That kind and degree of mental exertion which would 
afford gratification and amusement when we are well, become laborious and 
irksome when we are ill ; and to compel, or to urge the attention, under such cir- 
cumstances, is injurious. This state is probably only the first degree of delirium, 
and therefore these slight approaches to derangement of the internal senses are by 
no means to be disregarded. It is curious that the delirium of fever is always 
most marked during the night; this seems to be owing to the circumstance that 
the erroneous notions and wandering thoughts of the patient are not corrected by 
impressions made upon his external senses. You will find, conformably with 
the same principle, that your patient sometimes ceases to be delirious upon your 
visiting him : the sight of a new face rouses him for a time, but he soon relapses. 

Voluntary motion is another function connected with the nervous system, and 
one which affords a great variety of important symptoms. Like the power of the 
senses, it may be excessive, or deficient, or perverted. Excess of voluntary motion 
is not common, nor very important. Maniacal patients sometimes exhibit an extra- 
ordinary degree of muscular strength; indeed, in the delirium of fever something 
of the same kind may be observed. 

But the opposite state, that in which the power of voluntary motion is deficient, 
muscular debility is exceedingly common. Debility is an original and essential 
part of fevers. It appears before there has been time for it to be produced by the 
exhaustion of disease. It is not always proportional to the other symptoms, and 
does not necessarily imply any great degree of danger. This sudden and early 
weakness has been a very striking symptom in our two recent visitations of influ- 
enza. Persons previously in apparent good health would be seized as they walked 
along the street, and be glad to sit down in a shop, or a carriage, and to get home 
and go to bed. Young and strong persons would be thus rapidly prostrated. 

In some instances debility does not appear till late in the disease, of which it 
then forms an important prognostic symptom, and an important guide for our 
treatment. It shows us that there is a tendency to death by asthenia, and we have 
to endeavour to keep the patient alive by supporting his strength as well as we 
can, this being the chief or the only indication. 

Debility is occasionally the principal symptom of the whole disease — as in 
hemiplegia, paraplegia, or in more partial palsy, palsy of one limb, even of a 
finger, or of a single muscle, as of the levator palpebrarum. This, though it may 
seem trivial in itself, is far from being so in reality ; it often forms a fragment only 
of a most serious disease. From such partial manifestations of palsy we presage 
a more general and alarming attack; as the loosening of a few stones in the wall 
announces the commencing earthquake. A slight degree of paralysis, affecting 
some of the muscles of the eye, will produce a squint, and consequent double 
vision ; and this occurs not only in hydrocephalus, when it is a most significant 
phenomenon, but also as a prelude to more extensive palsy. General palsy is 
sometimes prefaced by a similar affection of the tongue, producing a faltering and 
indistinctness of speech. 

Spasm is an instance of disturbance and perversion of the power of ^voluntary 
motion. It consists in an irregular and violent contraction of muscular parts — 
involuntary, even when the voluntary muscles are concerned. Cramp is a familiar 
example of it ; and we have been taught, since the cholera came among us, to 
regard cramp as sometimes a very formidable symptom : not formidable in itself, 
but formidable in respect to the condition that gives rise to it. Tonic spasm is 
the principal symptom, also, of that frightful disease — frightful in its phenomena 
and in its frequent fatality— tetanus. The convulsions of epilepsy and hysteria, 



DISORDERED FUNCTIONS. 



91 



and the jactitation of chorea, are ordinary examples of the perversion of the func- 
tion of voluntary motion. Sometimes convulsions bode great danger, sometimes 
none at all. 

So, also, tremor, which is near akin to spasm, is a sign, frequently, of a morbid 
state of the greatest peril; while it is sometimes violent without being attended 
with the smallest hazard. 

If we turn now to the great function of respiration, we shall find that it affords 
a very large number of morbid symptoms, and those of the highest importance. 

Dyspncea, difficulty of respiration, is one of the most prominent of these 
symptoms. It may depend upon various causes. In inflammation of the lungs 
or pleurae, there are several circumstances in operation to impede the breathing; 
for example, pain, which would be enough of itself; the effusion of lymph into 
the texture of the lung, or of serum into the cavity of the pleurae, mechanically 
resisting the entrance of air. In dyspnoea the breathing is almost always most 
difficult when the patient is lying flat on his back. One reason for this is plain. 
In the supine horizontal posture the action of the diaphragm is obstructed by the 
weight and pressure of the abdominal viscera ; and the erect position obviates 
this. Upright breathing, orthopncea, has come to be considered as a distinct 
modification of dyspnoea. The patient cannot lie down. 

Sometimes, as in asthma, the difficulty of breathing comes on in separate parox- 
ysms ; the respiration becomes all at once noisy, wheezing, and laborious. A 
person who had never seen any cases of this kind would imagine that the patient 
was at the point of death — that it was all over with him ; but the most frightful 
of these attacks are seldom attended with any immediate danger. They depend 
frequently upon organic disease of the lungs, heart, or aorta ; sometimes they seem 
to be purely spasmodic; sometimes to result from transient congestion of blood in 
. the lungs. 

Cough is a violent spasmodic action. A full inspiration is taken ; then the 
glottis is closed pretty firmly; and in expiration the air is forced suddenly out, 
and with it, frequently, mucous or other matters which had irritated the air- 
passages. It seems to be one of the efforts of nature to expel from the lungs 
things which ought not to be there. There are several varieties of cough. It is 
a symptom belonging to so many dangerous complaints — pneumonia, pulmonary 
consumption, and diseases of the heart — that it always demands strict attention. 
No one who has once heard it can ever mistake the hooping cough. There is 
also a startling obstreperous sort of cough, shattering one's ears almost, like the 
noise of a person coughing through a brass trumpet — which depends upon some 
peculiar state of the nervous system, implies no danger, and is more distressing to 
the bystanders than to the person who utters it. I believe you may often distin- 
guish the cough of^inflammation of the lungs from that of phthisis, and each 
from the cough of hysteria, by their respective sounds : but we have much better 
methods of distinguishing them — viz., by the concurrence or the absence of 
certain other sounds belonging to the breathing, and ascertained by auscultation. 

Sneezing is another morbid symptom, which, though it may appear trifling, 
is not to be overlooked. It is a very common symptom in catarrhal affections. 
When sneezing occurs in combination with cough, it affords a presumption that 
the cough is not phthisical. Sneezing may even happen as a primary disorder, 
occurring in long-continued paroxysms. I have at present under my care a young 
lady of an hysterical disposition, whose main distress consists in violent and pro- 
tracted attacks of sternutation, which have harassed her almost daily for many 
months. One of our bishops is subject to very inconvenient fits of this kind. 
He will begin to sneeze and go on sneezing incessantly for a long time together. 
I believe that he finds an effectual remedy for these attacks in plunging his head 
into cold water. 

I say nothing here of those direct symptoms of pulmonary disease which are 
ascertained by the sense of hearing — by auscultation and percussion. I shall 
enter fully into that subject hereafter. A systematic account of symptoms, if this 



92 



SYMPTOMS. 



were the fitting place for it, which it is not, would require a dozen or twenty 
lectures. In order to perceive the relation of symptoms, taken one by one or in 
diverse combinations, to the various known forms of disease, you must have some 
prior knowledge of diseases. But I am obliged to suppose (however incorrect 
the supposition may be in respect to some among you), that you are mere begin- 
ners, and have still to learn even the rudiments of such knowledge. Different 
diseases may have many symptoms in common. The same symptom may bear 
a very different import according as it is combined with other symptoms ; or con- 
nected with this or that disorder. The proper place for a comprehensive and 
complete review of symptoms would, therefore, be at the end of a course of lec- 
tures on the practice of physic. When the various forms of disease had been 
gone through, in reference to the symptoms belonging to them, then would be the 
time to take the converse aspect of the case, and^to consider the long list of 
symptoms in reference to the diseases they denote or accompany. All that I am 
at present attempting, is to give you some general notion of what symptoms are; 
to put before you, as samples, a few of the most prominent; and to show you, 
even by this cursory and imperfect view of them, of how great importance it is 
that we should make their relations to each other and to different diseases, and 
their signification, diagnostic, prognostic, and therapeutic, the objects of our most 
diligent attention. 

I might find matter for two or three lectures, if my present purpose would 
admit of them, in the symptoms that are drawn from the functions belonging to 
the circulation. Everybody knows how much importance is attributed to the 
state of the arterial pulse. It is expected of us, as a matter of course, that before 
we think of prescribing for a patient we should at any rate feel his pulse. And 
really the information obtained by that little touch of the wrist is often of the most 
interesting and instructive kind. But it requires practice and intelligence to appre- 
ciate that information. The qualities that we most attend to in the pulse are its 
frequency, its regularity, its fullness, and its force. It is necessary that we should 
know the number of beats which the heart habitually makes in health ; for it 
varies much in different persons. Its average number of pulsations in a healthy 
adult is from 70 to 75 ; but there are persons who, when they are quite well, 
have always a pulse of 80 or 90; and there are others in whom the pulse seldom 
rises above 60. In early life the pulse is more frequent, in old age it is more 
slow, than the standard I have given. Cseteris paribus, its beats are more nume- 
rous in the standing than in the sitting posture; in the sitting than in the recum- 
bent. If we do not inform ourselves of these peculiarities, we may fall into great 
mistakes. In disease the pulse may acquire a degree of frequency which is 
scarcely calculable ; and the less so because, when it is extremely frequent, it is 
also extremely feeble; it will reach 150, 160, or even 200 beats in a minute. In 
other cases — as in apoplexy sometimes, and in some organic affections of the 
heart — the pulse will become extremely slow. The slowest pulse I ever felt was 
that of a man sixty-eight years old, who was for some time a patient of mine, 
with diseased heart and dropsy. His pulse was often no more than 25 in the 
minute. He died suddenly in his chair, and I was very desirous of examining 
his body, but his widow would not allow it. In the 17th volume of Duncan's 
Medical Commentaries a case is related in which the pulse was as slow as nine 
beats in the minute. We learn a good deal in certain disorders from the varia- 
tions and fluctuations of the pulse in respect to frequency — in hydrocephalus, for 
example, and in continued fever. 

Irregularity of the pulse is another condition which is often full of meaning, 
and of interest. I hope, as the lectures proceed, to be able to point out the bear- 
ings of these several qualities of the pulse upon our views of disease, and espe- 
cially upon its treatment. At present I must repeat that I pretend to do no more 
than furnish you with a few samples of the phenomena that characterize disease. 
Irregularity of the pulse is natural to some persons. I have a brother who enjoys 
very good health, and whose pulse is habitually irregular; I have been told that 



DISORDERED FUNCTIONS. 



93 



when he was ill with a fever at school, it became regular. I have heard of seve- 
ral precisely similar cases. There are two varieties of irregular pulse — in one 
the motions of the artery are unequal in number and force, a few beats being from 
time to time more rapid and feeble than the rest: in the other variety a pulsation 
is from time to time entirely left out — the pulse is said to intermit. These two 
varieties may coincide in the same person, or they may exist independently of 
each other. 

Irregularity of the pulse may be caused by disease within the head ; by organic 
disease of the heart; by simple disorder of the stomach; or it may be merely 
the result of debility and the prelude to the complete stoppage of the heart's action 
from asthenia. How important must it be to ascertain and construe each of these 
meanings of the same symptom. It may indicate mortal disease — it may imply 
no danger at all; it may afford no clue to any available treatment; or it may 
teach us how to ward off impending dissolution. 

Another most important quality of the pulse is what is called its hardness, or 
incompressibility. You find that you can scarcely abolish the pulsation by any 
degree of pressure; the blood still forces its way through the artery beneath your 
finger. Sometimes it is felt to strike a large portion, also, of the finger, and then 
we say that the pulse is full, or large, as well as hard. When it strikes a very 
narrow portion of the surface of the finger, it is compared to a thread ; it is a 
small pulse: and if at the same time it be hard, such a pulse is often described 
as a wiry pulse. It requires some education of the finger to appreciate with exact- 
ness the several varieties of the pulse, even those which are practically important ; 
for many have been mentioned by authors which are purely fanciful or useless 
and unnecessary refinements. 

Now this hard pulse I shall soon have to speak of again, in connection with 
the treatment required in inflammation. It is one of the best warrants we have, 
in many cases, of the propriety of bleeding our patient. It does not occur, how- 
ever, in all inflammations, and it may occur when there is no inflammation. It 
may depend upon hypertrophy of the left ventricle of the heart, and then it is 
beyond the reach of blood-letting as a remedy. It often seems to be connected 
with a morbid condition of the artery itself, brought on, as Dr. Latham has sug- 
gested, by the pernicious habit of dram-drinking. It is, however, at all times 
considered so much a guide to our practice, that whenever it occurs, it is very 
necessary to make careful inquiry into its real cause. 

Before I conclude this rough review of symptoms, I must point out one or 
two that belong to the third class mentioned ; viz., changes of sensible qualities. 
These include variations in the temperature of the body; in the colour of the 
surface, and especially of the face ; the diminution or increase of bulk; the latter, 
when general, we call corpulence; when partial, swelling; and various other 
symptoms, especially those which are detected byauscultation. 

Wasting, or emaciation, is sometimes the first observable symptom of disease. 
It occurs in complaints that are not commonly dangerous — as in dyspepsia, and 
in hypochondriasis, which is often connected with dyspepsia: and when it does 
appear, it marks the reality of the disease. This wasting happens also in many 
fatal maladies — in phthisis pulmonalis, for example — and in dropsy, although the 
dropsical enlargement sometimes masks it. It accompanies many acute diseases, 
and is reckoned an unfavourable symptom ; for it shows that the body is not 
properly nourished. Sometimes the emaciation is so extreme that the integu- 
ments give way — the bones of the patient are said to come through his skin. 

We have examples of symptoms that consist in changes of colour, in the 
flushed face of fever; in the pallor belonging to many diseases ; in the contrast 
exhibited by the white cheek with its central red spot, so characteristic of hectic 
fever; in the yellowness of the skin and conjunctiva in jaundice; in the dusky 
hue of the countenance and the lividity of the lips noticeable whenever the due 
arterialization of the blood in the lungs is interfered with ; and in a long catalogue 
of cutaneous disorders. 



94 



INFLAMMATION. 



Various and full of meaning are the conditions and appearances presented by 
the tongue. A patient would think you careless, or ignorant of your craft, if you 
did not, at every visit, look at his tongue, as well as feel his pulse. 

Let me once more remind you of the peculiar importance of accustoming your- 
selves to take notice of the symptoms comprised in the last two classes, and 
especially in the last class, that you may attain to a quick perception of them. 
Changes of sensible qualities speak for themselves, and speak the truth. They 
cannot deceive us, as the verbal statements of even conscientious patients respect- 
ing their uneasy feelings might. They direct us in the choice and order of our 
inquiries : nay, they frequently spare us the necessity of putting many questions ; 
questions that might be irksome or fatiguing to our patients, or offensive to their 
natural delicacy, or even hurtful by letting them know our thoughts respecting 
their disorders. Of the changes in sensible qualities we judge by our own eyes, 
and ears, and fingers, and often by our noses also ; and the change is sometimes, 
of itself, perfectly characteristic of the complaint. 

Many more morbid phenomena, or symptoms, or tokens of disease, might have 
been mentioned ; but I have said enough, I hope, to rouse your attention to the 
extent and the fertility of this field of study. When we next meet I shall begin 
to consider one of the special forms of disease to which all parts of the body are 
liable — a disease that meets us at every turn — I mean inflammation. 



LEC TURE IX. 

Inflammation. Its Morbid and its Salutary Effects. Sketch of the Local 
. and Constitutional Phenomena of Inflammation as it occurs in External 

Parts. Examination of the Symptoms of Inflammation; Pain; Heat; 

Redness ; Swelling. State of the Capillary Blood-vessels and of the Blood 

in a part inflamed. 

Inflammation must needs occupy a large share of the attention of both the 
surgeon and the physician. In nine cases out of ten the first question which 
either of them asks himself upon being summoned to a patient is, " Have I to 
deal with inflammation here ?" It is continually the object of his treatment and 
watchful care. It affects all parts that are furnished with blood-vessels, and it 
affects different parts very variously. It is more easily excited by many external 
causes, and therefore it is more common than any other special disease. A great 
majority of all the disorders to which the human frame is liable begin with 
inflammation, or end in inflammation, or are accompanied by inflammation during 
some part of their course, or resemble inflammation in their symptoms. Most of 
the organic changes of different parts of the body recognize inflammation as their 
cause, or lead to it as their effect. In short, a very large share of the premature 
extinction of human life in general, is more or less attributable to inflammation. 

Again, inflammation is highly interesting not only in its morbid phenomena 
and destructive consequences, but in its healing tendencies also. It is by inflam- 
mation that wounds are closed, and fractures repaired — that parts adhere together 
when their adhesion is essential to the preservation of the individual — and that 
foreign and hurtful matters are conveyed safely out of the body. A cut finger, a 
deep sabre wound, alike require inflammation to re-unite the divided parts. Does 
ulceration occur in the stomach or intestines, and threaten to penetrate through 
them ? Inflammation will often forerun and provide against the danger — glue 
the threatened membrane to whatever surface may be next it — and so prevent 
that worse and universal inflammation of the peritoneum, and the almost certain 
death, which the escape of the contents of the alimentary canal into that serous 



INFLAMMATION. 



95 



bag would infallibly occasion.* The foot mortifies ; is killed by injury or by 
exposure to cold : — inflammation, if it be not anticipated by the knife of the sur- 
geon, will cut off the dead and useless part. An abscess forms in the liver — or 
a large calculus concretes in the gall-bladder : how is the pus or the stone to be 
got rid of? If they make their way to the external surface of the organ, as they 
always tend to do, they enter the cavity of the abdomen, and excite fatal peri- 
tonitis. But a natural safeguard arises ; partial inflammation precedes and pre- 
pares for the expulsion ; the liver or the gall-bladder, as the case may be, becomes 
adherent to the walls of the abdomen on the one hand, or to the intestinal canal 
on the other ; and then the surgeon may plunge his lancet into the collection of 
p US — or the abscess or the calculus may eat their own way safely out of the body 
— through the skin, or into the bowel. Inflammation, limited in extent and 
moderate in degree, becomes conservative by preventing inflammation more 
severe and more widely spread, which would be fatal. This is what I mean 
when I speak of the curative properties of inflammation ; and surely this pro- 
cess, which may save life or destroy it, deserves and demands our most careful 
study. 

But inflammation has a still further and peculiar claim upon our attention. The 
salutary acts of restoration and prevention just adverted to, are such as nature 
conducts and originates. But we are ourselves able, in many instances, to direct 
and control the effects of inflammation — nay, we can excite it at our pleasure; 
and having excited it, we are able, in a great degree, to regulate its course. And 
for this reason it becomes in skilful hands an instrument of cure. This instru- 
ment the surgeon employs when, after letting out the water of a hydrocele, he 
wilfully excites inflammation of the tunica vaginalis, whereby its cavity is oblite- 
rated, and the re-accumulation of the fluid rendered impossible. It is by availing 
himself of the same agent that he is enabled to remedy many afflicting deformi- 
ties : — to unite the cleft lip ; to close up the fissured palate ; to restore the dilapi- 
dated nose. There is no other special disease which is thus at our command ; 
we cannot, if we would, produce a tubercle or a cancer. For all these reasons 
inflammation possesses a very high degree of interest for us — and for every one 
who would inquire, with any prospect of success, into either the pathology or the 
treatment of diseases. 

Of the amount of our knowledge respecting the intimate nature of inflamma- 
tion, I shall have occasion to say a few words by and by. We first become 
acquainted with inflammation in its symptoms, and as it displays itself externally. 
After we know what they are, it may be right, and cannot but be interesting, to 
inquire how they come about. Now the symptoms which, when they exist 
together in an external or visible part, betoken or denote inflammation of that 
part, are four in number : pain — redness — heat — swelling ; preternatural red- 
ness, and 'preternatural heat. These, from the earliest ages, have been recog- 

* [We doubt very much the correctness of this statement. Is it true, that wounds are 
closed and fractures united by inflammation, in the proper acceptation of the term 1 Union 
of divided surfaces, it is true, may be a result of inflammation; but, that what has been 
termed by surgeons " union by the first intention," takes place altogether independent of 
inflammation, and that the occurrence of the latter is calculated to impede or prevent it, 
must be evident, we think, to any one who will carefully watch its phenomena. Neither 
is it, we conceive, correct to describe the adhesions of the peritoneum which often precede 
the perforation by an ulcer of the coats of the stomach or intestines, and prevent the escape 
of the contents of the latter organs into the cavity of the abdomen, as a provision to guard 
against the universal and fatal peritonitis that would otherwise occur. The inflammation 
by which the adhesions alluded to are produced, is as strictly a morbid process as that 
which caused the ulceration of the alimentary canal, and cannot, with any propriety, be 
viewed as a process set up, in anticipation of the escape of the contents of the alimentary 
canal into the peritoneal sac, and to guard against the danger that would hence result. The 
danger is, we admit, occasionally lessened or even entirely prevented by the adhesions, 
but we have no right to infer from this circumstance, that the adhesions occurred to pro- 
vide against its occurrence. — C] 



96 



INFLAMMATION. 



nized as the signals of outward inflammation. " Notae inflammationis (says 
Celsus) sunt quatuor — rubor et tumor cum calore et dolore." 

No definition, however, or general description, can be made to emb-ace all the 
forms in which inflammation presents itself. We can give no useful account of 
it in the abstract ; and therefore I shall first sketch the phenomena of inflamma- 
tion under one of its most common external forms ; and taking this as a type of 
the disease, proceed afterwards to trace its modifications and varieties, and tj fill 
up the picture. 

Let us suppose, then, that a healthy man receives some local mechanical injury 
— that he falls, for instance, against a window, and gets a piece of glass stuck into 
his arm. In a short time he begins to have pain in that part of the arm, and this 
is soon succeeded by redness, and increased heat and swelling. The skin be- 
comes of a bright red colour ; the swelling increases. In the immediate place of 
the injury the swelling is firm and hard, and exquisitely tender: at some distance 
from that centre, although there is still swelling, the parts are softer and more 
yielding. In the seat of the redness and swelling the patient experiences a sense 
of heat, a burning pain ; the part is sensibly hotter than natural to the touch of a 
bystander; and if its actual temperature be measured by means of a thermome- 
ter,"it will be found to exceed the temperature of the neighbouring surface. The 
part is inflamed. This is what is called phlegmonous inflammation. Q-hsy/xovy 
is a Greek word, and inflammatio is a Latin word, and they both mean the same 
thinsr, viz., a burning, or a flame. Phlegmonous inflammation is, therefore, in 
truth, a tautological phrase. But custom has assigned a particular signification to 
the epithet phlegmonous ; — it denotes that kind of violent inflammation in which 
the affected part seems all on fire ; and chemistry teaches that, philosophically 
speaking, there is actual and excessive combustion going on in that part. 

If the inflammation reach a certain degree of intensity, other signs of dis- 
order present themselves at a distance from the injured spot. The patient usu- 
ally at first feels chilly and feeble ; but soon the temperature of the whole of the 
surface rises, the skin becomes hot and dry, the pulse more frequent and fuller 
and harder than is usual ; lassitude comes on, with headache, and wandering 
pains in the limbs. The patient is unable or unwilling to exert himself, and 
finds that he is unapt for any mental effort; he cannot command his attention, 
gets confused and restless, and sleeps ill ; he loses his appetite, his tongue 
becomes white, his mouth is parched, he is unusually thirsty, and the various 
secretions of the body are deranged and diminished. 

This is inflammatory fever. This is an indirect symptom of inflammation, 
manifesting itself through the medium of the system at large. Various names 
have been given to this general derangement of the vascular and nervous systems : 
constitutional disturbance — sympathetic fever — symptomatic fever. It matters 
little what term is used, provided that we affix always the same meaning to it: 
but inasmuch as the word fever, in this and in other languages, is taken to express 
a specific disease, it would perhaps be better to employ the term pyrexia, as 
Cullen and others have done, to denote that secondary febrile state which grows 
out of, or is associated with, primary local inflammation. 

Now what is the end of this remarkable state of things ? Why, it may end in 
one of two or three different ways. Supposing the piece of glass to have been 
extracted, and proper measures to have been taken for subduing the inflammation, 
or even supposing that no other measure has been adopted except removing the 
bit of glass, then it will often happen that the phenomena just described will gra- 
dually recede and disappear; the pain will abate, the redness fade, the swelling 
diminish, the heat decline, the pyrexia cease; until the part at length regains its 
usual sensations and its natural appearance. When inflammation subsides in this 
way it is said to be resolved, to terminate by resolution; and this is its most 
favourable and desirable mode of terminating, whenever inflammation occurs as a 
morbid process. 

But in many instances the inflammation does not thus subside. The irritant 



PAIN. 



97 



cause still remains in action — or the original intensity of the inflammation has 
been too great to admit of resolution — or the means proper to abate it have not 
been used — or have not succeeded. The symptoms already described continue, 
and are aggravated in degree: at length the swelling begins to assume a more 
projecting and pointed form, and the skin in its centre to look white; the central 
part of the swelling, formerly so hard, becomes softer — the pain is of a throbbing 
kind: a pulsative sensation, keeping time with the beats of the heart, is experi- 
enced in the part, and often a feeling occurs as if something had given way within 
it: at last (if art does not interpose) the cuticle breaks, and a yellow cream-like 
fluid is poured out, which we call pus, and upon its escape there generally ensues 
a considerable and speedy abatement of all the local symptoms of inflammation — 
of the pain, the heat, the redness, the tumour. 
This is suppuration. 

Meanwhile, especially if the suppuration be long-continued, and the discharge 
of pus profuse, the character of the general febrile excitement undergoes a change. 
Slight but frequent shiverings, or feelings of chilliness, take place, followed by 
flushes of heat, which end in perspiration. 

This is hectic fever. 

If the injury has been still more serious, and the inflammation more intense, 
the part which it has invaded perishes by the violence of the disease : there is a 
partial death. In that case the vivid red colour alters to a purplish or livid, or 
even a black, or greenish- black hue, the tension of the part exists no longer, the 
cuticle is elevated by a sanious fluid, the pain ceases, the part is devoid of all 
sensation — is dead and putrid, and exhales a peculiar and offensive odour. 

This is mortification. 

When the injury has been extensive, a corresponding and characteristic change 
is again observable in the constitutional febrile disturbance. The patient grows 
more and more feeble, and delirious; he has involuntary startings of the tendons 
of the voluntary muscles; his pulse is weak and very frequent; his tongue be- 
comes dry, brown, tremulous; his lips are black with accumulated sordes ; his 
countenance is shrunk, haggard, damp, and ghastly ; his stools and urine escape 
from him without his appearing to be conscious that they do so. 

'i'h is is typhoid fever. 

Under more favourable circumstances the dead or mortified part, which is 
called a sl>ugh, separates from the living parts, and leaves a breach of surface. 
The separation is effected by a vital process which is denominated ulceration ; 
but which I need not now describe. The cavity thus formed gradually fills up, 
and heals in a peculiar way. 

There is one other circumstance, not to be omitted in this rough outliive of the 
local and general phenomena and effects of inflammation. If during its progress 
blood be drawn from a vein, it exhibits, after standing and coagulating, the pecu- 
liar appearance known by the name of the huffy coat, %. e., on the surface of the 
coagulutn, Ami to a certain depth in its substance, the colouring matter of the blood 
leaves the fibrin, which is therefore seen of a yellowish hue, or buff colour. 

Taking the preceding statement as a groundwork, let us look back upon it, and 
trace its particulars a little more in full. The four characteristic signs of inflam- 
mation being pain, heat, redness, and swelling, it will be useful to examine more 
closely each of these symptoms in its turn. 

The pain varies much in different cases of inflammation, both in degree and 
in kind. It is different! v felt, ensteris paribus, by different persons, according to 
their natural susceptibilities, h varies from the slightest degree of sensibility to 
the utmost agony and torment. Parts which, when sound, are endowed with 
little or no capacity of sensation ( s tendons, ligaments, cartilage, bone), become 
often exquisitely sensible under inflammation. The organs of sense are variously 
affected in this respect. .Thus the specific sensibilities of the mouth and nose 
are blunted by inflammation — those of the eve and ear are often rendered pain- 
fully acute. There are great diversities also in the kinds of pain. Sometimes it 



98 



INFLAMMATION. 



is of a dull aching character, as in toothache ; sometimes it is a pricking, tingling, 
smarting sensation — this is the case in some forms of inflammation of the skin, 
as in erysipelas for example, and in herpes ; sometimes it is sharp and piercing, 
as if the part were stabbed or cut with a knife — such is frequently the feeling in 
inflammation of the serous membranes, in pleurisy for instance ; sometimes the 
pain is tensive or stretching ; and sometimes there is scarcely any pain at all. 
This last chiefly happens in the mucous membranes and in the parenchymatous 
textures of organs. Very often the pain is a " bulking" or throbbing pain — every 
beat of the heart makes itself felt in the tender part. The pain of inflammation 
results, no doubt, from the implication of the nerves in the diseased process. 
The stretching of the vessels and textures adds to the pain. Everybody who 
has been plagued by boils (and few escape them) has had proof of this : the pain 
is most harassing a short time before the ripening little tumour gives way, or is 
laid open by means of a scalpel; but as soon as the distension is thus relieved, 
perfect ease and comfort ensue. It is the same in common earache. It is upon 
this principle, I believe, that the differences in regard to pain, which occur in 
different structures under inflammation, are partly to be explained. Speaking 
generally, there is more pain felt in external inflammations, and in the inflamma- 
tion of investing membranes, than in inflammation of the substance of the vis- 
cera, or of the lining membranes ; and it has been conjectured that this may be 
because, in the latter cases, the parts affected have fewer nerves of common sen- 
sation. But I do not think this explanation satisfactory. If it were well founded 
we should not have such exquisite pain in some of the textures already mentioned, 
which appear to be furnished with very few nerves of common sensation, and 
scarcely feel at all in their healthy state : tendons, ligaments, and cartilages, I 
mean. I think it will be found that most pain is felt in those parts which are 
least capable of yielding — in which the tension produced by the swelling, or the 
tendency to swell, is the greatest. The substance of the liver, spleen, and viscera 
generally, is soft and yielding — the mucous membranes are spongy in their tex- 
ture, and often attached to the subjacent parts in loose folds, and they allow of an 
accumulation of blood within thern without becoming much stretched, or very 
tense. The investing serous and fibrous membranes are more tightly applied, 
and much less capable of yielding: and their inflammation is usually attended 
with severe pain. 

The pain that belongs to inflammation sometimes precedes any other apparent 
change. This is specially observable in respect to internal parts. Sometimes 
the pain is continued and uniform. Sometimes it is continued, but irregular in 
severity, having periods of great exasperation: sometimes again it is intermittent, 
and even periodic. 

It is an unsettled question that has often been mooted, whether in inflamma- 
tion, the state of the blood-vessels is determined by that of the nerves, or the 
reverse. Mere nervous pains are known sometimes to be followed by congestion 
of the part in which they are felt. Whatever may be the true state of this ques- 
tion of priority, it is certain that the disordered condition of the blood-vessels, 
when produced, greatly augments the sensibility of the part. We may suppose 
that this depends, partly on over-distension and stretching of the vessels and 
fibres, partly on pressure made upon the nerves by the swelling. 

It is important to remark of the pain belonging to inflammation, that it is usually 
aggravated by pressure: frequently it is not felt at all, except when pressure is 
somehow made upon the affected part — intentionally by the medical man — or 
accidentally, from the movements or position of the patient. This is tenderness. 

And this is a point which requires a little further notice. I say the aggravation 
of the pain by pressure is an important circumstance, because it continually helps 
us to distinguish pain that is inflammatory from pain that is not inflammatory. 
Thus pain of the abdomen may result from colic, or spasm — from a distension of 
the intestines by air, and a stretching of the textures and nerves belonging to 
them : and this sort of pairi will mostly be relieved by pressure ; you will find 



HEAT. 



99 



patients lying upon their bellies across the hack of a chair for the sake of obtain- 
ing ease : but if the pain proceed, as it may, from inflammation of the peritoneum 
— oh! then the gentlest pressure, even that of the superincumbent bed-clothes, 
causes intolerable torture. The suddenness with which the pressure is made — 
and its being made on a part only of the suffering organ — these circumstances 
have much to do with the augmentation of the pain; and it is curious, and in- 
structive too, to know that gradual pressure, applied uniformly to the whole organ 
or part under inflammation, is sometimes so far from enhancing the pain, that it 
relieves or removes it. Dr. Elliotson puts a very good case in illustration of this. 
** If (he says) you have a blister upon the sole of the foot, or at the ball of the 
great toe, and you rest gradually upon the part, the pain becomes mitigated, till at 
last it seems to be almost entirely removed ; but the moment you take oft* the 
pressure, and raise the foot from the ground, you feel the part begin to throb — to 
throb with violent pain." 

Now all this exemplifies what I said just now — that though a deranged condi- 
tion of the nerves, marked by pain, may, for aught I know, first lead to the 
vascular fullness — yet that same fullness, and the distension which it implies, will 
greatly increase the pain. In fact, the expulsion of the blood by means of well- 
regulated pressure is made the foundation of certain proposed methods of cure. 
This has been lately recommended in hernia humoralis, or swelled testicle — what 
is now more scientifically called orchitis. It gives one a sort of horror even to 
think of pressure being made on the healthy testicle — much more when it is ren- 
dered prelernaturally sensible by inflammation : yet, when properly managed, it 
is said (by Dr. Fricke, of Hamburgh, and others) not to increase the pain, but 
entirely to remove it, so that the patient can at once walk about the room ; and 
the disease is thus ultimately cured. In the same way it has been proposed to 
cure erysipelas, and gout, and rheumatism. Without inquiring here into the 
general merits of this remedial expedient, I may remark that pressure, soemployed 
as to benefit an inflamed part by supporting its strained and oppressed capillaries, 
must be steady, gentle, continued, and (above all) uniform pressure. All these 
conditions are strictly supplied in an apparatus recently devised by Dr. Arnott; 
whose air-press promises to be scarcely less useful to suffering humanity than 
his earlier contribution to the comfort of the sick — the water-bed. 

It is sometimes necessary to recollect, especially when the existence of internal 
inflammation is suspected, that all expression of the sense of pain, and probably 
all sensation of pain, may be prevented or abolished by the presence of stupor or 
coma. So also, if the nervous connection between the inflamed part and the 
sensorium be cut off, no pain is felt. Limbs in a state of 'palsy are often (though 
not always) destitute of sensibility also; and inflammation readily occurs in them, 
but is accompanied with no pain. 

That mere pain will not constitute inflammation, must, I think, be plain to you. 
Spasmodic contractions of the muscles, stretching and tension of the tissues, a 
particular state of the nerves, and other conditions which do not imply inflamma- 
tion, may, nevertheless, be attended with severe pain. 

Let us next consider the heat. 

Of course, as I hinted before, this means preternatural heat: the temperature 
of the part exceeds that which belongs to it in health; but in truth, the heat is not 
in general so much increased as the sensations of the patient or his heightened 
sensibility would persuade him it is ; nor even so much as a bystander might 
suppose. The heat of inflammation does not rise above the maximum heat of 
the blood in the central parts of the body. The natural heat of the blood is about 
98° or 100°, but in fevers and inflammatory diseases it has been known to reach 
107°, and the maximum heat of the blood in fever is probably the limit of the 
temperature as it exists in inflamed parts. The surface of the body, in its natural 
state, is not quite so warm as the internal parts, and the extremities are generally 
less warm than the trunk; so that the contrast between an inflamed and a healthy 
part, in respect to heat, is greater in the extremities than on the trunk. Thus if 



100 



INFLAMMATION. 



a blister be placed upon the chest, the heat of the part inflamed by its application 
will not exceed that of the neighbouring healthy surface by more than a degree 
or two; while a blister applied upon the leg may occasion a difference of five or 
six degrees. John Hunter took great pains to ascertain the degree of heat. pro- 
duced in inflammation. He excited inflammation in the cavity of the thorax of a 
dog, and in the vagina and rectum of an ass, and he could not find that the tem- 
perature of the parts thus inflamed ever exceeded that of die blood at the centre 
of the circulation. He did not neglect the opportunities that came before him of 
making similar observations on the human body. He had occasion to tap a 
patient in St. George's Hospital for hydrocele: as soon as he had let the fluid out, 
he introduced a thermometer through the puncture made by the trocar, and placed 
it in contact with the testicle. He found the temperature to be 92°. He repeated 
this experiment the next d iy, when inflammation had set in, and then the ther- 
mometer rose to 98|°. So that here an increase of 6?° had taken place in con- 
sequence of the inflammation; but even this, you see, did not go beyond the 
natural warmth of the blood. 

The increase of heat depends upon the increased influx of arterial blood, and 
therefore of oxygen, into the part. Animal heat appears to be derived, in all 
cases, from the mutual action that takes place between oxygen and the elements 
of the tissues, their carbon and hydrogen ; the tissues themselves undergoing 
meanwhile perpetual changes, which, in the natural condition of the body, belong 
and are necessary to health. In a part that is inflamed this kind of combustion 
is, I say, excessive in amount; while unnatural metamorphoses occur in the 
affected tissues. It is, however, a curious fact, a fact worth rememhering, that 
the heat of inflammation does not transgress or surpass that of the blood in the 
central parts of the body. 

Heat alone neither constitutes nor implies inflammation : for parts of the body 
may be made preternaturally hot by holding th^m before the fire, by friction, by 
exercise, while there is no inflammation. 

[ apprehend that increased heat is essential to inflammation, in some stage or 
other of its progress, although there are cases in which the augmented tempera- 
ture is not perceived or appreciated. Sometimes the increase of heat is very 
slight, and may be easily overlooked, there being, nevertheless, unequivocal 
inflammation, redness and swelling, which go slowly into suppuration. The 
neat is often concealed from the observation of the physician or the surgeon, by 
the situation of the part a fleeted,, and it escapes the notice of the sufferer, because 
the sensibility to heat is less generally diffused through the body than the suscep- 
tibility of common sensation. The heat of inflammation is usually less felt 
and less complained of by the patient than the pain. A vivid sensation of heat 
is pain. 

The redness of infl animation must also be preternatural in degree, for many 
parts of the body are by nature, and in health, more or less red. This phenome- 
non depends upon the greater quantity of blood contained in the vessels of the 
part, and sometimes also upon the extravasation of a portion of the blood into 
the affected texture. There is more blond than usual in those vessels which 
naturally carry red blood; red blood enters too into vessels which in the healthy , 
state are destined to receive and convey colourless fluids only, or which naturally 
admit so few of the red particles, that from their paucity, and the quickness of 
their motion, they cannot be seen. We are sure of this from what takes place in 
ophthalmia. Doubtless, also, the redness is sometimes increased by the forma-" 
lion of new vessels which admit the colouring particles of the blood in visible 
numbers. 

That the vessels which naturally circulate red blood are actually distended and 
enlarged in inflammation, there can be no doubt. John Hunter (whose treatise 
on inflammation is a mine in which all succeeding writers have dug), excited 
inflammation in one of the ears of a rabbit, and then killed the animal. He next 
injected the head and ears from the aorta, so that the fluid injected, passing 



SWELLING. 



101 



through both the carotids, was driven with equal force towards each ear. The 
arteries of the inflamed ear were enlarged one-third beyond their natural size, and 
arteries in it were injected which had no visible counterparts in the sound ear. 
That the apparent increase in the number of blood-vessels is often owing to the 
circumstance that red blood enters tubes which already existed, but which did not 
previously admit the colouring matter, or did not admit it in sufficient quantity to 
be visible, is evident from the rapidity with which the redness may be produced 
in many textures : in the eye, for example, it may be effected in a few seconds ; 
and many of the vessels which become suddenly apparent are evidently continua- 
tions of the trunks that could be seen before. 

There is much variety in the tint of the redness of inflammation, depending on 
the kind and degree of the inflammation, and on the nature of the part affected. 
Sometimes the redness is bright and vivid, as if the part were full of arterial 
blood : this generally happens in the acuter forms and the earlier stages of inflam- 
mation. Sometimes the redness is dark, or livid, or purplish ; more as if the 
part were gorged with venous blood: this occurs in some of the chronic and slug- 
gish forms of inflammation, and it is often the case when there is a tendency to 
gangrene. Sometimes the redness is distinctly circumscribed, or in patches ; and 
sometimes it is diffused in a general blush over a large space. 

The redness may, and often does, remain for some time after the inflammation 
has ceased. 

Now seeing that redness accompanies inflammation of the external parts, we 
presume that it exists also in internal inflammation : indeed we may convince our- 
selves that it is so. If a portion of intestine be drawn out through a slit in the 
parietes of the belly of a dog, and suffered to remain exposed to the air, it will 
soon inflame; and inflaming, it grows red. We see also that internal parts are 
left red after death, which parts we have no other reasons for knowing had been 
inflamed during life : and we infer that redness may have been present during 
life, although we find none remaining when the body is examined. That when 
it has been owing to mere fullness of the natural blood-vessels, it may disappear 
with parting life we know, because the same thing happens externally, as in 
erysipelas and scarlet fever: but in such cases the inflammation has not gone to 
any great height. 

It is proper to remark that, as the absence of redness is no proof that there has 
not been inflammation, so its presence is no proof of the contrary. There are 
many kinds of redness, both within the body and on its surface, that have nothing 
to do with inflammation : yet some of these are very apt to be mistaken for traces 
of inflammation. I shall endeavour to instruct you how to avoid such a mistake, 
when we come to examine the morbid anatomy of particular forms of disease. 

While inflammation actually exists, redness, of some shade or degree, is seldom 
absent, even though the other symptoms may be scarcely apparent. 

Lastly, let us take a glance at the swelling. This also depends, in some degree, 
upon the distension of the blood-vessels ; but no great amount of swelling can be 
attributed to this cause; and as much as does proceed from it occurs early in the 
disease. Some, also, and usually almost the whole, of the swelling, results from 
the presence of matters poured out into the interstices of the affected part. These 
effused matters are of very different kinds, although they are all modifications of 
the same liquid, the blood. I mentioned, in describing the condition of the part 
inflamed, that the central portion of the swelling is, at first, hard and resisting, 
while, at a greater distance from the centre, the swelling is softer, and yields more 
readily when pressed by the point of the finger, and, sometimes, even pits a little 
under that pressure. Now, the central hardness is to be ascribed to an effusion 
into the areolar texture of the part, of a fluid, which, transparent at first, speedily 
becomes opaque and more consistent, and at last assumes a solid form. This is 
what is commonly called, in this country, coagulable lymph. The softer swelling 
at the circumference of the tumid part proceeds from the effusion of a thinner fluid 
of serum into the areolar tissue. Under very violent inflammation, blood, in 



102 



INFLAMMATION. 



substance, is poured out into the same parts. When the central portion of the 
swelling softens and becomes pointed, this part of the whole enlargement is owing 
to the presence of a quantity of pus. The different liquids that I have now been 
mentioning are of great importance, and play a conspicuous but diversified part 
in altering textures. Blood, serum, albuminous fluid or coagulable lymph, pus. 
They are called the products of inflammation. We are sure that inflammation 
has been at work, if we meet with certain of these products. We are not sure 
that there has been inflammation if we perceive mere redness : — we are not always 
sure if we find serum only: — we are not sure if we find blood alone: — we are 
tolerably certain if we discover pus ; we are certain, at least, that there has been 
inflammation somewhere, though doubts have been started whether the pus is not 
sometimes conveyed from an inflamed part to other parts of the body. We are 
quite sure that there has been inflammation in a part if we find coagulable lymph 
in that part. This often remains, as a monument of the inflammation, during 
life; it frequently becomes organized, furnished with blood-vessels; and a great 
number of changes, some reparative, some morbid, depend upon its presence. I 
shall have to recur to these products of inflammation hereafter. 

The degree of swelling in different cases depends partly on the intensity of the 
inflammation, partly on the nature and texture of the structures affected. 

I need scarcely observe that swelling may exist without any inflammation. 
Hernia, simple anasarcous enlargements, dislocations, will occur to you as every 
dav examples of swellings that have no necessary connection with inflammation. 

On the other hand, inflammation may exist without any appreciable swelling. 
Inflammation of the sclerotic coat of the eye, for instance, may be present, without 
any swelling cognizable by our senses. 

We have seen, in this review of the symptoms of inflammation, how much 
they severally depend, the pain, the swelling, the redness, and the heat, upon the 
increased influx of blood into the part. 

It may not be uninteresting to pause here for a moment to inquire what has 
been ascertained in respect to the actual condition of the capillaries of an inflamed 
part, and of the blood they contain. Much has been learned on these points by 
patient and minute observation with the microscope, and by reasoning upon the 
facts thus brought to light. Kaltenbrunner, Gendrin, Miiller, and others, have 
corrected many erroneous notions which formerly prevailed upon this subject. 

In order to comprehend the minute phenomena of inflammation, you must have 
a clear conception of the constituent elements of the blood, and of the main changes 
it is liable to undergo. The rough anatomy, rather than the chemistry of the blood, 
is what I allude to. 

The blood consists of red particles, or globules, and of a transparent colourless 
fluid called lymph, or liquor sanguinis. Miiller succeeded in separating these 
two constituents of the blood by filtering through paper that of a frog, which 
contains very large red globules. The liquor sanguinis thus obtained separates 
spontaneously, by coagulation, into two parts, into serum and fibrin, the last 
having previously existed in solution in the liquor sanguinis. 

When the coagulation is suffered to take place without any attempt to remove 
the red particles, these are entangled and enclosed in the fibrin as it becomes solid ; 
and the common well-known appearance of clot and serum results. You may even 
then wash out the red particles from the clot, and leave the fibrin. 

I must now recur to the experiments and observations of Kaltenbrunner. I 
should have told you, on a previous occasion, that various stimulant substances, 
mechanical or chemical, when applied to the" web of a frog's foot, will produce 
irregular disturbances in the circulation, which irregular disturbances you are not 
to confound with true congestion : in like manner you must avoid confounding 
them with the phenomena of inflammation, which are always preceded by those 
of true congestion. Kaltenbrunner, found, likewise, that (just as in congestion) 
a certain interval of time generally happened between the application of the 
exciting cause and the apparent development of the inflammation. This accords 



/ 



BLOOD AND BLOOD-VESSELS. 



103 



with what we observe to be the case in respect to local injuries, and to those local 
internal inflammations that are apt to be produced by exposure to cold. There is 
a pause before the mischief lights up : or (to take the metaphor from the eggs of 
birds) there is a period during which the inflammation seems to be hatching, and 
it is called accordingly the period of incubation. Kaltenbrunner describes inflam- 
mation to be a regular process — as he had also described congestion to be. 

On looking, then, at the web, to which some violence had been done, he ob- 
served, after the first irregular disturbances were over, and when the period of 
incubation had elapsed — he found (I say) that an afflux of blood took place to the 
part about to be inflamed ; the velocity of the blood in the vessels was greatly 
accelerated; the vessels themselves were distended and tense, and therefore dis- 
posed to tighten upon the blood they contained — the functions of the part, that is 
to say, the secretion and absorption of lymph, were interrupted ; the blood under- 
went an evident change — or it failed to undergo the proper changes : its globules 
stuck together, and the parenchyma of the web became tumefied. Now all this 
is just what I represented to you in a former lecture as constituting the state of the 
blood-vessels under active congestion ; and I also told you, at the same time, that 
such congestion was just one step short of inflammation. The congestion row 
described increases, until, at length, this remarkable alteration happens : the capil- 
lary tubes, instead of tightening upon their contents, dilate, or grow larger; the 
circulation, at first so rapid, begins to be delayed in some of the capillaries ; the 
direction of its motion becomes uncertain ; it oscillates, as it were, irregularly in 
those vessels, and at last stops altogether, the globules cohering in irregular masses, 
and thus points of stagnation are formed ; and these points of stagnation, if the 
affection goes on increasing, augment in size, and multiply in number. Around 
thern, beyond their circumference, the circulation remains still very rapid, and the 
congestion persists. This is inflammation — of which the characteristic or pathog- 
nomonic feature is the formation of these points of stagnation. 

Now one early consequence of the stagnation of the blood is, that a portion of 
it transudes through the sides of the vessels containing it : the serum, or the liquor 
sanguinis, or even sometimes the blood itself ; red particles and all. The effused 
serum remains, or is absorbed, as serum. The fibrin, when it has so transuded, 
concretes, and thus the interstices of tissues are filled up, and layers of coagulable 
or coagulated lymph are formed upon the surfaces of inflamed parts, constituting 
false membranes. Under certain circumstances, already adverted to, other or 
further changes take place. Microscopic investigation has recently discovered a 
number of colourless corpuscles floating in the liquor sanguinis. These corpus- 
cles, passing into the interstices of the inflamed tissue, or stagnating in its capil- 
laries, surfer remarkable changes, assume a yellow colour, and are thus transformed 
into globules of pus. So that pus is nothing else than altered blood. During the 
inflammatory state, the corpuscles sometimes appear to multip y with surprising 
rapidity ; and are poured forth, in their new shape, like a secretion. Pus streams, 
almost, from certain mucous membranes under inflammation. Whether the colour- 
less corpuscles be independent of the red globules of the blood ; or whether, as 
some suppose, they are originally derived from the red particles, are questions 
which must be regarded as being adhuc sub judice. 

Certainly much which used to be thought mysterious in the process of inflam- 
mation has been rendered more simple and intelligible by modern research. Most 
of the events or consequences of that process are traceable to the stagnation of the 
blood in the capillaries, and to the changes which the stagnant blood subsequently 
undergoes. 

I must not omit to tell you what Kaltenbrunner says about the direct absorption 
that takes place in the inflamed part. He found that the colouring matter, and 
the adipose matter, were thus taken away. The web of a frog's foot is speckled 
over with little stars of five rays, caused by a black pigment. The extremities 
of these rays gradually disappear until mere black points are left in the places 
of the stars. He says that he has been lucky enough to catch the exact 



104 



INFLAMMATION. 



moment when the blood, circulating rapidly in the canals, has detached a particle 
from one of the rays, and carried it into the torrent of the circulation. In the 
sound state, the mesenteric vessels of the rabbit are surrounded with much fat. 
When the mesentery is inflamed, the adipose cells soon empty themselves: a 
number of capillary canals are developed upon the walls of those cells, and it is 
probable that the fat is carried off by the blood circulating in these canals. 

Another curious and interesting sight witnessed by Kaltenbrunner, was the 
formation of new blood canals. He says that in an organ recently inflamed, when 
the circulation is accelerated, globules of blood may be seen to sally, all of a 
sudden, from some capillary, pass into the surrounding parenchyma, force them- 
selves a channel, and reach another capillary canal. Thus a new capillary chan- 
nel is formed ; the blood circulates through it ; its formation is often the work 
of a few seconds only. As the same thing is repeated in different parts, a rich 
net-work of new capillary canals is added to the original set, whereby it happens 
that organs which in the sound state are but slenderly furnished with capillary 
vessels (as the mesentery of the rabbit) present an astonishing number of them 
under inflammation. 

While new capillary vessels form, the old ones dilate, and assume the appear- 
ance of small arteries or veins according as they are continuous with the arteries, 
or border on the veins. 

The fact has long been known that when coagulable lymph has been poured 
out, in inflammation, blood-vessels gradually form in it, whereby it obtains a vas- 
cular connection with the surrounding textures, and becomes a living portion of 
the body: and these microscopic disclosures of the manner in which they form 
appear to me to possess a peculiar interest. 

I should be making a very wasteful use of your time and of my own, if I en- 
tered into the undecided and unprofitable disputes that have been raised respecting 
the vital conditions of the vessels engaged in inflammation. While some have 
pretended that the action of the small vessels is increased, others assert that it is 
diminished: that the vessels are in a state of atony. For my own part, I have 
never yet seen any conclusive evidence that the capillaries possess any vital con- 
tractile power distinct from their elasticity. And granting them such a power, it 
is extremely difficult to conceive how any increase in their vital contraction 
should produce the changes that are observed in inflammation. Certainly we 
have no warrant that any such contraction takes place, in the results of micro- 
scopical examination of the vessels of an inflamed part. The inquiry might be 
more properly directed, I think, towards the vital conditions of the nerves of the 
part: but here we are wholly in the dark. 

I do not think it so evident as some have supposed it to be, that a greater 
quantity of blood than is natural passes through an inflamed part in a given time. 
It is quite true — and it is proper that you should be aware of it — that the arterial 
trunks leading to an inflamed part often pulsate with more than ordinary force, 
and, if opened, project a jet of blood further than they would naturally project it. 
It is true also that a venous trunk leading from an inflamed part will discharge 
blood faster and more copiously than a corresponding vein leading from a sound 
part. Mr. Lawrence declares that he has frequently tried this experiment, and 
always with similar results. Finding it necessary to bleed a patient whose hand 
and forearm were inflamed, he has directed a vein to be opened in both arms at 
the same moment; and he has ascertained that about three times more blood 
flowed, in a given time, from the vein of the inflamed limb than from that of the 
sound. But it scarcely follows from this that more blood circulates through the 
whole of the part actually inflamed: the activity of the circulation in the vessels 
that remain pervious, and are merely congested, around the focus of inflammation, 
is greatly increased, and more blood circulates through the limb : and yet the 
blood may be stagnant, or, scarcely circulate at all, in the very part that is strictly 
and truly inflamed. However, the fact of this increased afflux of blood towards 
the parts concerned in the inflammatory process is an important one. 



BUFFY COAT OF THE BLOOD. 



105 



LECTURE X. 

Inflammation continued. Buffy Coat of the Blood. Terminations or Events 
of inflammation. Resolution — Delitescence — Metastasis. Effusion of Serum, 
Effusion of Coagulable Lymph, or Fibrin. Organization of this Lymph. 
Suppuration. Ulceration. 

In the last lecture, after giving a very general sketch of the phenomena of 
inflammation, I particularly considered its four characteristic symptoms, pain, 
heat, redness, and swelling: and endeavoured to describe the changes that take 
place in an inflamed part, as they are seen through a microscope. 

There is one very remarkable and important circumstance which is not often 
absent in cases of inflammation, but which hitherto 1 have barely mentioned: I 
mean a peculiar appearance of the blood itself after it has been drawn from a vein. 
A portion of the fibrin at the upper surAice of the coagulum parts with its colour- 
ing matter; so that upon the deep red clot there is to be seen a layer of a yellow- 
ish, or sometimes of a bluish white colour, varying in thickness from a line or 
two to perhaps three-fourths of an inch. This uppermost whitish layer of the 
coagulum is called in this country the huffy coat of the blood. Sometimes the 
surface of the buffy coat is flat and wide; but often it is contracted and concave; 
i. e., the diameter of the buffy surface is less than the diameter of the lower portion 
of the clot, and it is hollowed out into a cup-like form. Accordingly the blood is 
said, in these circumstances, to be both buffed and cupped. The formation of 
this buffy coat appears to be favoured by many circumstances which have nothing 
to do with the disease under which the person may be labouring ; such as the 
size of the aperture in the vein, the manner in which the blood flows, the form 
and size of the vessel that receives it : but it does not occur at all except in certain 
conditions of the system ; and it belongs so especially to the state of inflammation, 
that blood having the buffy coat upon it is often spoken of as inflammatory blood, 
or, with less propriety, as inflamed blood. Both these expressions indeed are 
incorrect, for inflammation sometimes exists without buffy blood ; and buffy 
blood sometimes occurs without inflammation. The phenomenon is, however, 
upon the whole, a very valuable index of the nature of many cases of disease, 
and an important guide in their treatment. 

Now this erust, or upper layer, or buffy coat, consists of pure fibrin, mixed 
with a certain quantity of serum, which M. Gendrin says is fuller of albumen 
than the rest of the serum. You will not fail to notice the great analogy that 
subsists between the buffy coat, and the coagulable lymph poured out in inflam- 
mation, either into the texture of the part, or (as I shall show you more particu- 
larly by and by) upon its surface, forming what are called false membranes. 
Both in appearance, and in chemical composition, the two seem to be identical; 
and no doubt exists in my mind of their being actually the same substance: the 
separation in the one case taking place from the blood while contained in its pro- 
per vessels ; in the other case from the blood after it has been removed from the 
body. 

There has been a great deal of speculation among pathologists as to the cause 
of this buffy coat. From its situation it is plain that gravity has something to do 
with its formation: that the red particles, leaving the colourless fibrin before it 
coagulates, sink downwards by their own weight. But though the subsidence of 
the red particles is occasioned by their greater specific gravity, their separation, 
from the fibrin is not to be explained upon that principle alone. If it were, then 
it would follow that the slower the coagulation of the blood, the more time would 
there be for the sinking of the red particles, and the thicker and more decided 
would be the buffy crust: and it used to be supposed that this was the true 



106 



INFLAMMATION. 



explanation of the phenomenon. Careful observations, however, have shown that 
the formation of the buffy coat often takes place when the coagulation of the 
blood is unusually rapid. Dr. Davy and M. Gendrin both state, as the result of 
much attention to the subject, that the coagulation of blood drawn from a vein 
during inflammation begins sooner, and is more quickly completed, than that of 
healthy blood. But certain observations made and published by Dr. Stokes have 
settled this question. He noted the appearance of the blood in twenty-seven 
cases. In fifteen of these the buffy coat presented itself ; in twelve it did not. 
Now in three of these twelve, the coagulation of the blood did not begin till from 
twenty to forty minutes after it was drawn ; and in four others there was no coagu- 
lation for eight minutes. So that there was plenty of time for the red particles to 
have left the fibrin, and subsided; but they did not do so. On the other hand, 
in twelve out of the fifteen cases in which the blood was buffed, the coagulation 
took place in five minutes ; and in the remaining three it was delayed only four- 
teen minutes. 

The slowness of the coagulation, therefore, although it may and doubtless does 
favour the subsidence of the red particles when they have a tendency to subside, 
cannot be regarded as the cause of the buffy coat. The red particles very soon 
begin to subside when they subside at all : you may tell, immediately after it has 
been drawn, and prior to any coagulation, that blood is about to buff, by a pecu- 
liar bluish hue on its surface. A German writer, Shroeder Van der Kolk, has 
stated observations to the same purpose, showing that in the blood abstracted by 
venesection during inflammation there is an unusual disposition to a separation of 
the fibrin from the red particles; a sort of repulsion between them. This separa- 
tion takes place in mere films of blood, so thin as not to permit a buffy stratum 
to lie above a red stratum. The fibrin and the red particles then separate from 
each other laterally by horizontal movements, and the films acquire a speckled or 
mottled appearance, quite as characteristic of the state of the blood as the buffy 
coat itself. 

That the formation of the buffy coat depends, however, upon some vital change 
in the blood appears probable from this — that it will sometimes vary greatly in 
different portions of blood abstracted at the same bleeding. Thus, if the blood be 
received into four different cups in succession, it will, perhaps, be buffy in. the 
first, and in none of the others; or it will be buffy in the last only; or in the 
second and third only, the first and fourth cups being free from buff. Attempts 
have been made to explain these rapid variations. Some have fancied that the 
inflammatory state having been remedied by the removal of a certain quantity of 
blood, the blood that flows subsequently is, therefore, without the usual index of 
the presence of inflammation ; but this explanation will not apply at all to those 
cases in which the portions last drawn are the only portions that exhibit the buffy 
crust. Others have suggested that the state of the nervous system is principally 
concerned in these sudden changes ; that the depression caused in the outset of 
the bleeding by fear, and the faintishness produced towards its termination by the 
loss of blood, may prevent the appearance of the buffy coat on the first and last 
cups, when it shows itself only in those that are intermediate between the first 
and last. We cannot rely much on these hypothetical explanations : I mention 
them to impress upon your memory the facts which they are intended to explain. 

There are two or three different forms presented by buffy blood ; and with 
these you ought to be familiar. 

In one form the buffy coat is thick, tough, contracted, puckered at its circum- 
ference, and its surface is cupped. There is a complete separation of the red 
particles, and a strong aggregation of the particles of the fibrin among themselves. 
The red portion of the coagulum is also, in these cases, round and contracted, of 
a globular shape, firm, detached from the sides of the vessel, and floating, gene- 
rally, in transparent serum. 

This is usually seen when the inflammation is violent; when it occurs in strong 



BUFFY COAT OF THE BLOOD. 



107 



and vigorous constitutions; and more I believe when it has its seat in certain 
tissues, in fibrous and serous parts especially. 

In another form, the whole coagulum is large, like a cake, or of the figure of 
the vessel containing it, not so much collected into a spherical shape; and the 
buffy coat is thin and flat, and easily broken. Here there is an imperfect sepa- 
ration of the colouring matter from the fibrin, and no great aggregation of the 
particles of the latter. This kind of buffy blood is apt to accompany slight or 
partial inflammation. 

In a third form, the buffy coat is thick and abundant, but it is flat and soft, 
loose and flabby, like paste; and the coagulum often adheres by its edges to the 
vessel in which the blood has been received : there has been considerable sepa- 
ration, and but slight aggregation. The serum is apt to contain a few red particles 
distinct from the clot. Such blood is commonly said to be sizy. Dr. Alison 
states that when it is observed, some other cause of general disorder of the system 
(continued fever, for example) usually co-exists with the local inflammation. 
Probably the qualities of the blood are altered, independently of the inflammation ; 
the buffy coat taking place, in consequence of the inflammation, upon blood 
which was previously in a diseased or unnatural condition. 

It is a curious fact that blood drawn by leeches never exhibits the buffy coat. 
It seldom appears (yet I have seen it) upon blood that has been removed by means 
of cupping glasses. 

Arterial blood is liable to the buffy coat. I have myself, twice at least, seen it 
upon blood drawn from the temporal artery. One of the patients was violently 
maniacal when the blood was taken. The other was labouring under acute in- 
flammation of the membranes of the spinal cord, of which inflammation he died. 

Blood is more likely to buff, cseteris paribus, when it is made to flow in a full 
stream, and when it is received in a deep and narrow vessel. 

On the other hand, the formation of the buffy coat appears to be hindered, 
when the blood trickles from a small opening in the vein, and when it is caught 
in a large flat vessel. It is said, also, that the buffy coat may be prevented by 
adding to the blood a solution of caustic potass ; by keeping it for some time in 
a state of agitation; by receiving it in a very cold vessel ; or by suffering it to 
fall from a height of three or four feet. In this last case M. Gendrin supposes 
that the prevention is owing partly to the agitation which the descent of the stream 
produces in the blood already in the vessel, and partly to the circumstance that 
the blood is cooled as it passes through the air. 

It is seldom, I believe, that the buffy coat appears on blood drawn at the very 
outset of inflammation ; generally a day or two elapses before it shows itself. 
This is just what we might expect if it be true, as it has been conjectured, that this 
unnatural property of the blood is acquired only in the course of its transit through 
the vessels of the inflamed part. 

I have dwelt the longer upon this peculiar appearance of the blood, because it 
leally is of very great importance in determining the nature of various complaints, 
and in directing our treatment of them. Speaking generally, when a given organ 
is inflamed, the buffy coat is more marked in proportion to the intensity of the 
inflammation: when the organ is not known, it is more likely to be of a fibrous 
or a serous texture, in proportion as the blood is more decidedly buffed. The 
appearance of the buffy coat is especially valuable as an indication of treatment in 
cases concerning which we are in doubt whether they are inflammatory or not. 
On the other hand, if we have good evidence, in other symptoms, of the exist- 
ence of inflammation, we are not to be shaken in our opinion by the absence of 
the buffy coat. Inflammation may certainly exist without it. I am not speaking 
now of slight cases of inflammation, which do not disturb the general system. 
You would not look for buffy blood in the inflammation that supervenes on a cut 
finger, or in a small boil; but in serious inflammation, attended with pyrexia, 
the buffy coat may be wanting. It is not unfrequently absent in inflammation of 



108 



INFLAMMATION. 



the mucous membranes, especially in inflammation of the mucous lining of the 
bronchi. 

I stated before — what it is quite necessary to remember — that buffy blood is 
not confined to cases of inflammation. The blood of persons affected with gene- 
ral plethora is often found to present a buffy coat: and the same thing is true in 
respect to pregnant women. 

Buffy blood is no necessary measure of the danger of the disease. . The blood 
drawn in acute rheumatism is always very much buffed and cupped : yet so long 
as the disease is confined to the joints, it is quite free from danger. 

Neither is the appearance of buff on the blood, taken by itself, a sufficient 
warrant for abstracting more blood : for the blood will sometimes, in common 
inflammation, continue to be buffy, long after it has ceased to be useful, or safe, 
to bleed the patient. 

Some pathologists enumerate several terminations of inflammation. Others 
quarrel with that word, as inappropriate; alleging, with great truth, that the 
inflammation does not necessarily cease or terminate whenever these so-called 
"terminations" happen. Some of them are in fact " co-existent states, or suc- 
cessive stages in the progress of the same inflammatory disease." It has been 
proposed to speak rather of the local effects of inflammation : but even this phrase 
is not free from objection, for sometimes (though rarely) there are no local effects 
produced, beyond the four symptoms which characterize the inflammation itself. 
I think the events of inflammation is an expression not open to similar cavils. I 
have no ambition to introduce new modes of speech, unless when those already 
in use are inexact or inapplicable. It is enough if you clearly comprehend the 
meaning of the terms I employ. Among the events of inflammation I include 
only the local changes observed in its course. To those which are constitutional 
I must afterwards revert. 

You will recollect that I did allude, in the last lecture, though in a very brief 
manner, to these local events of inflammation. Their frequency and importance 
render it necessary that we should consider them somewhat more particularly. 

One of these events is the simple subsidence or resolution of the inflammation: 
this may strictly be called a termination also. The congestion of the blood- 
vessels increases till the blood stagnates in some of the capillary canals towards 
the centre of the affected part, which is then said to be inflamed; but the disease 
goes no further; there is no escape of the blood, nor of any part of the blooJ. nor 
of any of the constituents of the blood, beyond its natural channels; or, at any 
rate, there is no sensible evacuation into the inflamed tissue, or next to none. 
The inflammation begins to recede; the stagnant blood is again set in motion ; if 
there have been some slight effusion, it is reabsorbed ; the rapidity of the circu- 
lation in the surrounding vessels diminishes; and the part returns, in all respects, 
to its former condition and integrity. This may be considered the spontaneous 
cure of inflammation ; and to this event there seems to be always a natural tend- 
ency. It may be promoted, sometimes, by art. 

When the process of resolution is unusually sudden and rapid, (as it occasion- 
ally is, the well-marked phenomena of inflammation completely disappearing in a 
few hours,) it is called by our neighbours, the French, delitescence. And when 
the symptoms of inflammation thus suddenly desert one part, and show them- 
selves immediately afterwards in another (as not unfrequently happens in respect 
to the joints in acute rheumatism, and between the parotid gland and the testicle 
or mamma in the mumps), metastasis is said to take place. 

This transference, as it were, of morbid action from one part to another is a 
very curious circumstance. It is one which we sometimes endeavour to imitate. 
We excite inflammation upon the surface, where we know its effects will be of 
comparatively little consequence, in the hope of diverting it from some internal 
organ in which it threatens to work serious or even fatal changes. We follow 
the same principle perhaps when we apply purgative medicines to the mucous 



COAGULABLE LYMPH. 



109 



membrane of the alimentary canal. To denote this mode of cure, by stimulating 
distant parts, the terms counter-irritation, derivation, and revulsion, are employed. 

Most commonly, even under moderate inflammation, some amount of extrava- 
sation takes place into the texture or from the surface of the part. 

The first effect or event of that kind which we notice, is the pouring out or 
effusion of serous liquid. The liquid is so like the serum of the blood, that it is 
called serosity or serous liquid ; and there can be no doubt, 1 conceive, that it 
consists of the serum of the blood, slightly modified perhaps. You will recollect 
my stating that the swelling which accompanies phlegmonous inflammation is not 
equally firm throughout the whole extent of the inflamed part; that it is hard in 
the centre, softer towards the circumference; and that in the latter situation it 
sometimes retains for a few seconds the impression of one's finger; — pits. Now 
this results from the effusion of serous fluid into the areolar tissue immediately 
surrounding the part inflamed: it is neither more nor less than cede?na, — cedema 
(which may exist also quite independently of inflammation) being a fillinjjf or infil- 
tration of the areolar tissue with serous fluid. Anasarca is an example of the 
same state, on a larger scale. Now anasarca is very constantly produced by some 
impediment to the passage of the blood along the veins ; die serous portion of the 
stagnating blood transudes through the coats of the vessels: and I apprehend that 
the same explanation m,ay be given of the less extensive oedema which takes 
place around a phlegmon ; the blood being stagnant in the neighbouring capillaries. 

But whatever may be the intimate cause of serous effusion, it is one of the 
earliest events of inflammation ; and in some cases it is its most important event; 
producing, mechanically, new symptoms, and giving rise to conditions of the 
most perilous kind. The quantity of serous fluid poured out in a short time is 
often immense. One of the pleura may be thus filled in a few hours, and the 
whole of one Itiog strongly compressed, and the respiratory apparatus reduced to 
one half of its customary efficiency. And if inflammation and effusion should 
take place on both sides of the chest at once — if double pleurisy should occur, as 
it sometimes does — the patient must presently perish by apncea, unless his con- 
dition is recognized, and free vent is given to the fluid. More than once or twice 
have I seen persons snatched from the brink of suffocation by what is called tap- 
ping the chest. Fatal coma is no uncommon result of the effusion of serosity, as 
an event of inflammation, into the ventricles of the brain. 

Even in the areolar tissue, where it is properly enough called • oedema, a very 
trifling amount of this serous effusion may be sufficient to destroy life: when, for 
instance, it takes place into the submucous areolar tissue of the glottis, dosing up 
by its pressure that little chink, the rima glottidis, and suffocating the patient after 
another fashion. Here also art may come to the rescue : an artificial chink or 
hole is made for the entrance and exit of air, below that part of the larynx in 
which the disease is situated, and the patient is delivered from imminent death. I 
have had two cases under my own care, and have seen several others, in which 
life urns so preserved. I allude to such cases now, 'merely to convince you of the 
importance of attending to this event of inflammation, and of studying the indica- 
tions of its existence. 

Sometimes some of the small vessels give way, and hemorrhage into the part 
becomes an event of inflammation. Some slight degree of this occurs probably 
in most cases ; and we frequently find that the colouring matter of the blood is 
mixed with the other effusions, giving to the serous liquid a deep tinge of red. 

I hinted before, that we must not infer inflammation from the presence of serous 
effusion alone. Serum wdl exude. 1 believe, from loaded veins, even after death; 
but this never can be much in amount. It is certain that dropsical ( ftusiens may 
be, and very often are, the result of congestion of a purely mechanical kind. 

A third event of inflammation is the effusion of what is ca lied coagvlaLIe lymph, 
which, as I explained to you before, appears to be nothing else than the fibrin 
separated from the other constituents of the blood, and concreted. It is poured 
forth, at first, in a state of solution, or in a soft semi-fluid condition, and mixed 



110 



INFLAMMATION. 



with more or less serosity; but the fluider parts of the effusion are either soon 
reabsorbed, or soon separate themselves from the fibrin, which becomes firmer, 
and at length solid. The hard central portion of a phlegmon, in its earlier stages, 
owes its hardness to the presence of coagulable lymph in the natural insterstices 
of the inflamed part; and a similar interstitial deposit of the same substance is 
common in various parts of the body, as a result or concomitant of inflammation. 
What is called hepatization of the lung is one instance: the spongy texture of the 
lung is blocked up and solidified by this lymph. In certain cases of erysipelas, 
as well as in phlegmonous inflammation, the subcutaneous areolar tissue is ren- 
dered dense and hard in the same way. The white opaque spots which are often 
seen upon the cornea are produced by lymph interposed between the layers of 
that naturally transparent structure. But the most striking examples of the effu- 
sion of coagulable lymph are to be seen upon the surfaces of inflamed membranes: 
it forms a web or layer which by degrees assumes, itself, a membranous appear- 
ance ; and is accordingly called by morbid anatomists a false or an adventitious 
membrane. Sometimes several layers of this kind are spread over each other, 
forming adventitious membranes of great thickness. When coagulable lymph is 
thus poured out between membranes that are habitually in contact with each 
other, it often causes them to cohere ; just as two leaves of a book may be made 
to stick together by a layer of paste put between them. This result is very com- 
mon indeed with serous membranes, especially the pleurae, the pericardium, and 
the peritoneum. Lymph is said also to be poured out, under violent inflamma- 
tion, from mucous surfaces. In croup, the interior of the trachea is inflamed, and 
a substance exudes which assumes a membranous form, and adheres more or less 
firmly to the sides of that tube, or is coughed up in ragged fragments. A similar 
effusion takes place occasionally from the mucous lining of the alimentary canal, 
and is expelled, with the other contents of the bowels, in shreds, or in tubular 
portions, which are, in fact, casts of the interior of the gut. I say coagulable lymph 
is said to be thus poured out; but it is more than doubtful whether the false mem- 
branes in these cases are really composed of fibrin. Similar films form within 
the uterus, and are moulded to the exact shape of its cavity, and marked with 
indentations that correspond to its rugae ; and these membrane-like casts are at 
length separated and extruded. These last are not very common ; but I show you 
one which came from the uterus of a young woman who was a patient of mine 
in the Middlesex Hospital not very long ago. You may see lymph deposited 
like beads, upon the anterior surface of the iris under inflammation ; or gluing 
its posterior surface to the crystalline lens behind it, and rendering the pupil irregu- 
lar, and sometimes immovable. The internal surface of the heart, and especially 
its valves, are often studded with portions of lymph much resembling warts. 
When the opposite sides of an artery are brought together by a ligature, they 
inflame, and become united by the same medium. Coagulable lymph is effused, 
in. the course of a few hours, upon the edges of a cut wound ; and they adhere, 
under favourable circumstances, when placed in mutual apposition. This surgeons 
call union by the first intention; and the inflammation which is accompanied by 
this kind of exudation of lymph, or fibrin, is called adhesive inflammation; or the 
adhesive stage of inflammation. 

It is seldom that coagulable lymph alone is thus poured out. Sometimes it is 
tinged with the colouring matter of the blood. Oftener it is mingled with, or at 
first dissolved in, a large quantity of serous fluid. When this happens in serous 
bags — as in the pericardium or pleura — the thinner fluid may keep the opposite 
membranes apart; and for some time, or entirely, prevent their agglutination. 
Sometimes the agglutination is partial, and the uniting portions of lymph are 
stretched out, by the distending effect of the fluid effusion, or by the natural 
movements of the parts, into strips or bridles of adhesion. 

I must call upon you to notice, in passing, that although this event of inflam- 
mation may sometimes perhaps have a detrimental or destructive consequence, 
yet that in a vast majority of instances it is distinctly a salutary and conservative 



COAGULABLE LYMPH. 



Ill 



event. Vision may, no doubt, be destroyed by a plug of lymph which shuts up 
the pupil of the eye. A portion of intestine may become strangulated by a band 
of adhesion. Of this, which is a mere accident of the adhesion, I have seen 
some fatal examples. The closure of the trachea by the membrane of croup is 
not, in my opinion, a fair case in point. There are, at any rate, but few excep- 
tions to the rule, that the effusion of coagulable lymph proves beneficial by pre- 
venting some worse event of the inflammation. It is better that inflammation of 
the areolar tissue should be limited and hemmed in by a barrier of lymph, than 
that it should extensively diffuse itself. It is better that the bag surrounding the 
heart, when it happens to be inflamed, should become adherent to that organ, than 
that the inflammation should run on into suppuration, and fill the pericardium, and 
oppress the heart, with pus. In the one case life may continue for several years; 
in thetother it seldom lasts many days. It is clearly more desirable, and more 
consistent with the safety and comfort of the patient, that his lungs should be 
fastened to his ribs, than that they should be compressed and flattened against his 
vertebral column. I shall have occasion so frequently to speak of this protecting 
and reparative tendency of adhesive inflammation, that I do not more than point 
it out to you at present. 

When lymph has been effused upon an inflamed surface, it very readily be- 
comes vascular and organized. Red streaks begin to be visible in it. These are 
incipient blood-vessels, which may soon be seen to communicate freely, and to be 
continuous with the blood-vessels of the inflamed part. The plastic lymph is 
fashioned into a definite structure, and made a living constituent portion of the 
body. It is in truth this remarkable plastic property belonging to the effused lymph, 
this aptitude for being organized, which invests the adhesive inflammation with 
its guardian and reparative character. None of the other fluids poured out under 
inflammation are capable of this change. It is in this way that the lips of recent 
wounds, and the surfaces of inflamed membranes in contact with each other, 
are permanently stitched together (if I may use so homely a metaphor), by living 
vascular threads. By this needlework of nature parts recently severed from the 
body may sometimes be replaced ; or even transferred and affixed to other situa- 
tions, as in the Talicotian operation, whereby a new nose is engrafted in the place 
of that which had been lost. It is thus that ulcers fill up ; successive layers of 
lymph exude, and are in succession attached to the ulcerated surface, and incorpo- 
rated by this organizing process, until the breach of texture is repaired. The 
lymph thus organized comes at last to resemble, very exactly, areolar tissue, 
more or less condensed. 

The length of time required for the pouring out of coagulable lymph in inflam- 
mation — and for its organization after it has been poured out — is variable under 
different circumstances. It is often effused very early. Dr. John Thompson found 
a distinct layer of it covering wounds he had made in an animal, in less than four 
hours after they were inflicted ; and cases are related, in which vascular organiza- 
tion of the effused lymph has appeared to have been effected within the space of 
twenty -four or thirty-six hours. Sometimes, on the other hand, many days seem 
to elapse before any such organization is observable. 

When se*rous fluid and coagulable lymph have been poured out in considerable 
quantity, and simultaneously, the serous fluid is often rendered turbid by the 
admixture of small portions of lymph, or of albumen, diffused through it; and 
flakes of lymph sometimes float in it, or settle, in virtue of their specific gravity, 
at the lowest part of the cavity containing the effused matters. 

Several conditions seem necessary to ensure this adhesive form, or adhesive 
stage of inflammation. The inflammation must reach a certain degree of intensity, 
or no lymph will be effused ; it must not go beyond a certain degree of intensity, 
or the next event I have to mention, 4he formation of pus, will interfere with the 
adhesive process. We learn also from what takes place in recent wounds, that 
seclusion from the air, and the absence of all other causes of irritation, are neces- 
sary for adhesion, or union by the first intention. 



112 



INFLAMMATION. 



The formation of pus — suppuration — is a fourth event of inflammation, to 
which brief allusion has already been made. 

Many opinions have been broached respecting the nature of pus, and the man- 
ner in which it is formed. I shall not trouble you by discussing, nor even by 
narrating them, but limit myself to stating what are the notions held on these 
points by the most able and the most recent observers. 

Pus, then, as I told you before, is altered blood. It is an opaque, smooth, 
yellowish fluid, of the consistence of cream, and having no smell. I speak now 
of well-formed, or what is called good, or healthy pus; what the old writers 
spoke of as pus laudabile. This has been thought an absurd epithet: but it 
serves as well as any other to express what was meant, viz., that kind of pus 
which accompanies benign forms of inflammation, and indicates that all is going 
on regularly, and promises a fortunate ending: pus, in short, the appearance of 
which was to be commended. It is certainly not more absurd than the term 
healthy pus. This pus laudabile was described as being album, Ixve, et aequale 
— light-coloured, smooth, and homogeneous. This description of good pus has 
descended from the time of Hippocrates, who says, To Be ftvov. aptatov tevxov -tt 
Ivai, xai 6>afcov, xai tetov, xai «oj qxtota SvawSss. It consists of yellowish globules, 
diffused through a thinner fluid, which resembles in some respects the serum of 
the blood. " If six or eight ounces of good pus be suffered to stand in a phial, 
it will separate into two portions: a yellowish matter will sink to the bottom, and 
there will be a slightly yellow, clear, supernatant fluid, like oil in appearance, but 
not greasy to the touch." The sediment consists of the globules; which Gen- 
drin supposed to be the red globules of the blood, altered ; deprived of their 
coloured envelops, and swollen or enlarged. But, as I slated before, the opinion 
now prevalent among pathologists is that these pus-globules are transmitted, 
"colourless corpuscles;" moreover, that they are hollow cells. 

There are various modifications of pus ; and its qualities are liable to rapid 
alteration by various circumstances. Sometimes the globules are few in proportion 
to the more watery part; and then the pus is said to be ichorous. It is sanious 
when some of the colouring matter of the blood is poured out with it. It is some- 
times viscid and slimy, from an admixture of mucus; or flaky and curdled, which 
is common in scrofulous persons. Sometimes, also, instead of being inodorous, 
it is horribly fetid. All abscesses that form in or about the alimentary canal are 
apt to contain pus of an offensive odour; as those which occur in the tonsils and 
near the rectum. A patient of mine, in the hospital, had a fluctuating tumour in 
the epigastrium, which Mr. Arnott opened. There came out the collapsed bags 
of two or three hydatids, and a quantity of stinking pus. The liver, no doubt, was 
the seat of the suppuration in this case — and perhaps the stench might be owing 
to the death and decomposition of the hydatids. 

Great pains have been taken by many persons to discover some sure criterion 
between pus and mucus. Healihy pus and healthy mucus are so totally unlike 
each other, that they never can be confounded together. But sometimes we can 
scarcely say whether we are looking at mucus so altered as to resemble pus, 
puriform mucus — or at genuine, though not perhaps praiseworthy, pus. I shall 
tell you what has been made out upon this point hereafter, when I treat of phthi- 
sis ; and I shall show you at the same time that the distinction has not that great 
importance which is sometimes assigned to it. 

Pus may be poured out into one of the natural cavities of the body, and then it 
is called purulent effusion. It may be contained in a closed cavity, which is not 
natural, but formed by lymph and condensed areolar tissue : and then the collection 
of pus is called an abscess. It may also proceed from a free surface of the body 
— as the skin, or a mucous membrane, or a superficial sore. 

In the natural cavities of the body pus seems, sometimes, to mingle gradually 
with the serous effusion, which grows turbid and whitish, anil at length distinctly 
assumes a puriform character. But in much the greater number of cases the for- 
mation of pus is preceded by the effusion of coagulable lymph, with or without 



ULCERATION. 



113 



the effusion of serous fluid. The pus in these cases appears to be poured forth 
or secreted by the coagulable lymph after it has become organized. Its formation 
seems to characterize a more advanced stage of inflammation — to denote that the 
inflammation has been pressed a little beyond the adhesive stage. This was the 
opinion of John Hunter, who was the first to teach us any thing worth knowing 
about the process of inflammation. It is also the opinion of Gendrin, one of the 
latest and most successful investigators of that process. Hunter thus expresses 
himself on this subject: — " The new formed matter peculiar to suppuration is a 
remove further from the nature of the blood than the matter formed by adhesive 
inflammation." And Gendrin says, " between the purulent fluid of inflamed 
tissues, and the organizable coagulable fluid (i. e., between pus and coagulable 
lymph), there is but one degree of more." 

Even the preventing or the allowing the access of air to the surface of a recent 
cut will make all the difference between adhesion and suppuration. And the 
same influence of the air in promoting the suppurative process in preference to 
the adhesive is remarkably seen in various other cases. In simple pleurisy — from 
exposure to cold — we seldom have any liquids effused, except coagulable lymph 
and serous fluid. But if the inflammation has been caused by a punctured wound 
from without, or by laceration of the pulmonary pleura by the sharp end of a 
fractured rib, or by a perforation of the pulmonary pleura by the extension of a 
vomica in the lung — in all which cases air finds its way into the cavity of the 
pleura — then true empyema results — pus is formed. So also in pneumonia : at 
first the inflamed lung is rendered solid by the effusion of coagulable lymph into 
the air cells ; but if the inflammation persists, the next thing that happens is what 
is called by Laennec gray hepatization — a puriform infiltration takes the place 
of the lymph. The same principle is exemplified in the case of the urethra ; 
inflammation of ihe free surface of its mucous membrane leads rapidly to the for- 
mation of pus; inflammation of its attached surface occasions the pouring out of 
lymph, which produces stricture. And in general I think it may be said of sur- 
faces that are open to the air, of tegumentary membranes, that either pus is formed 
upon them, under inflammation, without any previous effusion of plastic lymph, 
or the lymph is slight in amount, and transient in duration, and presently super- 
seded by a puriform discharge. We have every-day examples of this, in inflam- 
mation of the conjunctiva, of the bronchi, and of the bladder. Perhaps it is in 
this principle that we may find an explanation of the fact that whereas in the 
inflammation of areolar tissue, of glandular organs, and of the parenchyma of the 
viscera generally, the pus which forms is collected into an abscess ; circumscribed 
abscess in the substance of the lung, from common inflammation, such as we are 
now considering, is very rare indeed. This is a point which will of course come 
under our consideration again. 

There is, however, manifestly a close connection in many cases between the 
effusion of lymph and the effusion of pus ; although the progress and effects of 
adhesion and suppuration are very different. When suppuration takes place, the 
pain belonging to the inflammation usually abates, or ceases, except when the 
pus is imprisoned so as to keep up the pre-existing tension. Certain remarkable 
constitutional phenomena also declare themselves, which I shall notice again 
hereafter. 

The effusion is longer continued in the case of suppuration ; and the quantity 
of pus is more copious generally than of lymph, especially in the serous and 
tegumentary membranes. When pus is diffused through the natural textures it 
tends to soften and separate them — to break them down : whereas the direct effect 
of the deposition of lymph in the same parts is to consolidate and harden. 

The time required for the formation of pus is extremely variable. Suppuration 
sometimes very quickly follows the commencement of the inflammation ; within 
a few hours, as in gonorrhoea. Sometimes it is postponed to a very distant 
period, even for weeks. 

The duration of the suppurative process is also uncertain, and seems to have 
8 



114 



INFLAMMATION. 



no fixed relation to the intensity of the inflammation by which it has been pre- 
ceded or accompanied. 

A fifth event of inflammation is ulceration. You may remember my telling 
you that Kaltenbrunner observed the progress of absorption in the inflamed tis- 
sues which he examined by the help of the microscope: how the stellated spots 
gradually vanished from the web of a frog's foot, and the fat from the mesentery 
of the rabbit. 

Independently of these microscopical observations, it is quite evident that 
absorption goes on, often very actively, during the continuance of inflammation. 
The effused fluids, or products of inflammation, the serum, the lymph, the pus, 
are partly taken up again ; and not only are these products of inflammation liable 
to be so removed, but the original textures of the body are carried ofT by absorp- 
tion. We cannot have a better proof of this than the progress that an abscess 
makes to the nearest surface at which the pus it contains maybe discharged ; the 
intervening textures are gradually absorbed. Perhaps a great part of the principle 
concerned in this progressive approach to the surface is pressure. The harder 
tissues of the body, the bones themselves, yield and disappear before the increas- 
ing pressure of an aneurismal tumour. In this case the absorption appears to be 
independent of inflammation. 

But taking the process as one of the events of inflammation, we may say with 
Dr. Alison that, whenever the absorption of the effused lymph, and of the sur- 
rounding textures, takes place in excess — in a greater degree, that is, and more 
irregularly than seems to be required for any useful purpose — the result is ulcera- 
tion.- The term is, however, commonly restricted to those cases in which the 
loss of substance occurs upon some surface, internal or external. 

Many;circumstances influence the occurrence and progress of ulceration; and 
great differences are observable between the different tissues, in respect to the 
facility with which they severally ulcerate. Ulceration is most common in the 
tegumentary membranes. It is frequently met with, also, in the inner coats of 
the arteries, in cartilages and in bones. But we are not always sure that it is in 
these cases an event of inflammation. Ulceration is rare in fibrous tissues of all 
kinds, in serous membranes, and in the outer coat of arteries. These differences 
have important pathological bearings. But I may not stop to consider these at 
present : they will be particularly noticed as the course proceeds. When I state 
that ulceration may lead to perforations of the alimentary canal — of the air-tubes 
— of the gall and urinary bladders — of the blood-vessels ; and to the fatal escape 
of the natural contents of these organs ; I have said enough to convince you that 
ulceration, so frequently the object of the surgeon's care, requires no less atten- 
tion on the part of the physician. 

There are certain forms of ulceration that are specific in their nature : with 
these I do not at present meddle. The process of ulceration is very clearly 
explained in Dr. Alison's admirable Outlines of Pathology. 

There are three things generally going on at the same time in an ulcerated sur- 
face. First, there is an effusion of plastic lymph, by which what are called 
granulations are formed. Granulations eonsist of coagulable lymph which has 
become organized ; furnished with numerous delicate blood-vessels. Secondly, 
there is suppuration ; and, thirdly, there is absorption or the removal of parts. 

Sometimes, apparently, there is no suppuration / we see no pus in ulcers of 
the cornea, nor in certain cases of absorption of articular cartilages. 

When the first of these three processes gets the better, if I may so speak, of 
the others, the lymph overspreads the surface of the ulcer, fills up the cavity, and 
the ulcer heals: cicatrization takes place.' 

When, on the other hand, the absorbing process predominates, the ulcer ex- 
tends itself — the excavation grows larger, or deeper-— or both larger and deeper : 
and when this excess of absorption is great, and the extension of the ulceration 
rapid, it is called phagedenic ulceration. When a part of the textures perishes 
during the process of the ulceration, and is separated in entire and sensible 



MORTIFICATION. 



115 



masses, the ulcer is said to be a sloughing ulcer. " When the process is slow, 
the lymph effused at the base and round the edge of the ulcer is hardened, and 
the granulations on its surface are deficient, the ulcer is then said to be callous or 
indolent : and when the granulations are larger and softer, and more flabby than 
usual, and require to be repressed before the ulcer will heal : to this variety of 
ulcer the name of fungous ulcer is given;" and the qoarse and too luxuriant 
granulations are called, by the vulgar, proud flesh. These several terms, in the 
senses now assigned to them, you will please to remember. 

It is by regulating the three processes now described — so far as they are capa- 
ble of being regulated by art — that the surgeon and the physician endeavour to 
obviate the threatened ill consequences of ulceration, and to promote the repair of 
the textures which have been destroyed. 

I explained to you, in a former lecture, that inflammation may lead to a wast- 
ing of parts, although there is no suppuration or ulceration. The testis some- 
times withers as a consequence of inflammation : interstitial absorption takes 
place. Atrophy, in short. 



LECTURE XI. 

Mortification, as an event of Inflammation. Inflammatory Fever. Hectic 
Fever. Typhoid Fever. Modification of Inflammation by differences of 
Tissue; Areolar Tissue; substance of Glands and Solid Viscera; Serous 
Membranes; Synovial Membranes; Tegumentary Membranes — Skin — 
Mucous Membranes ; Muscular Tissue; Arteries; Veins; substance of the 
Brain. 

We were occupied, when last we met, with what may be properly called the 
events of inflammation. We passed in review, 1st, resolution as an event of 
inflammation ; 2dly, serous effusion; 3dly, the pouring out of coagulable lymph, 
constituting the adhesive form or stage of inflammation ; 4thly, the formation of 
pus, or suppuration ; and 5thly, ulceration. The pathology of these several 
events, so far as it is understood, and the change of symptoms to which they may 
respectively lead, were also treated of as fully as the limits of my course allow. 
At the close of the lecture I was about to speak of the sixth and last event of in- 
flammation that requires to be noticed : viz., gangrene, sphacelus, mortification. 

When mortification thus succeeds to inflammation, the part dies ; it becomes 
cold ; all circulation through it is at an end ; all sensation in it is over. If it be 
an external part, its colour changes; from being red, it becomes mottled, pur- 
plish, green or black ; decomposition takes place ; vesications appear, filled with 
dark-coloured liquids; air is extricated also. If there be a great accumulation of 
fluid in the part there will still remain tension; but usually the mortified pari is 
flaccid and boggy ; and it emits a cadaverous smell. 

When internal parts mortify under inflammation, they do not always assume 
this black appearance : often they are yellowish ; or the soft tissue of the dead 
part readily imbibes fluid, and takes the colour of the substances with which it 
has been in contact. We see sloughs of the mucous membrane of the intestines 
presenting the ochrey hue of the faecal matters which had rested upon them. 

What I have described as mortification, occurring externally, and succeeding 
to inflammation, is such as the surgeon witnesses. Sometimes it spreads, and 
loses and confounds itself, insensibly, with the adjoining parts, which still retain 
life; and which may continue actively inflamed, and subsequently perish also. 
Under more favourable circumstances, a distinct boundary line is formed between 
the dead and the living parts ; and nature proceeds to amputate the portion which 
has lost its vitality. The process by which this is effected is extremely interest- 



116 INFLAMMATION. 



ing. Adhesive inflammation constructs a barrier of lymph against any further 
advance of the mortification; a furrow of ulceration marks out upon the surface 
the commencing separation, and (supposing a part of one limb to have become 
gangrenous, the foot for example) the furrow gradually deepens, until the dead 
part is completely cut off. This very fact shows that all the textures of the body, 
skin, muscle, nerve, blood-vessel and bone, are capable of being removed by the 
ulcerative process. Meanwhile very interesting changes occur in the part that 
lives .- the large vessels are plugged up, to a certain distance, by the coagulation 
of the blood contained in them ; the coagulation of the blood following its stagna- 
tion. They are further sealed up, and the smaller vessels also are closed, by 
coagulable lymph. Were it not for these changes, fatal hemorrhage would fol- 
low the separation of the dead part. Now this is just what a surgeon rudely imi- 
tates when he amputates a limb; he cuts through the parts with knife and saw, 
and lie ties the larger blood-vessels as he goes along. He follows the path which 
the natural processes point out: and, in truth, a great part of both physic and 
surgery consists in learning what are the expedients of repair and preservation for 
which provision has been made in the living body ; in exciting, or repressing, or 
directing, or imitating those natural actions which generally tend, and often suffice, 
to restore health and to save life. 

Mortification is more common in some internal parts than in others. It is 
frequent in the areolar tissue; and in the mucous and submucous tissues of the 
alimentary canal ; in the throat, for example, in cynanche maligna ;* and in the 
glandular parts of the intestines in fever. It seldom affects the other mucous 
systems — those which belong to the air-passages and the urinary organs. It 
occurs sometimes — but not very often — in the substance of the lungs. It is 
seldom met with in serous and fibrous tissues. It is not at all uncommon in 
bone : producing exfoliation when it is slight and superficial ; necrosis when the 
entire shaft of a long bone dies. In these cases the process is slow, and we 
can watch its repair; and a beautiful process it is: but I must not stop even to 
admire it. 

Now mortification is no certain or constant event of inflammation. It depends, 
more or less, upon various causes and conditions. Sometimes, upon the mere 
intensity of the inflammation, as in sloughing inflammation of the genitals: the 
progress of the mortification being best checked by those measures which are 
calculated to abate the violence of the inflammation. The sloughing of the cornea 
in gonorrheal ophthalmia is another example to the same purpose. 

Again, whatever tends to weaken the circulation in the part affected — or in the 
system at large — tends also to promote the perishing of the textures that are in- 
flamed. In persons who are debilitated by fever, the mere pressure of the body 
against the bed is enough to produce sloughing of the integuments of the sacrum, 
hips, and elbows. The same phenomena are apt to occur in parts that are palsied. 
In dropsical patients, with feeble and impeded circulation, we find that a blister on 
the extremities, where the circulation is the most feeble, will sometimes cause 
mortification; while it might be applied to the chest without any risk of that event. 
Probably, in each of these instances, the unhealthy condition of the blood con- 
duces to the sloughing process. Inflammation of the stomach and intestines is 
marked by a strong disposition to run into gangrene — -and this again is consistent 
with what I formerly mentioned, of the depressing influence of inflammation of 
these organs upon the heart. 

It is necessary to remember that mortification is capable of being produced by 

* [The affection of the throat in cynanche maligna is not, strictly speaking, mortifi- 
cation. It has been shown by Bretonneau and others, to be a true pellicular inflammation. 
The false membranes, by which the fauces are covered, either in part or entirely, becoming 
tinged with blood, assume a dark or almost black appearance, and exhale an intolerable 
fetor — which circumstances have caused them to be mistaken for sloughs — but when they 
become detached the mucous membrane is found to be perfectly entire, and without any 
appearance of softening; the peculiar odour of gangrene, also, is absent. — C] 



INFLAMMATION. 



117 



other causes, as well as by inflammation. The death of frost-bitten parts is per- 
haps scarcely an exception — the phenomena of mortification occur in them after 
the reapplication of a certain degree of heat — sufficient, probably, to give rise to 
more action than the frozen parts can bear without perishing. But the mere 
cutting off the supply of arterial blood, independently of any inflammation, will 
cause mortification. Ossification of the arterial trunks, and consequent stagnation 
and coagulation of the blood in them, is the commonest cause of the dry gangrene 
of old persons — the gangrena senilis ; which, by the way, is not always dry 
In the majority, however, of these cases, the gangrenous part, not being preter- 
naturally loaded with fluid, does not so rapidly putrefy ; but remains dry and 
shrinks up. Again, whatever tends to prevent the return of the venous blood from 
a part (as a firm ligature placed round a limb — or the constriction of the gut in 
strangulated hernia), is favourable, also, to the production of mortification. Pro- 
bably here, too, the direct or indirect pressure made upon the arteries is chiefly 
concerned in occasioning the death of the part. We see limbs mortify sometimes 
after their principal artery has been tied for the cure of aneurism, when the col- 
lateral arterial circulation fails sufficiently 'to establish itself: we see the same 
thing when the passage of the blood through the main artery is stopped by exter- 
nal injuries. 

There is also a very curious form of chronic and dry gangrene, produced by the 
continued use of diseased grain as food — and particularly of the spurred rye; and 
to this, as a distinct disease, I may perhaps have occasion to direct your attention 
hereafter. 

The different stages and events of inflammation that have now been described 
are accompanied by coresponding disturbances of the system at large. These 
were touched upon (barely mentioned, however) in that rough and general outline 
which I attempted to sketch in the outset, of the various phenomena of inflam- 
mation ; and to which I have since referred as a type. They require, for many 
reasons, to be considered somewhat more minutely. 

When, as surgeo?is, you have to deal with external inflammation, you have no 
difficulty, in the first place, in ascertaining its actual existence : you see it; and 
you know, besides, merely by looking at the part, and perhaps handling it, what 
changes it has undergone. You may perceive that the opposite lips of a wound 
have adhered : or that a phlegmon, in which you can also detect fluctuation, has 
assumed a pyramidal form, and begins to look white upon its summit; or you 
observe that the abscess has broken and left an ulcer behind it, which pours out 
pus, and which shows a tendency to contract, or to enlarge itself: or you may 
remark the alteration of colour and of temperature which denotes the approach of 
mortification, or the actual death of the part. The mere exercise of your exter- 
nal senses apprises you, not merely that there is inflammation, but also whether 
it is of the adhesive kind ; or has reached the degree of suppuration ; or has pro- 
duced gangrene. At the same time you do not fail to notice the nature of the 
constitutional disturbance that may be present ; and the knowledge thus obtained 
of the local and of the general symptoms determines your plan of treatment. 

But when, as physicians, we have to do with inflammation of internal parts of 
the body, and when the local changes attendant upon that process are concealed 
from our view, the case is very different. We should often be unable to make 
out the nature of the disease at all, if the presence of pyrexia did not instruct us. 
Sometimes the constitutional disturbance is all that is apparent until after death. 
And, as the disease proceeds, we frequently are able to judge that this or that 
event of inflammation has taken place, only by observing the indirect symptoms 
which declare themselves through the medium of the system at large. Yet it is 
in many cases of the greatest importance to mark the transition from one stage or 
event of inflammation to another; and to learn whether, and in what degree, the 
more urgent of the symptoms depend upon the inflammation itself; or upon the 
effects which it has produced. I do not mean to say that we have not, some- 



118 



INFLAMMATION. 



times, as sure indications afforded us by direct symptoms, cognizable by the sense 
of hearing or of touch, of the state of internal organs, as we could have if they 
were exposed to our view. To these direct symptoms I am not now about to 
refer; they must be spoken of in connection with the diseases to which they 
belong. But the information which the physician gains from what may be called 
constitutional symptoms is always highly valuable : and it is sometimes the only 
information that offers any guidance to the remedial measures he ought to adopt. 

Inflammation sufficiently extensive or intense to disturb the general system at 
all, is attended with pyrexia; and the presence of pyrexia, when the part affected 
is unseen, marks the nature of the disease. The most prominent of the symp- 
toms that denote the existence of inflammatory fever are debility and chilliness, 
followed by, or alternating with, increased heat of skin, and increased frequency 
and force, and often hardness of the pulse, with considerable derangement of most 
of the natural functions of the body. Commonly there is headache and confusion 
of thought, languor, thirst, loss of appetite, a furred or white tongue. 

Among these leading symptoms, the chilliness, often amounting to shivering, 
has this particular importance attached to it, that it marks the date of the febrile 
disturbance. And it is worth observing, that rigors more commonly attend the 
commencement of spontaneous inflammation than of inflammation caused by exter- 
nal injury. 

Now, without going more into detail — of this febrile condition belonging to the 
early stage of inflammation, I make the following remarks: 

1. That it generally succeeds the manifestation of the local symptoms of the 
inflammation: and that we cannot, therefore, help considering the fever as the 
natural effect of the inflammation. 

Kaltenbrunner describes an experiment of this kind. He says, if a drop of 
alcohol be applied to the web of a frog's foot, the blood presently flows towards 
the part irritated, and the circulation in it is accelerated ; congestion takes place, 
and follows its known march. 

If the dose of alcohol be augmented, the phenomena of congestion increase con- 
siderably, and extend over a larger space : at length points of stagnation appearing 
in the focus of the affected part announce the establishment of inflammation. 

If the dose of alcohol be still further increased, we observe that, on the one 
hand, the inflammatory points of stagnation become larger and more numerous; 
and that, on the other, the circumferential disturbances of the circulation extend 
themselves, so as at length to implicate the whole of the circulating system : they 
give rise to a fever which is added to the inflammation. The circulation in the 
web of the opposite foot is as much accelerated as in the vessels surrounding the 
inflamed part in the first foot. If the word congestion had not a local meaning, 
we might call fever (he says) a general congestion. 

Perhaps the fever may be owing to the circulation of altered blood throughout 
the body. We know that the blood is altered in these cases, inasmuch as it is 
found to contain an unusually large proportion of fibrin ; and it has acquired the 
unnatural quality whereby, when withdrawn from the body, and allowed to coagu- 
late, it exhibits the buffy coat. 

That the febrile state follows the local inflammation in point of time, is then 
the rule ; but this rule has frequent exceptions. Erysipelas, and all the febrile 
exanthemata, afford instances of exception ; the fever sets in before any mani- 
festation at least of the local symptoms. These are indeed diseases of a specific 
kind : but the same is true sometimes of diseases that appear to be simply in- 
flammatory ; such as inflammation of the lungs, and cynanche tonsillaris. There 
are other cases in which the local symptoms and the general febrile disturbance 
appear to burst forth simultaneously: this is seen in certain instances of pleurisy, 
and of peritonitis. 

2. Again, it is a curious circumstance that the inflammatory fever is not always 
proportioned, in its degree of violence, to either the size or the importance of the 
part inflamed. The pyrexia is often very strongly marked in that common com- 



INFLAMMATORY FEVER. 



119 



plaint, the quinsy, inflammatory sore-throat, cynanche tonsillaris — which can 
scarcely ever be said to imply much danger. 

3. The situation, the extent, and the degree, of the local inflammation being 
the same, the fever commonly runs higher in young, and in plethoric persons, 
and in those of sanguine temperament, than under the opposite conditions. 

4. The inflammatory fever may be modified in the outset, or very early indeed, 
by the nature of the part upon which the inflammation has seized. I have several 
times mentioned the peculiar depressing effect upon the action of the heart, pro- 
duced by inflammation of the stomach and bowels, and of some other of the 
abdominal organs ; and particularly by inflammation involving their peritoneal 
covering. This lowering influence (which is analogous to that of certain me- 
chanical injuries to the abdomen) has been supposed to depend upon the subduing 
and sickening kind of pain which is apt to accompany inflammation of these 
parts. Probably such pain accompanies, rather than causes, the depression. 
However the latter may arise, it gives a peculiar character to the inflammatory 
fever: lessens the amount of reaction, or abridges its duration; affects especially 
the quality of the pulse; and carries with it a strong tendency towards death by 
asthenia. 

5. There is no doubt either that the character of the inflammatory fever is liable 
to be considerably modified, from the first, by the previous habits of the patient. 
In persons who have been habitually intemperate — or who have been subject to 
long-continued excitement of the nervous system of any kind — the fever which 
attends inflammation approaches more or less to the typhoid form, from the very 
beginning. The febrile reaction is less strongly pronounced. The functions of 
animal life are sooner and more deeply involved in the train of morbid actions. 
Stupor and delirium are apt to occur; with extreme debility and irregular move- 
ments of the voluntary muscles. Still more conspicuous are these peculiarities 
in some cases of inflamed veins; and whenever inflammation is produced or 
accompanied by the introduction of certain animal poisons into the system. 

6. The relative duration of the inflammatory fever is subject to some variety. 
It may persist for a little while, for a few days, even, after all the local signs of 
inflammation have disappeared : this happens chiefly in persons of an irritable 
habit. We watch such cases narrowly, not without some apprehensions of a 
relapse. On the other hand, a rapid abatement of the febrile symptoms some- 
times takes place, while the local changes continue, or even for a time increase in 
extent. Nevertheless, we hail this change as a favourable augury of the ultimate 
result. 

When inflammation, external or internal, has gone on to the formation of pus, 
that event is frequently marked by the supervention of peculiar symptoms; and 
the character of the fever undergoes, for the most part, a striking alteration. 

It is very important to ascertain the time when this event of inflammation takes 
place, or is at hand ; for the measures which might have been proper and neces- 
sary while any prospect remained of the resolution of the inflammation, may be 
useless, and even hurtful, if continued after that prospect is at an end. 

When the surgeon perceives any indication of the formation of pus in an 
external part, he mostly despairs of being able to bring about resolution: ceases 
to abstract blood from the part, or from the system ; and applies perhaps warmth 
and moisture, by means of a linseed poultice, to promote the suppuration. And 
a corresponding change of plan is required in internal inflammations. 

Now the commencement of suppuration is often marked by rigors; and its 
continuance by hectic fever. 

If, after the symptoms of inflammation have lasted for a certain time, the patient 
is attacked by cold shiverings, followed by some increase of heat, that circum- 
stance alone is enough to make us suspect that pus is formed, or is about to be 
formed : and to teach us that the measures employed to effect a resolution of the 
inflammation have not been successful. 

Rigors are very striking symptoms ; but they are by no means necessarily 



120 



INFLAMMATION. 



connected with suppuration. They usher in, as I presume you know, most 
forms of fever, appearing at the very outset of the disease. They recur, at regu- 
lar intervals, in intermittent fevers. Slight causes will, sometimes, produce them. 
They often follow the introduction of a bougie into the urethra. But when they 
occur after symptoms of internal inflammation have been for some time present, 
they denote, in most cases, the production of pus in the part or organ inflamed. 
Sometimes one such shaking fit only is observed : sometimes several take place. 
"When they recur it is usually at irregular intervals; but cases do happen in 
which the shiverings indicative of internal suppuration are so strictly periodic, 
that unless all the circumstances be carefully taken into the account, they may be 
mistaken for signs of ague. 

The leading symptoms of hectic fever (by which, I say, the continuance of 
suppuration is commonly marked) are an abiding frequency of pulse; alternations 
of chilliness with heat and flushing, followed by perspiration; a gradual wasting 
of the body ; and progressive debility. 

I shall hereafter have to speak of a very different kind of disease, in which, 
however, there is a succession of symptoms resembling more or less closely the 
series that characterizes hectic; I mean remittent fever; the succession of symp- 
toms being chilliness, heat, perspiration. But these two disorders are in most 
cases discriminated from each other by the circumstances under which they 
occur. 

The symptoms of hectic fever often creep on, at the outset, insidiously, and 
almost imperceptibly. " A very slight degree of emaciation, a pulse a little 
quicker than ordinary, with a small increase of heat, especially after meals, are 
often the first symptoms which can lead us to suspect the formation of hectic." 
Cullen has described hectic fever as consisting of two exacerbations in the twenty- 
four hours — one about noon, the other towards evening; but in many cases the 
latter alone is distintly marked. The patient feels shivery and cold towards 
night ; then the skin becomes hot and dry, especially in the palms of the hands 
and the soles of the feet, and the pulse more frequent ; and in the middle of the 
night or towards morning, he wakes from short and uneasy sleep, in perspiration, 
which is often profuse. Sometimes, however, there are two or three fits in a 
day. The paroxysms are shorter, and less regular, than those of intermittent or 
of remittent fever. Each of the three phenomena constituting the series may, in 
its turn, be wanting: and even if the paroxysms are regular for two or three times 
together, they never continue to be so. Many circumstances connected with the 
paroxysm itself are very distinctive. " The hectic patient," says Dr. Heberden, 
who has left us a very good account of this affection in his Commentaries, 44 is 
very little or not at all relieved by the breaking out of the sweat; but is often as 
restless and uneasy after he begins to perspire as he was while he shivered or 
burned. All the signs of fever are sometimes found the same after the perspiration 
is over: and during their height the chilliness will in some patients return, which 
is an infallible character of this disorder. Almost all other fevers begin with a 
sense of cold, but in them it is never known to return and to last twenty minutes 
or half an hour, while the fever seems at its height, which in hectic will some- 
times happen." 

Hectic fever is one of the fearful accompaniments, and sometimes the most 
strongly marked symptom, of pulmonary consumption: and where the existence 
of that complaint is suspected, yet a matter of doubt, we look for indications of 
hectic fever with the greatest anxiety and dread. 

With relation to hectic fever, considered as an indirect symptom that suppura- 
tion has succeeded to inflammation, and is still going on, it will be worth your 
while to notice the strong contrast it offers, in many particulars, with the inflam- 
matory fever that attends the earlier stages of inflammation. 

The pulse loses much or all of its hardness and strength, but it remains per- 
manently more frequent than the pulse of health : the appetite returns in great 
measure ; the thirst abates ; the tongue, instead of being covered with a white fur, 



HECTIC FEVER. 



121 



becomes clean and moist and towards the end is sometimes unnaturally red, or 
speckled with aphthas : there is no longer headache or confusion of thought., 

A few more touches will suffice to fill up the picture of hectic fever. 

The face is usually pale ; but during the exacerbations it is partially flushed, 
and very often a characteristic circumscribed red spot appears upon either cheek. 
Besides the evident emaciation, various minor changes mark the want of proper 
nourishment: the skin, when not perspiring, is harsh and scurfy ; little branny 
scales may be rubbed from the legs, merely by the friction produced in drawing 
off the stockings ; the hairs become fine and fall off ; the finger-nails are incur- 
vated into an adunque form ; and the sclerotic coat of the eye, as seen through 
the conjunctiva, becomes of a pearly white. As the disease advances (Edematous 
swellings of the ankles are very apt to come on. 

The connection between hectic fever and the formation of pus in some part or 
other of the body is so frequent, that it has been deemed, by pgrsons of great ex- 
perience and sagacity, a universal fact. Dr. Cullen tells us, in his First Lines, 
that he had never seen hectic in any case, when there was not evidently, or when 
he had not ground to suppose there was, a permanent purulency or ulceration in 
some external or internal part. And Dr. J. Thomson, speaking of the opinion 
that hectic might occur independently of suppuration, uses these words : " But 
till facts more decisive, and cases more accurately described than any which have 
yet appeared are produced in proof of that opinion, I shall think myself justified 
in adopting the common opinion ; and in believing that hectic fever is in every 
instance connected, if not with the absorption, at least with the formation of 
pus." 

The notion alluded to in the latter part of this quotation was at one time very 
commonly entertained, viz., that hectic fever resulted from the reabsorption of 
pus into the blood ; but there are many facts decidedly opposed to this belief. 
Considerable collections of matter not unfrequently disappear, i. e., are taken up 
again into the blood, without occasioning the slightest approach to hectic. Again, 
hectic will accompany, and be kept up by, a scrofulous joint attended with an 
open sore, and it will sometimes cease at once, and completely, upon the removal 
of the diseased limb by amputation ; although a greater quantity of pus is secreted 
by the stump, than had been secreted in the diseased part previously to the ope- 
ration. Facts like these prove, I think, that hectic is not simply a consequence 
of the absorption of pus into the blood : and they seem to have suggested to Mr. 
Abernethy the notion (which was held indeed by John Hunter also) that sympa- 
thetic hectic fever is a teased action of the system, endeavouring to throw off 
what annoys it; the cause of irritation being removed, it ceases forthwith. 

And there is another conclusive circumstance to be mentioned. Notwithstand- 
ing the opinions I have just now quoted from Cullen and Dr. Thomson, I believe 
few persons who have attended to the subject, doubt, now, that there is such a 
thing as idiopathic hectic; hectic unconnected at least with suppuration any- 
where. We often see hectic, or a general state of the system not to be distin- 
guished from hectic, in mothers who have suckled their infants too long ; we see 
it, too, sometimes, if I mistake not, in newly married husbands : and it may be 
noticed as occurring more or less distinctly in those who labour under diabetes. 
What is common to all these cases is, that there is an habitual drain upon the 
system beyond what the nutriment taken into it can supply and counterbalance. 
It is certain, too, that hectic fever sometimes happens in phthisis, not only before 
there has been any expectoration of puriform matter, but prior even to the soften- 
ing and suppuration of a single tubercle. I call to mind one instance in particular 
of this. The hectic was distinctly marked, and continued long. The patient 
died, at last, comatose, after two attacks of convulsion. Two or three large 
scrofulous tumours were found imbedded in the substance of his brain. Various 
other organs were infested with tubercles ; but the tubercles were all of them still 
hard and crude. 

However, setting aside these rarer cases of exception, there can be no doubt 



122 



INFLAMMATION. 



that hectic fever, considered as a constitutional symptom of mischief that may 
reveal itself by scarcely any other token, and especially as a sign of suppuration, 
deserves all the attention we can give it; and for that reason have I spoken of it 
rather at large. Whenever I mention hectic fever in the further progress of these 
lectures, you will know all that I wish to express by that term. 

I have very little to say at present respecting that modification of the general 
febrile disturbance, which sometimes attends mortification as an event of inflam- 
mation. I stated before that the fever is apt in these cases to assume the typhoid 
form ; and to be characterized by sinking of the pulse, shrunken features, cold- 
ness and clamminess of the skin, a dry and black tongue, low muttering delirium 
or stupor, tremors of the voluntary muscles, with spasmodic startings of their 
tendons, and insensibility to the passage of fasces and of urine. I must, however, 
now inform you that these typhoid symptoms are no constant or necessary con- 
comitants of mortification. The natural mode of death, under gangrene, is death 
by asthenia. But the typhoid state involves the nervous functions, and tends to 
death by coma. Whenever, therefore, typhoid symptoms supervene upon in- 
flammation which ends in sphacelus, they may with much probability be attributed 
to some contamination of the blood by an animal poison; and such contamination 
may have taken place previously to the mortification, and have even helped to 
produce it, as when inflammation arises during the progress of the contagious 
febrile disorders ; or it may occur as a consequence of the mortification itself, by 
the direct absorption into the system of some of the putrefying and poisonous 
elements, into which the dead part has been resolved. 

One circumstance, worth bearing in mind, as sometimes indicating the super- 
vention of internal mortification, is the sudden cessation of pain : giving hope to 
the patient and his friends that the danger is over ; but not deceiving the experi- 
enced physician. 

So much, then, for the local and constitutional events of inflammation, con- 
sidered generally. 

It remains for me to make some observations upon the modifications of inflam- 
mation, according as it affects the different tissues of which the body is composed. 
Many of these observations I have, indeed, already anticipated ; but it will be 
useful to bring together, under one view, the most material facts ascertained on 
this matter. 

When inflammation affects the areolar tissue, all the events of inflammation 
which I have taken some pains to describe are apt to occur ; and for that reason, 
inflammation of this tissue, as it exists beneath the skin, was chosen by me as a 
convenient type, or general representative of the inflammatory process. It is, 
therefore, the less needful that I should take up much of your time in speaking of 
the characters of inflammation exhibited in areolar tissue. There is a strong 
tendency to form circumscribed abscesses : the extension of the suppuration is 
prevented by a wall of lymph built up around it. The adhesive inflammation 
sets bounds to the suppurative. There is a good deal of pain when the areolar 
tissue is so situated that tension is occasioned by its swelling. 

But sometimes no such boundary wall is erected, and the inflammation spreads 
and diffuses itself, and becomes a very terrible disease, destroying the areolar 
tissue over a large and undefined space by a process compounded of sloughing 
and of bad suppuration. When the skin also is implicated in the inflammation, 
the disease is usually called erysipelas phlegmonoides : when the skin is not 
involved, it has been called diffused inflammation of the cellular membrane. 
This diffused form of inflammation frequently follows the introduction of animal 
poisons into the system; and accompanies the inflammation of veins and of 
absorbent vessels. It is this disease which is so often fatal to members of our 
professions when it results, from wounds or punctures received in opening dead 



SYNOVIAL MEMBRANES. 



123 



bodies. Dr. Craigie has recently put forth the opinion that in these cases of 
spreading inflammation it is the adipose tissue that is affected. 

The substance of the larger glands, and of the solid viscera of the body, suf- 
fers changes analogous to those observed in the areolar tissue : probably because 
areolar tissue enters largely into their composition. Acute inflammation of the 
liver, when it does not terminate in resolution, leads to abscess in that organ. 
Abscess is rare in the lungs, perhaps for the reasons mentioned in the last lecture. 
Gangrene is also uncommon in the pulmonary substance: and quite unknown, I 
believe, in the liver, and very rare in the kidney. Inflammation of the latter 
organ is not unfrequently attended by purulent collections. Inflammation of the 
substance of the viscera is not, in general, attended with much pain. 

The areolar tissue is liable to be rendered permanently thick and hard by chro- 
nic inflammation, as well in the parenchyma of internal organs as where it is 
spread out beneath the skin, or beneath serous or mucous membranes. Chronic 
induration and thickening of the areolar tissue which composes Glisson's capsule 
is no unfrequent result of slow inflammation ; producing that particular change in 
the liver which the French pathologists denominate cirrhose ; but of which the 
essence is atrophy of its lobules from compression of its nutrient arteries. 

The inflammation of serous membranes is characterized by sharp and severe ' 
pain ; by hardness of the pulse ; and by bufTy blood ; by its tendency to spread ; 
by the effusion of serous fluid, and of coagulable lymph ; and sometimes, when 
the inflammation is very violent, or air gets admitted to the inflamed surface, by 
the effusion of pus. Speaking generally, however, it is adhesive inflammation 
which we most expect in this tissue. False membranes, consisting of organized 
lymph, belong to it: and the agglutination of contiguous surfaces. Sometimes 
the lymph, instead of being deposited in flakes or layers, appears in the form of 
numerous small granules: this is a phenomenon frequently observable in inflam- 
mation of the arachnoid, and of the peritoneum. Sometimes it has a villous or 
papillary or shaggy arrangement; or is cellular like a honeycomb. This is com- 
mon in the pericardium. The surface (to use the happy simile of Laennec) 
resembles that which may be produced by separating two flat plates between 
which a layer of soft butter had been spread : and it probably depends upon a 
similar cause ; since in health a perpetual sliding motion of the pericardium over 
the heart is going on. Ulceration of a serous membrane is very uncommon. I 
mean ulceration commencing in that tissue ; for these membranes are frequently 
perforated by ulcers which approach them on their attached side, and which begin 
in other tissues, especially the mucous. Neither does mortification occur in 
serous membranes, except sometimes by communication from other parts. The 
effect of chronic inflammation of the serous surfaces is to thicken, harden, and 
pucker them. We see this effect in the omentum frequently; in the peritoneal 
covering of the liver ; in the serous membrane which forms so large a portion of 
the valves of the heart. 

The synovial membranes have a strong analogy with the serous. Gendrin 
includes the two in the same category: yet their behaviour under inflammation 
offers, in some respects, a marked distinction between them. They are less liable 
to inflammation than the serous membranes: they rarely throw out coagulable 
lymph, and, consequently, adhesion of their opposite surfaces is very uncommon. 
Joints do not become immovable, or what is called anchylosed, in consequence of 
the agglutination of their synovial surfaces ; but, generally, by means of granu- 
lations arising upon those surfaces after they have ulcerated. Very seldom, indeed, 
does pus form in the synovial sacs, except (again) the inflammation has been caused 
by mechanical injury, which has laid open the joint, and admitted air. When 
this is the case, very serious constitutional disturbance is apt to take place, and 
the existence of the sufferer is endangered. ' That this does not depend upon the 
mere violence of the exciting cause is evident from the circumstance that the same 
acute inflammation, the same general affection of the system, and equal danger, 
often result from the careful incision made into a joint by the surgeon, for the 



124 



INFLAMMATION. 



purpose of removing loose portions of cartilage. I have now at the hospital an 
out-patient who has, among other ills, a large cartilage floating about in fluid in 
one of his knee-joints : but I believe that Mr. Arnott, whom I have consulted on 
the case, will be very slow to recommend its removal, until the inconvenience 
produced by it is so great as to incapacitate the patient from pursuing his employ- 
ment, and until other methods of relief have failed. Suppuration of the joints is 
also one of the occasional consequences of phlebitis. Inflammation of the syno- 
vial membrane speedily leads to a serous effusion into the joint, which often, 
especially in rheumatism, is as speedily taken up again. 

Let us next inquire into the modifications which inflammation undergoes when 
it affects the tegumentary membranes. 

Considering the skin as one membrane, and neglecting its subdivisions into 
epidermis, rete mucosum, and cutis vera, we find that inflammation assumes a 
variety of forms in this external covering of the body. Many of these belong to 
specific diseases, and do not fall within my present purpose, which is that of 
noting how common inflammation varies in the different tissues. 

When the inflammation is superficial, it frequently is denoted by a diffused red 
blush only, which may be banished for a moment by the pressure of the finger, 
and which, after a certain time, disappears of its own accord — terminates by reso- 
lution ; the only consequence of the inflammation being the separation of the cuticle 
in small branny fragments; in one word, desquamation. We call the superficial 
inflammation, in this case, erythema. If the inflammation has been a little more 
intense — as in some cases of erysipelas, in scalds, and in that which we are every 
day exciting by cantharides — a serous fluid is poured out, which elevates the 
cuticle in larger or smaller patches of vesication. Remove the cuticle and admit 
air, and the serous effusion becomes purulent effusion : and if the inflammation 
be pressed beyond a certain point by any other stimulus besides that of air, we 
may have pus poured out. Erysipelatous (which is also a specific) inflammation 
of the skin, is characterized by its remarkable tendency to spread ; and a most 
singular circumstance attends several of the other specific inflammations of the 
skin, viz. : that having occurred once, they never occur again ; this peculiarity 
belongs, however, to the great constitutional diseases, of which the cutaneous 
affection forms merely a part. 

Inflammations of the internal tegumentary membranes — of the three internal 
surfaces that communicate with the air, and are clothed with mucous membrane 
— are very interesting to the physician : and the first thing which strikes our atten- 
tion in respect to them is the indisposition they manifest to adhesive inflammation : 
and we are struck at the same time with the beauty of this provision. If the 
mucous membranes were as ready to throw out coagulable lymph, and to adhere 
to each other as the serous, almost every occurrence of inflammation in them 
would prove necessarily fatal ; by closing up the inlets of the air passages ; or 
the outlets of the urinary passages ; or any part of that long mucous canal which, 
passing through the body, requires a free opening at both of its extremities. But 
the inflamed mucous membrane pours out serous fluid, or viscid mucus, or pus, or 
blood. Inflammation of these membranes is, however, sometimes [in children 
very frequently] attended with the exudation of something which is very like 
coagulable lymph, and which has been considered (but in my opinion erroneously 
considered) to be such lymph. The tracheal, bronchial, and pulmonary mucous 
membrane, the oesophageal, the intestinal, and that which lines the uterus, are all 
more or less subject to the formation of adventitious membranes under inflam- 
mation. Casts of the smaller branches of the air-tubes have, in rare instances, been 
repeatedly coughed up in large quantity ; constituting what have been very inaptly 
called bronchial polypi. The membranous exudation of croup is well known: 
a tubular substance is formed in the trachea, and, sometimes, fortunately expelled : 
but too often it suffocates the patient. Similar concrete exudations, broken into 
irregular shreds, are occasionally voided by stool. It is said that a long mem- 
branous mass of the same kind, in size and shape like an earth-worm, has been 



MUCOUS MEMBRANES. 



125 



discharged from the urethra; having formed there in consequence of the injudi- 
cious use of stimulating substances, injected with the view of checking the more 
innocent effusion of pus. The films, or membrane-like flakes which are thus 
incidental to inflammation of the mucous surfaces, resemble, I say, in their gene- 
ral appearance and disposition, the strata or layers of coagulable lymph which are 
the ordinary product of inflammation of the closed serous surfaces. But they differ 
from these in some remarkable points. They are softer. They never contract 
permanent or strong adhesions to the subjacent inflamed membrane; but are par- 
tially separated from it by the intervention of thinner matters, serous or puriform. 
Above all, they never become organized. They appear to consist of inspissated 
and altered mucus ; and are composed, in a great measure, of albumen. An 
opinion has been entertained that the want of apposition of the opposite surfaces 
has a great deal to do with their indisposition to cohere. The mucous air tubes 
are kept open and apart by their structure: the stomach and intestines by their 
contents, or by the frequent passage of solids and fluids through them : and there- 
fore (it has been supposed) they have no opportunity of adhering. But there can 
be no doubt that these mucous membranes are but little disposed to throw out true 
lymph at all : and when their opposite surfaces do grow together, I believe it will 
almost always be found that some abrasion or ulceration of the mucous surface 
had previously happened. 

Inflammation affecting the mucous membranes has sometimes a strong tendency 
to spread and wander: sometimes, on the contrary, it is strictly confined to a 
small and definite space. In the former case it commonly restricts itself for a 
long time, or altogether, to the mucous tissue, leaving the neighbouring tissues 
untouched. In the latter it is apt to penetrate to the subjacent parts, and to 
produce obvious and enduring alterations of structure. The membrane becomes 
fastened to the parts which it should loosely clothe, and not unfrequently it ulce- 
rates or sloughs. 

The spreading form of inflammation is most often met with in the air-passages. 
Ulceration and sloughing, and circumscribed inflammation, are more common ir. 
the alimentary canal. 

There is a remarkable contrast between the serous membranes and the mucous, 
in respect to the pain which attends their inflammation. Very little pain is expe- 
rienced in many cases, when inflammation affects the mucous lining in any of the 
three systems, except towards their openings, where the membranes are about to 
become continuous with the external skin : in the mouth and throat, for example, 
the pharynx, the rectum, the vagina, the extremity of the urethra. And as in- 
flammation of the mucous membranes is attended by less pain, so also it is accom- 
panied by less fever than when the serous membranes are attacked ; and the blood 
more seldom exhibits the buffy coat. 

The muscular tissue appears to take on the actions of inflammation very reluc- 
tantly : and its vessels seldom, if ever, pour forth any of the products of inflam- 
mation. The chief effect of inflammation upon muscle, is the destruction of its 
contractile properties. Serum and lymph, and even pus, are sometimes found 
diffused through muscular parts ; but there is reason to believe that these effusions 
are rather the consequence of inflammation of the areolar tissue which enters into 
the composition of the muscle, and ties together its fleshy fibres, than of inflam- 
mation of those fibres themselves. 

I have remarked already that inflammation of an artery presently leads to the 
effusion of lymph, and the coagulation of the blood, within the artery. But 
arteries do not readily inflame, except under mechanical injury ; they do not often 
suppurate either : and they possess a singular power of resisting mortification. 
Dr. J. Thomson declares that he has seen cases of phlegmonous erysipelas, in 
which " several inches of the femoral artery were laid completely bare by the 
gangrene, ulceration and sphacelus of the parts covering it, without its giving way 
before death." 

Inflammation of the veins is much more common than that of the arteries ; and 



INFLAMMATION. 



it is a disease of fearful interest. In some cases it leads to a deposit of fibrin upon 
the inside of the vessel, " furring it over," as Mr. Hunter says. The blood soon 
coagulates, and blocks up the inflamed vein, or leaves, perhaps, a narrow passage 
in its centre. From this mechanical obstruction to the current of the blood new- 
symptoms arise. The part from which the venous trunk receives its tributary 
branches becomes cedematous or dropsical. Inflammation of the femoral vein, 
obliterating its cavity, is the essence of the complaint known to pathologists under 
the name of phlegmasia dolens: a complaint which may happen to persons of 
any age, and of either sex; but which is most common in women soon after 
parturition. 

This, which may be considered the adhesive form of phlebitis, is also its most 
innocent form. Too frequently the inflammation runs into suppuration: and 
then it proves a most terrible and almost hopeless disorder. The vein remains 
pervious; pus, of an unwholesome and poisonous quality — or some morbid pro- 
duct of the inflammation — is carried into the blood ; which thus scatters, in its 
course, the seeds of inflammation, and determines the rapid formation of purulent 
collections, in various and distant parts of the body, and especially in the lungs, 
the liver, and the larger joints. Great constitutional disturbance ensues, and fever 
of a typhoid type is often established. To this, the destructive form of the dis- 
ease, parturient women are also peculiarly liable. Phlebitis of the uterine veins 
constitutes the source of the most dangerous and deadly varieties of puerperal 
fever. It is the same disease which gives to a vast majority of those surgical 
operations that are followed by death, their fatal character. 

We hear continually of inflammation of the brain ; but what is so called is, 
most commonly, inflammation of the membranes which invest the brain. Inflam- 
mation of the cerebral substance itself is, however, not very uncommon ; but it 
is more frequently the result of injury than of spontaneous disease, and it is 
usually confined to a limited portion of the brain. Softening and suppuration are 
its ordinary events. Sometimes pus is met with, occupying a distinctly circum- 
scribed space ; the pus is collected into an abscess. Sometimes, on the other 
hand, it lies loose, as it were, and surrounded by broken-down cerebral matter, 
or it is infiltrated into the cerebral pulp. Around the softened portions the 
inflamed substance of the brain is more dense and firm, sometimes, than is natural. 
Whether this be owing to the presence of coagulable lymph, has not (so far as I 
know) been clearly ascertained. Mortification must be very rare in the nervous 
substance. Dr. Baillie has described it as occurring after violent injury. Once 
or twice in my life, portions of brain have been shown to me,, protruding through 
an aperture in the skull, dead, of a dark colour, and having an offensive smell. 
Excepting in these cases of hernia cerebri, I have never seen sphacelus of the 
brain from any cause. 

Perhaps, hewever, I am incorrect in saying this. I formerly told you that 
portions of the brain often become soft and diffluent, when there has been no 
inflammation; but simply from atrophy, depending on a diseased state of the 
nutrient arteries of the brain. Now some persons call this, mortification of the 
cerebral substance. They consider it quite analogous to the gangrena senilis, 
which results from a similar cause, although it happens in another part of the body. 

The nature of the change, they say, is the same, although the physical cha- 
racters of it differ. If this be so, I have seen gangrene of the brain some scores 
of times ; but still I should be able to declare, that with, perhaps, the exception 
already mentioned, I have never seen unequivocal mortification of the cerebral 
substance as the result of inflammation: which is what we have now been 
considering. 

This concludes, gentlemen, what I have to say concerning the phenomena of 
common inflammation, as they are perpetually witnessed in the various textures of 
the body. I have not, indeed, gone through all the tissues ; I have said nothing of 
the peculiar effects of inflammation in cartilages, for example, and in bones ; but 
I have glanced at all those tissues in the inflammation of which the physician is 



VARIETIES OF INFLAMMATION. 127 

chiefly concerned. Upon such points as I have purposely omitted, you will be 
amply instructed by my colleague, the professor of surgery. 



LECTURE XII. 

Varieties of Inflammation : Acute and Chronic ; Latent; Specific. Scrofulous 
Inflammation. Tubercles. Relative frequency of Scrofulous Disease in 
different Organs. Signs of the Strumous Diathesis. 

We have now, gentlemen, considered the phenomena of inflammation, local 
and general; its symptoms and its events; and the intimation of those events 
which is afforded by the state of the system at large ; and we have surveyed the 
principal tissues of the body, and observed the modifications and peculiarities to 
which the process of inflammation is liable, according as it is situated in the one 
or the other of those tissues. 

There are still some varieties of inflammation ; and some epithets applied to 
inflammation ; which require to be explained. 

Acute, and chronic, inflammation : these are words perpetually in our mouths. 
I have frequently employed them already. What do they mean? Is acute in- 
flammation different from chronic in kind? No: they differ only in degree. 

When the disease runs its course rapidly, and is attended with much general 
as well as local disturbance, it is said to be acute. When, on the other hand, the 
local and constitutional symptoms are less violent, and the inflammation runs a 
longer course, its phenomena following each other in slower succession, it is 
said to be chronic. The process is the same, but its features are less strongly 
expressed. The disease passes through similar stages in both cases, but it travels 
at a different pace. The characters, then, of acute inflammation are intensity of 
symptoms and rapidity of progress: and the characters of chronic inflammation 
are mildness of symptoms and slowness of progress. Inflammation can scarcely 
be very violent, and at the same time of very long duration. When violent it 
has been likened (by Mr. Lawrence, whose language I have here adopted) to a 
blazing fire, which soons burns itself out. It may, however, be mild in its 
symptoms, and yet quickly over. The two terms acute and chronic are not 
directly opposed to each other: acute has more relation to the intensity, chronic 
to the duration of the disease ; and some term is wanted — although it is hardly 
worth seeking for — to denote such a degree of inflammation as exists in a pim- 
ple : which is neither severe nor long-continued. 

Now, in respect to intensity and duration, there are innumerable shades of 
difference in different cases of inflammation ; and the same difficulty occurs here 
which always occurs when general terms are employed to express mere differ- 
ences of degree. We feel no uncertainty or hesitation about those cases which 
occupy the two extremes of the scale; but with regard to those which lie in the 
middle we are often at a loss. To meet this difficulty some pathologists have 
invented a third epithet, viz., sub-acute, intending to designate thereby cases 
which hold an equivocal rank ; which are neither decidedly acute rior plainly 
chronic ; in which the inflammation may run a brief course, and be attended 
with a certain degree of fever ; but attains no great intensity, works no profound 
changes, and does not require very energetic remedies to control it. 

You must not suppose that, because chronic inflammation is attended with less 
tumult and disturbance, it is necessarily on that account less dangerous or less 
destructive than acute. The latter is commonly more obedient to the influence 
of remedies than the former : it is usually soon brought to an end : whereas 
chronic inflammation is often obstinate and abiding, and leads to very serious 
changes in the part upon which it fastens. Speaking generally, it tends to thicken 



128 



INFLAMMATION. 



and indurate when it is situated in the interior of organs, and to the effusion of 
pus when it affects membranes, or surfaces. It is more common in weakly and 
debilitated persons than in others ; but you must not forget that such persons are 
also very liable to acute inflammation. 

Chronic inflammation is not unfrequently a sequel of acute inflammation. And 
that the two differ merely in degree, and not in kind, is evident from this : that 
acute inflammation may sink or subside into chronic ; and that, on the other hand, 
chronic inflammation may readily be aggravated into acute. 

There is another, but less intelligible division of inflammation into active and 
passive. I believe that they who use the term passive inflammation intend to 
signify by it that languid and sluggish kind of inflammation which is apt to occur 
under the same circumstances, and in the same conditions, with passive conges- 
tion. When the granulations of an ulcer are in that state in which they may be 
made brighter, smaller, and healthier, by the application of a stimulus ; when the 
blood-vessels of the eye are left, after acute inflammation, turgid and tortuous ; 
and that condition is improved, instead of being worsened, by the use of a stimu- 
lating lotion: in such cases as these, some persons would say there was passive 
inflammation. But I see little difference between this and chronic inflammation ; 
nor do I know any difference between active and acute inflammation. 

The term latent inflammation is one of modern introduction. It is applicable 
to those cases in which internal inflammation runs its course silently, treache- 
rously, and unperceived ; without the usual warning tokens of its presence; with- 
out its more striking and prominent signs. Pneumonia, going on to disorgan- 
ization of the lung, may arise, proceed, and even prove fatal, without any of the 
symptoms which ordinarily announce that disorder : without notable cough, or 
obvious dyspnoea, or complaint of pain, or the expectoration proper to pneumo- 
nia. And the same is true of other inflammations. We discover, with surprise 
and horror, the traces of their operation, when we come to examine our patient's 
dead body. 

This is a most important form of inflammation ; for though it does not declare 
itself to ordinary observation, neither does it occur absolutely without symptoms ; 
but it requires that the symptoms should be looked for. The auscultatory signs 
of pneumonia, all those symptoms which are furnished by the physical condition 
of the affected organ, are present, and speak as clearly as in the more flagrant 
cases. 

Latent inflammation is apt to creep on during the progress of certain disorders, 
whereby it is modified and masked. It belongs to those states of the system in 
which the sensibility is dull, and the vital powers languid. In continued fever 
not only have I known the lung pass into suppuration, when the existence of 
pneumonia had been unsuspected ; but I even have seen one case in which that 
usually torturing accident, perforation of the bowel, took place, with the escape 
of its contents into the cavity of the abdomen, and extensive peritonitis — yet the 
patient expressed no sense of pain, and the inflammation was revealed, while he. 
continued to live, by no intelligible symptom. 

Inflammation of this insidious and lurking character is most to be apprehended 
in the aged, in those who are habitually intemperate, and in persons of sluggish 
temperament. It sometimes occurs during convalescence from acute diseases. 

Besides tke varieties which have been mentioned in degree, there are also dif- 
ferences in kind among inflammations. What I have been speaking of during 
the preceding lectures I have called common inflammation. It is the most com- 
mon form in which that process displays itself. All persons are liable to it; and 
that again and again. None are at any time privileged from its attacks. But 
there are several forms of inflammation different from this, which are called 
specific. There are various forms of specific inflammation affecting the skin, 
discriminated from each other by the local appearances they exhibit, and by the 
constitutional disorder which attends them. The rash and the fever of measles, 
are very unlike the rash and the fever of scarlatina ; and both differ remarkably 



TUBERCLES. 



129 



from those of small-pox, the eruption of which consists of little phlegmons. In 
each of these diseases the application of a specific poison is required for its pro- 
duction: and whereas common inflammation has a tendency, when once it has 
happened, to happen in the same part again — to recur — these forms of specific 
inflammation never, or almost never, occur more than once. 

There is again the gouty inflammation — differing from common inflammation 
in several signal respects ; in the production of chalk-stones; in its attacking those 
who are descended from ancestors who have had the disease, and scarcely any 
others. Then there is rheumatic inflammation, cousin-german to the gouty, yet 
distinguishable from it. And another variety of inflammation is that which arises 
from the introduction of the syphilitic poison into the system. 

Of the specific forms of inflammation now adverted to I shall speak when I 
come to consider gout and rheumatism, and the contagious exanthemata, as dis- 
tinct diseases. But there is one variety of inflammation — I mean the scrofulous 
— which meets us on every side ; and is apt to affect so many parts of the body, 
and so great a number of persons ; and has so fatal a tendency in most cases ; 
that it cannot be left out of the account that I have been desirous to give you of 
inflammation in general. 

Scrofulous or strumous inflammation (for struma and scrofula are convertible 
terms) is a slow process ; it falls therefore within the class of chronic inflamma- 
tions. It is not attended with much pain, or heat, nor for some time with much 
change of colour; and the redness which does accompany it has often a livid or 
purplish tinge. 

These, however, are the negative properties of merely chronic inflamma- 
tion. But suppuration at length occurs, which also lasts long : and the pus 
formed is peculiar and characteristic; and by no means laudable. It is not homo- 
geneous or smooth, but consists partly of a thin serous whey-like fluid, and partly 
of fragments of a substance resembling curd : and the ulceration that ensues is 
marked by corresponding peculiarities. The ulcers are indolent; show but little 
disposition to heal. Scrofulous inflammation, compared with common, or what 
is called healthy inflammation, is in general but little influenced by remedies. 

Besides this scrofulous inflammation, it is necessary that I should now direct 
your attention to another form of disease, which is likewise properly denominated 
scrofulous. It is marked by the appearance, in various parts of the body, of what 
are called tubercles. These tubercles are masses of unorganized matter — also 
resembling curd or new cheese, more or less; but of various shapes and sizes. 
They suffer gradual changes ; soften or break down ; undergo a sort of suppura- 
tion; and the softer matter into which they thus (as it were) melt, has the cha- 
racters that distinguish the pus of a scrofulous ulcer or abscess. 

Now tubercles and scrofulous inflammation occur very continually in the same 
individuals: and what is remarkable, although they affect a very large portion 
of the whole human race, and conduce more often and more surely than any one 
thing else to shorten the natural period of human life, yet they belong, almost 
exclusively, to certain classes of persons. We can tell, beforehand, that such 
and such persons are likely to become affected with scrofulous inflammation, or 
with tubercles : and we say of those persons that they have the scrofulous dia- 
thesis. I will not positively affirm that these forms of disease cannot be produced 
in any or in all persons; but thus much is certain — that some persons are par- 
ticularly prone to them : fall into them as it were spontaneously : or on the 
operation of very slight external causes ; and even when all possible care is taken 
to prevent the operation of every ascertained cause ; while other persons never 
show any tendency to scrofula, even when continually exposed in the same man- 
ner ; or if they do become scrofulous at all, it is only when the external circum- 
stances most favourable to the production of such disease have been extreme in 
degree, and protracted in their application. 

The occurrence of scrofulous inflammation in various parts constitutes distinct 
diseases; and the occurrence of tubercles in various organs constitutes other 
9 



130 INFLAMMATION. 



diseases. It will facilitate our future inquiries into these several diseases, if I 
take this opportunity of stating to you what is known respecting the scrofulous 
diathesis generally ; and of the modifications of inflammation which are determined 
by its presence. 

A good deal of discrepancy, obscuring the whole subject, and puzzling the 
student, has existed — and I believe I may say still exists — among pathologists, as 
to the nature, and origin, and precise seat of tubercles, and as to the changes 
which they undergo. 

In general they have been loosely described as being round masses of firm but 
friable matter, deposited in various parts of the body. Laennec, who paid great 
attention to tubercles, states that they are, at first, small, firm, grayish, semi- 
transparent bodies, which gradually enlarge and become opaque. In that condition 
he calls them crude tubercles. At length, after an indefinite period, these crude 
tubercles begin to grow soft in their centres, and are by degrees converted each 
into a liquid mass, having the consistence of cream. There is much error in this 
description. 

Andral, another great authority, says that tubercles are, in the outset, small, 
round, opaque, yellowish bodies, unorganized, and of various degrees of con- 
sistence. He ascribes their softening (not to any spontaneous changes in their 
central parts, but) to the admixture of pus, poured out by the textures imme- 
diately surrounding the tubercle; which has irritated and inflamed those textures 
as any other foreign body might. 

In some respects this statement is nearer the truth than Laennec's. 

But in the account which I am about to give you, I shall chiefly follow our 
countryman, Dr. Carswell, the first Professor of Pathological Anatomy in Univer- 
sity College ; who is one of the latest, and, as I think, most satisfactory writers 
on the subject. His opinions were formed after a long and careful examination, 
for himself, of the parts infested by these tubercles. He devoted several years to 
the study of morbid anatomy, in Paris, where he made a very large collection of 
drawings, in which various diseased appearances are beautifully, and doubtless 
faithfully delineated. Some of these he has since published. I show you enlarged 
copies of those which relate to tubercle. They bear out some novel opinions 
which are stated in the letter-press that accompanies them. 

After all, the points in question possess more of curious interest than of practical 
importance. But as you cannot help forming some notions respecting them, I 
think myself bound to lay before you those which most recommend themselves 
to my own judgment. At the same time you are to understand that I do not 
vouch for their absolute correctness. 

Tubercles, then — or rather tubercular matter, is deposited from the blood. 
Whether it is something totally new, something foreign to the natural materials 
of the body, introduced into the blood from without- — or whether, as seems more 
likely, it is the result of some defect or error in the due elaboration of the blood 
itself — I cannot satisfy you. If, as has been supposed, the deposit is at first fluid, 
it afterwards becomes firmer, through the absorption of its more watery particles ; 
and there then remains a " pale yellow, or yellowish gray, opaque, unorganized 
substance." This tubercular matter, so deposited, does not always assume a 
round form : far from it ; the shape in which it appears depends upon the nature 
of the part wherein it is planted. It used to be held that the tubercular matter 
was always laid down in the areolar tissue. But Dr. Carswell asserts that its 
most favourite seat (if one may so speak) is the free surface of mucous mem- 
branes. In whatever organ it is met with, if mucous tissue enters into the com- 
position of that organ, that particular tissue js either (he says) exclusively affected, 
or much more extensively affected than aay of the other component tissues. 
These remarks apply to the lungs, the alimentary canal, the liver, the urinary 
organs, and the organs of generation ; but the presence of the tubercular matter is 
much more easily detected in the mucous tissue of some of these organs than in 
that of others. It is very conspicuous in the Fallopian tubes and uterus. 



TUBERCLES. 131 



But tubercular matter is often deposited on serous surfaces also ; among which 
Dr. Carswell includes the plates of the areolar tissue. It is even to be seen some- 
times in the blood itself : not indeed while it is retained in its proper vessels, but 
when it is collected in the cells of the spleen. You know that the spongy texture 
of that organ allows the blood to accumulate in it in considerable quantity : and 
the tubercular matter may be seen forming in the blood at some distance from the 
walls of the cells in which the blood is contained. In one cell, according to Dr. 
Carswell, you may perceive simply the blood coagulated : in another, it will be 
coagulated and deprived of its colouring matter; and in another, converted into a 
mass of solid fibrin, having in its centre a small nodule of tubercular matter. 

Now when a speck or morsel of tubercular matter has been deposited anywhere, 
it is liable to increase. It grows larger by continued accretion ; by additional 
deposits upon its surface. This being the case, we see plainly enough how it 
happens that tubercles assume different shapes, according as they occur in differ- 
ent parts. The round form which is so often observed is purely accidental. 
When a tubercle is deposited in the substance of the brain — and becomes larger 
by the repeated accession of fresh tubercular matter upon and around it — it natu- 
rally takes a spherical form, because there is nothing to limit its enlargement, 
except the soft cerebral matter itself, which presses it with equal force on every 
side. For the same reason tubercles deposited in the areolar tissue are globular. 
In like manner, if tubercular matter be laid down in one of the pulmonary vesicles, 
so as to fill it up, it exhibits the roundish form of the vesicle. When it fills the 
cavity of a mucous follicle, it has a similar figure. But in the smaller bronchi it 
takes a more cylindrical arrangement. When (as often happens) it occupies one 
of these tubes, and also all the air-cells to which that tube leads, then we have 
twigs of tubercular matter, with cauliflower terminations. You see this depicted 
in the drawings before you. In the cavity of the uterus, and the Fallopian tubes ; 
in the infundibula and pelvis of the kidney, and in the ureters; and in the lacteal 
and lymphatic vessels ; the tubercular matter is moulded to the forms of these 
parts respectively. We are more in the habit of examining tubercles in the lungs 
than anywhere else ; and you will observe that in making sections of these organs, 
and looking only at the surfaces of those sections, we may easily overlook the 
branch-like disposition of the tubercular matter in the smaller bronchial tubes. 
We see the transverse section only of the tubes, which is necessarily more or 
less circular. On the surfaces of serous membranes, whether natural or adventi- 
tious, the tubercular matter will assume a rounded, or a lamellated form, according 
as the morbid secretion in which it originates has taken place from separate points, 
or from a continuous surface. 

From what has now been stated you will perceive that no alteration can be 
expected to take place in the tubercular matter after once it has been deposited, 
except through the agency of the parts around it and in contact with it. It is 
never organized, or capable of organization ; and, consequently, no vital change 
in its consistence can originate in the tubercle itself. If any spontaneous change 
arises, it must be a chemical one : and of such we have no evidence at all. 

It may therefore seem odd, that so accurate an observer as Laennec should 
have persuaded himself that the softening of tubercles begins in their centre. 

Now Dr. Carswell has given what appears to me a sufficient explanation of 
this mistake. Take the lungs ; the morbid conditions of which were the most 
especial object of Laennec's investigations. The tubercular matter is effused 
(principally) upon the mucous surface ; upon the inner lining of the air-cells, and 
of the bronchial tubes communicating with them. Yet it need not so accumulate 
as to Jill the^ cavities; and it often does not; there is left a central vacuity, 
which contains mucus, or other secreted fluids : and if the lung be cut across under 
these circumstances, the divided air-vesicles will look like rings of tubercular 
matter grouped together ; and each divided bronchial tube will present also the 
appearance of a tubercle, with a central depression, or soft central point. On the 
other hand, when the tubercular matter has completely filled and blocked up these 



132 



INFLAMMATION. 



cavities, both vesicles and bronchial tubes will look, when divided, like sections 
of round solid tubercles. These Laennec seems, in fact, to have regarded as crude 
tubercles: while he mistook the former appearances for tubercles which were 
beginning to soften in their centres. 

But you sometimes find large masses of tubercular matter in the lungs, or else- 
where : and in these masses you see that the process of softening is going on at 
several points, within the mass, at the same time. How is this to be explained ? 
Why these large masses are formed, in fact, by the aggregation of many smaller 
masses, which lying near each other, have coalesced as the deposit continued to 
increase : and the areolar and other tissues originally intervening between these 
coalescing masses at length suppurate, by reason of the augmenting pressure; 
and by their suppuration, they soften, and gradually break down the tubercular 
matter which they enclose, and by which they are also enclosed. This is just 
the process by which tubercles are frequently expelled from the body. They 
increase till the surrounding parts take on inflammation, just as they might do if 
any foreign body exercised the same degree of pressure upon them. The inflam- 
mation thus excited is of the scrofulous kind ; the thin pus which is thrown out 
pervades and loosens the tubercular matter ; a process of ulceration goes on in the 
surrounding textures ; and at length (supposing the lung to have been the seat of 
disease) the detritus of the tubercle is brought up, gradually, by coughing. 

Both Laennec and Louis, the latter also being a very close observer, describe 
the nascent tubercle as a gray semitransparent corpuscle. I have frequently seen 
such ; but the appearance is rare, in comparison with the more opaque form of 
tubercle. Of this, too, Dr. Carswell offers what I think a very probable explana- 
tion. He says that the mucous membrane of the air-tube* separates from the 
blood, not only the matter of tubercle, but also its own proper secretion : and 
that, frequently, when the two have been poured out together, a dull yellow 
opaque point of tubercular matter becomes set, as it were, in a portion of gray, 
semitransparent, and, sometimes, inspissated mucus. The same deceptive 
appearance is common on serous membranes : in tubercular peritonitis, coagulable 
lymph exudes, portions of which envelop little globular masses of tubercular 
matter. 

The account which I have now given yon, and which I hope I have made 
intelligible, is, I think, extremely interesting — and much credit is due to Dr. 
Carswell for having so greatly simplified our views of a subject which had pre- 
viously been wrapped in profound obscurity. In no other writer, that I know of, 
is there to be found so complete and credible an explanation of the origin of tuber- 
cles ; of the forms they assume, of the phenomena attending their enlargement, 
and subsequent softening, and occasional expulsion. 

These processes — of softening, produced by surrounding inflammation, and of 
ultimate expulsion — may be regarded as a natural mode of cure. Such a cure is 
in truth occasionally accomplished. A scrofulous abscess forms in the glands of 
the neck; and pus and tubercular matter are discharged. At length the ulcer 
heals, and no trace of the diseased process remains, beyond a scar. The same 
thing takes place also in the lungs ; and, if there have been only one or two 
masses of tubercle deposited, the patient may thus get quite well: but unfortu- 
nately, as the scrofulous matter is extirpated from one part of the lung, it is apt 
to be multiplied in another, till at length we have death by hectic, and all its 
melancholy accompaniments. 

But I am desirous of pointing out to you another way in which tubercular dis- 
ease may be said to be cured by a natural process. And this also has been 
better described by Dr. Carswell than by any other writer. One fo^m of scrofu- 
lous disease, exceedingly common, too, especially among children, is what is called 
" tabes mesenterica" Tabes and phthisis, the one a Latin and the other a Greek 
word, signify, I need scarcely tell you, the same thing: a wasting away, or a con- 
suming: and phthisis is applied to the same disease in the chest, to which tabes 
is applied in the belly. The common English word is consumption ; and we 



TUBERCLES. 



133 



might very well speak of thoracic consumption, and of abdominal consumption 1 ,; 
but the technical name of the latter complaint is tabes mesenterica. This is not 
only a very common but a very fatal disease in children and young persons. The 
glands of the mesentery enlarge and become charged with tubercular matter: but 
they very rarely suppurate. Their enlargement is commonly connected with 
scrofulous disease and ulceration of the mucous follicles of the intestines ; and the 
little patients die, because the lacteals are no longer able to take up from the food 
a sufficient supply of nutriment: they die starved. But some few do recover 
from tabes mesenterica. Dr. Carswell relates an interesting case in which such 
recovery took place, and in which he had an opportunity of examining the glands 
at a subsequent period: it is the only case of the kind perhaps on record. He 
says, •* the patient who when a child had been affected with tabes mesenterica, 
and also with swellings of the cervical glands, some of which ulcerated, died at 
the age of 21, of inflammation of the uterus, seven days after delivery. Several 
of the mesenteric glands contained a dry cheesy matter, mixed with a chalky- 
looking substance ; others were composed of a cretaceous substance ; and a tumour, 
as large as a hen's egg, included within the folds of the peritoneum, and which 
appeared to be the remains of a large agglomerated mass of glands, was filled 
with a substance resembling a mixture of putty and dried mortar, moistened with 
a small quantity of serosity. In the neck, and immediately beneath an old cica- 
trix in the skin, there were two glands containing in several points of their substance 
(which was otherwise healthy), small masses of hard cretaceous matter." 

Now what Dr. Oarswell here saw in the mesentery and in the neck, is what 
sometimes occurs in other parts of the body; in the lungs; and particularly in the 
bronchial glands at their root, and about the bifurcation of the trachea. From 
these situations, the hard chalky matter left by the absorption of all the more 
watery part of the morbid deposit, and by the concretion of its earthy salts, is 
often coughed up. But it may remain, when the tubercles are few, and there is 
no tendency to their increase, for years, as an inert, and almost harmless mass. 

I mentioned just now that the secretion or separation of the matter of tubercle 
from the blood, takes place, by preference, upon the free surface of mucous mem- 
branes, and very frequently also upon the surface of serous tissues, including the 
areolar. 

It may not be uninteresting to inquire into the relative frequency of scrofulous 
disease in different organs, or in different parts of the same organ. The facts 
which we possess on this head afford us very valuable assistance sometimes in 
respect of diagnosis. 

During the periods of childhood and youth the lymphatic glands are exceed- 
ingly prone to scrofulous inflammation: especially the mesenteric and the cervical 
glands. But in adult age tubercles are, beyond all comparison, most frequent in 
the respiratory organs; and they occupy the summit of the lung much more 
commonly and thickly than any other part. The superior and posterior portion 
of the upper lobe is the spot in which, if any tubercles at all exist in the lung, 
they are almost sure to be found. It is here also that they first begin to suppu- 
rate or soften. This law has long been well known: and so constant is it, that 
Dr. Carswell holds the formation of tubercles in any other portions of the lung to 
be always of secondary occurrence. He declares it to be the result of his experi- 
ence (and few persons can have had more opportunities of examining diseased 
lungs), that there is no deviation from this rule, except when some other portion 
of the lung may have been the seat of an inflammatory attack, which has deter- 
mined the priority of tubercular disease in that portion. We shall see hereafter 
what a very important bearing a knowledge of this law has, in settling the nature 
of a complaint which might, without it, be doubtful. 

Scrofulous ulceration of the larynx and trachea, when they occur, are usually 
concomitants of tubercular deposits in the lungs. 

Next, tubercular or strumous disease is exceedingly common in the digestive 
organs : most of all in the mucous follicles of the small intestines ; both in those 



134 



INFLAMMATION. 



follicles which are separate, and are called glandulae solitariae ; and in those which 
are collected into roundish or oblong groups, the glandulae agminate. It is second- 
arily to these affections of the follicles, in many cases at least, that the glands of 
the mesentery become implicated. Tubercular deposits are frequent also in the 
solitary glands belonging to the caecum. The ulceration which follows the evacua- 
tion of the strumous matter from these parts gives the interior of the bowel an 
appearance somewhat resembling that of a moth-eaten garment. Tubercular 
matter is seldom deposited in any other parts of the intestines, great or small, than 
those which I have mentioned. Dr. Carswell supposes that it may often be 
secreted upon the free surface of the membrane, but that, not being entangled or 
confined in any mucous crypt, it is removed as soon as it forms. It is not often 
that scrofulous tubercles are found in the liver of adults : they are not very uncom- 
mon in that organ in children, but even then they are few in number and small 
in size. It is a curious fact that they are much more frequently seen in the spleen 
also in children, than in grown up persons. The uterus, the testicle, the prostate 
gland, are all liable to them: they are common enough upon the surface of the 
peritoneum. 

In the nervous system, tubercles are by no means unfrequent: they are met 
with oftener in the brain than in the spinal cord. That fearful disorder of child- 
hood, known by the name of hydrocephalus, occurs principally, if not altogether, 
in connection with the scrofulous diathesis. 

Strumous deposits are rare in the organs of circulation. Tubercles have been 
seen, I believe, in the muscular substance of the heart: but this must be a very 
uncommon thing. Scrofulous disease is not at all unfrequent in bone, especially 
in the bodies of the vertebrae, and in the spongy extremities of the long bones. 

It is very seldom, indeed, that scrofulous tubercles occur in any one organ only. 
Almost always they are met with in at least two, and frequently in all the parts 
at once which are liable to be infested by them. Sometimes the lungs alone are 
affected ; but generally both the lungs and the intestines are occupied by the disease. 
It has been affirmed, by a great living pathologist, M. Louis, that if you find tuber- 
cles in any other organ, you are sure to find them also, and in greater number, and 
further advanced, in the lungs. But this, though true as a general rule, is not 
without exceptions. I have seen the peritoneum crowded with myriads of these 
tubercles, when the most careful examination could not detect a single one in the 
lungs. And similar examples have fallen under Dr. Carswell's observation. 

The question has been much and eagerly discussed, whether the deposition of 
tubercular matter be not, what I should call, an event of inflammation. Some 
persons have strenuously argued that the curd-like substance is nothing more than 
a particular kind of vitiated lymph, and that it is never poured out except as a con- 
sequence of inflammation ; and they cite cases of persons who always had enjoyed 
good health, until inflammation was accidentally excited in their lungs, immedi- 
ately after which the well-known signs of phthisis began to display themselves ; 
and, after death, the lungs were found full of tubercles. But they forgot to take 
into the account another fact equally well established, viz.: that tubercles are 
found, in great abundance, in the lungs of persons who were never known, in their 
lives, to have any functional disturbance of those organs ; and whose lungs pre- 
sent, after death, no other traces of having been inflamed. We even find tubercles 
in the lungs of unborn children. Not that this is conclusive; for inflammation 
does sometimes attack the fetus in utero, and leave permanent and unequivocal 
traces of its action. 

Moreover, inflammation continually happens, in all the component textures of 
the lung, in the forms of bronchitis, pneumonia, and pleurisy, without the subse- 
quent development of tubercles. I admit that this fact, to be of weight, should be 
proved of persons who possess the scrofulous diathesis; and I believe the proof 
might be found ; but the search for it would require much carefulness and candour. 

In my own opinion, there is not a shadow of evidence to show that the deposit 
of tubercular matter is always and necessarily preceded by inflammation. Yet 



TUBERCLES. 



135 



an undoubted and most important connection obtains between the occurrence of 
inflammation and the occurrence of tubercles. Tubercles will cause inflammation, 
and inflammation will determine the development of tubercles. The enlarging 
tubercles excite inflammation in the surrounding textures, by the pressure they 
exert upon them ; and probably in other ways; by mechanically interfering with 
the healthy circulation of the blood, for example: and the inflammation lit up is 
usually of the scrofulous kind ; it is slow, and partial, and easily quieted by treat- 
ment, though scarcely to be cured. On the other hand, there are numerous facts 
to prove that, in a person having the scrofulous diathesis, the occurrence of in- 
flammation within the chest may rouse that previously dormant tendency into 
action, and become the exciting cause of the secretion or separation of tubercular 
matter from the blood. The cases in which other parts of the lung than the apex 
are found exclusively occupied with tubercles, are also cases in which, apparently, 
the same parts had been the seat of inflammatory action : of which we sometimes 
see other traces in adhesions of the neighbouring pleura. 

The connection between tubercles and inflammation is shown also by their 
occurrence in the substance of false membranes, And the same phenomenon 
marks the fact that they are something distinct and different from coagulable lymph. 

You must not suppose, from any thing I have said, that persons of the scrofu- 
lous habit are not susceptible of common inflammation : we know that they are, 
by the readiness with which slight injuries often heal in such persons; but there 
is always much reason to apprehend that inflammation occurring in them will 
take on the scrofulous form ; become chronic, if it was not so at first, suppurate 
tardily, and produce that unhealthy kind of puriform secretion which is charac- 
teristic of strumous disease. 

Another question relating to tubercular diseases is, whether they are contagious : 
capable, i. e., of being communicated from one individual to another. The gene- 
ral belief, in this country, is that they are not. Indeed their very dependence upon 
a peculiar diathesis would seem to disprove the supposition. Yet some practi- 
tioners, even here, have, I know, misgivings on the subject: and in some parts 
of the continent, in Italy particularly, consumptive patients are shunned, from the 
persuasion that their complaint is infectious. I shall revive this question when I 
speak of phthisis hereafter. 

I have stated that scrofulous disease appears, almost exclusively, in certain 
classes of persons, of whom, therefore, we say, that they have the scrofulous 
diathesis. 

It is both interesting and useful to be able to distinguish those in whom the 
scrofulous habit of body, or the predisposition to strumous disease, exists. 

Now there are certain physical and moral characters which teach us to appre- 
hend the existence of a tendency to scrofulous disease, even when there has not, 
hitherto, been any local manifestation of such disease. 

Again, we infer the scrofulous diathesis, in many persons, from knowing that 
scrofula has existed among their progenitors. 

On these two points I have a few observations to make : and first, on what may 
be considered the external tokens of a scrofulous constitution. 

The persons, in whom scrofulous disease is most apt to declare itself, are 
marked, during childhood, by pale and pasty complexions, large heads, narrow 
chests, protuberant bellies, soft and flabby muscles, and a languid and feeble cir- 
culation. They present many of the features belonging to that pattern of body 
which is denominated the leucophlegmatic. But the strumous disposition very 
often, indeed, accompanies a variety of the sanguine temperament also; and is 
indicated by light or red hair, gray or blue eyes, with large and sluggish pupils, 
and long silky lashes, a fair transparent brilliancy of skin, and rosy cheeks. This 
red colour, which is well defined in general, is easily changed, however, by cold, to 
purple or livid; the skin is thin and readily irritated; the sclerotic has often a peculiar 
pearly lustre ; and the extremities are subject to chilblains. Such children are, 
many of them, extremely clever and ready of apprehension, of eager tempers, 



136 



INFLAMMATION. 



and warm affections, lively, ardent, imaginative, and susceptible. This precocity of 
mind and intellect, while it delights the fondness of the parent, awakens the fears 
of the more far-seeing physician. 

But the disposition to scrofula is by no means confined to persons of the serous 
or of the sanguine temperament. It is frequent, though less common, in what has 
been called the melancholic or bilious temperament ; in persons of dark muddy 
complexion, and harsh skin ; in whom the mental and bodily energies are more 
sluggish and dull. And it is remarked that in persons of this cast, scrofula, when 
it does occur, is even more than usually obstinate and intractable. 

Scrofula does often, indeed, appear in persons who exhibit none of those signs 
of a strumous disposition which I have been enumerating; but it is more likely to 
rappear, ceteris paribus, where those signs are observed. 

There are several alleged marks of a scrofulous diathesis, which are, in fact, 
instances of scrofulous disease. Such, for example, is that chronic lippitudo, 
which so frequently disfigures strumous children, rendering them what is called 
blear-eyed: and chronic inflammation of the conjunctiva, lasting long, without 
much redness or heat, and with extreme impatience of light, and a tendency to 
form little pustules near the edge of the cornea. The tumid and chapped upper 
lips, the redness and swelling of the columna nasi, and lower parts of the nostrils, 
so common in children, especially during winter, are early fruits of the strumous 
taint. Certain maladies of the joints, what are popularly called white swellings, 
are instances of scrofulous disease. So may, perhaps, rickets be considered: at 
any rate, rickety children are very often affected with scrofula also. Moist erup- 
tions behind the ears ; chronic enlargement of the glands of the neck ; that slow, 
eating ulceration of the nares, termed lupus ; may all be included within the class 
of strumous disorders. 

When any one of these scrofulous affections has once shown itself in any 
person, we know, by that circumstance, that he possesses the strumous consti- 
nuion ; and we look for the recurrence of his complaint in the same part, or in 
other parts. 

In a former lecture I mentioned scrofula as one of those distempers the here- 
ditary tendency to which is indisputable. The scrofulous diathesis is hereditary : 
and sometimes scrofulous disease is so too. I have seen lungs, taken from the 
body of a foetus, stuffed with tubercles. There were some fine examples of this 
in Mr. Langstaff's museum, in the city. We have, therefore, in respect to scro- 
fula, the rare conjunction of congenital disease, and hereditary disposition. I 
need not repeat here the remarks I made before respecting hereditary diseases in 
general. No one, of the least observation, can doubt that the disposition to con- 
sumption is very often transmitted from parent to child. We see whole families 
swept away by its ravages. Like other hereditary tendencies, it may skip over 
one or two generations, and reappear in the next, just as family-likenesses are 
known to do. There are other families in which you can trace no such predis- 
position ; but such families are perhaps few. A little leaven is sufficient, some- 
limes, effectually to taint a whole pedigree. The tendency, however, exists in 
various degrees. It may be so strong that no care, no favourable combination of 
circumstances, will prevent its local manifestation ; and it may be so faint that it 
would never break out into actual mischief if the exciting causes of scrofulous 
diseases could be warded off. It is important, therefore, to know what these 
exciting causes are. 

" They may all be ranked together (to use the language of Dr. Alison ) as 
causes of debility, acting permanently, or habitually for a length of time, although 
not so powerfully as to produce sudden or violent effects." 

The circumstances to which, acting separately, or in combination, we most 
confidently ascribe the power of developing scrofula, are insufficient nutriment, 
exposure to wet and cold, impurity of the atmosphere, the want of natural exer- 
cise, and mental disquietude. To estimate the separate effect of each of these 
causes may be difficult; but their combined influence is unquestionable. 



SCROFULOUS DISEASE. 



137 



There can be no doubt that improper diet, or rather imperfect nourishment, is 
one main exciting cause of scrofulous disease. Yet of this it is not an easy thing 
to obtain evidence, which shall be entirely free from fallacy. The disease occurs 
very often among the poor ; but then it very often occurs also in the families of 
the rich. There is one fact which has always struck me as very instructive and 
convincing on this point. Infants at the breast, having good milk and plenty of 
it, seldom show any signs of scrofulous disorder : whereas, as soon as they are 
weaned, they become subject to various complaints of a strumous kind. When 
an unweaned child is brought to us with ophthalmia, we expect almost always to 
discover inflammation of the common and acute kind ; the purulent eye. In nine 
children out of ten who come after weaning, we look for and find some form of 
scrofulous inflammation, such as pustular ophthalmia. 

The greater prevalence of scrofulous disease among the poor may be ascribed, 
in great measure, to their frequent exposure to wet and cold. Scrofula seldom 
breaks out in the mild and dry weather of summer. The influence of climate in 
fostering or repressing the disease is notorious. There is no climate in which it 
flourishes more than in our own. Consumption is called, in some parts of the con- 
tinent, the English disease. Persons who migrate from this country to warmer 
and more equable climates, seldom become scrofulous ; nay, it very often happens 
that the incipient indications of strumous disease are completely arrested or quieted 
by the change. Phthisical patients, much troubled by symptoms here, are some- 
times so thoroughly freed from them soon after their arrival in Madeira, as to be 
deceived into the belief that their case had been mistaken. They think themselves 
well. A return to this country undeceives them. The native inhabitants of hot 
regions are by no means, however, exempt from struma, in any of its forms. 
When they come into these latitudes they are more subject to scrofula than we 
ourselves are. And the same effect of climate is very distinctly visible in the 
lower animals. The physicians in ordinary to the inmates of the Zoological 
Gardens will tell you that the beasts and birds which are brought hither from 
warm latitudes perish in great numbers from scrofulous diseases. John Hunter 
observed this long ago in respect to monkeys. 

Of the debilitating influence of impure air I spoke in a previous lecture. That 
it promotes the evolution of scrofulous disorders we have proof, on a large scale, 
in the great mortality produced by such disorders among the lower classes in large 
cities as compared with agricultural districts. The per-centage of deaths from 
consumption, hydrocephalus, and various other diseases which spring from a 
strumous habit, is much greater in London than in the country. Even in indi- 
vidual cases this influence is too manifest to be overlooked or mistaken. It is 
impossible to question the beneficial effect, upon children afflicted with scrofula, 
of a removal from London to the sea-coast. 

I said, when I first began to speak to you of inflammation, that it was the only 
disease which we were able to excite at will : that we could cause inflammation, 
in various ways, whenever we desired to do so; but that to make a cancer or a 
tubercle was beyond our power. Now in strictness of language, and in the 
practical meaning of these words, this assertion is quite true. But it is not so 
exact if we extend it to all the predisposing causes of disease. We are able to 
bring about the formation of tubercles, in the lower animals at least, by so arrang- 
ing external influences as to concentrate ther prejudicial effects. By shutting 
rabbits up in a cold, damp, dark, and narrow place — and feeding them on food not 
natural or suited to them — we can produce or evolve in them tubercular disease. 
Of course no experiment of that kind can be purposely made upon a healthy man ; 
but accidental opportunities arise of witnessing an approach to a similar trial of 
the human species. Instances are recorded of persons, previously well (but 
having probably the strumous diathesis), becoming affected with scrofula after 
being confined in the dungeons of a prison, and there scantily fed. 

Something of this kind I have, very recently, had the opportunity of seeing. 

A number of male prisoners, chiefly young men 5 became aflected with glandular 



138 



INFLAMMATION. 



swellings of the neck, after incarceration for some length of time in the Peni- 
tentiary at Milbank. The circumstances of their health led to a relaxation of 
their punishment. Instead of being kept in solitary confinement in a coldish cell, 
and on the prison diet, they were permitted to work, for several hours daily, in 
each others' company, in the garden of the establishment. Some porter was at 
the same time given them, and their allowance of meat was increased. The 
improvement in their condition was rapid and striking. Here we have the dis- 
order germinating under one state of external circumstances, and checked imme- 
diately under the opposite state. 

If you consider the way of life of the children of the poorer classes in this 
metropolis, and in our large manufacturing towns, you will find that they are 
much exposed (though in a less degree) to the same injurious influences, the com- 
bination of which appears to generate tubercles in the rabbit. They live, for the 
most part, in an atmosphere made stagnant by narrow streets ; and in small, 
crowded, ill-ventilated and dark rooms in those narrow streets ; the stagnant 
atmosphere is contaminated in a thousand ways ; they are very insufficiently pro- 
tected from transitions of temperature, against cold and wet, by their clothing; 
they are commonly ill fed — their diet being frequently scanty, and generally of a 
kind quite unsuited to their growing years. We need not be surprised, there- 
fore, at the ravages which scrofula, in its manifold shapes, makes among the chil- 
dren of the poor in large and populous towns. If ever scrofula be generated, in 
this country, independently of any hereditary strumous taint in the constitution, 
it is in them. But in most cases I believe it is the latent disposition that is called 
into action. Moderate exercise, in pure air, and in the open daylight, with suit- 
able nourishment, sufficient clothing, and attention to the state of the bowels : 
these circumstances comprise nearly all that we can attempt, in a given cli- 
mate, towards preventing the development of struma: and from each and all of 
them many of these poor children are habitually debarred. 



LECTURE XIII. 

Cancer; its Species or Varieties. Scirrhus ; Encephaloid Cancer; Colloid 
Cancer. Its mode of Growth and Dissemination. Habitudes of the several 
Varieties. 

Treatment of Inflammation. Antiphlogistic Regimen. Blood-letting. 

I have more than once coupled cancer and tubercle in the same sentence. 
Though very different in many respects, they are alike in their intractable cha- 
racter and destructive tendencies. Of the two, cancer, while it is happily much 
the more rare, is also much the more painful, loathsome, and hideous in its con- 
sequences. It is to cancerous diseases that the epithet malignant especially 
belongs. Not resulting from any change in the natural textures of the body, but 
constituting an addition to them, and therefore assuming, usually, the shape of 
tumours, they are commonly and correctly spoken of as cancerous growths. But 
there are other growths which, by comparison, are innocent ; which do not imply 
any necessary destruction of contiguous parts, nor any inevitable danger to life, 
nor even any marked deterioration of the general health. Such are certain fatty 
tumours, and fibrous tumours, and osseous tumours. All these last, as their 
names denote, resemble in their sensible qualities some one of the healthy and 
natural textures. They have accordingly been styled analogous, or homologous 
growths ; while cancer and tubercle, which find no counterparts in the sound 
body, are said to be heterologous. Some varieties of cancer are, however, very 
similar in outward appearance to the substance of the brain ; and microscopic 
observers say that in their minute and original structure there is no perceptible 



CANCER. 



139 



distinction between the most innocent and the most malignant growths ; nay, 
that both agree in their primary corpuscular elements with the healthy tissues of 
animals, and even of plants.* 

* [This statement is not perfectly accurate. The microscope has not, it is true, thrown 
much light upon the nature and causes of morbid growths; it has, however, shown that 
in many of the particulars of their intimate structure, they not only differ from the healthy 
tissues of the body, but that they differ in this respect from each other. 

That such is the case, is rendered evident by the result of all the more recent researches 
into the intimate structure of cancerous formations. 

By Muller and other pathologists, cancerous formations have been arranged in two 
great families or groups — the encephaloid and the scirrhous. — Of the first there are three sub- 
divisions. 

1. Medullary Carcinoma ; in which there is a predominance in the medullary mass, of 
round globules over loose fibrous tissue. The globules are of various sizes; but the smallest 
are larger than pus-corpuscles. Each contains a granular substance or nucleus within. 
They are very similar, in many respects, to those of common cancer, and of reticulated 
carcinoma or scirrhus. 

2. Medullary Carcinoma, consisting of pale, elliptic, non-elongated corpuscles, and of a 
fundamental cerebriform mass. These corpuscles are usually twice or three times as 
large as the globules of the blood. There is never any appearance of fibres proceeding 
from their surface, and they rarely exhibit any traces of nuclei within them. 

3. Medullary Carcinoma, with Jibrated or puriform corpuscles. This species of encepha- 
loid structure has, at times, on laceration, a sort of fibrous aspect, when the puriform 
corpuscles are arranged in a somewhat determinate direction ; according to which the 
morbid mass will present a radiated or a tufted appearance. In many cases their direc- 
tions are so various that the lacerated surface exhibits no traces of fibres anywhere. The 
puriform corpuscles are sometimes nucleated, at others they contain granular points, but 
without distinct nuclei. They are elongated, on one or two sides, into fibres of different 
lengths. They may be considered as cells that are arrested at the period of transition 
from the cellular to the fibrous condition. 

The three forms of disease now described, may, most probably, be regarded as so many 
degrees or stages in the development of the same tissue ; these successive stages being 
characterized, 1, by rounded nucleated globules ; 2, by elongated oviform globules, which 
are either non-nucleated or indistinctly so ; and 3, by puriform globules. 

These several kinds of globules may be regarded as so many successive epochs of evo- 
lution through which a cell must pass before it can become a fibre. Thus we find, it is true, 
that in an encephaloid mass there is the same transformation of the primitive elements, 
as occurs in many normal tissues — with this difference only, that the process of evolution 
is not complete — being arrested before the fibrin is perfectly formed. 

The essential element of an encephaloid tumour is the presence of cells. In some cases 
the entire mass is composed of them, placed one along side of the other, but without having 
any perceptible bond of union, while in others there is a network of fibrous or cellular 
tissue interposed between the cells. When the fibrous tissue prevails, the encephaloid 
then approaches in character to the scirrhous structure. In the latter the existence of the 
two elements, cells and fibres, is always more distinctly marked than in the former. The 
fibres are often quite perceptible to the naked eye. Sometimes they are lengthened, and 
run parallel to each other ; at others, they form rounded capsules, within which the glo- 
bules are contained. As in the case of the newly formed fibres of the cellular tissue, so 
those of a scirrhus formation are destroyed by acetic acid, leaving nuclei or nucleated 
fibres behind. The fibres sometimes exhibit, at different points, a sort of varicose enlarge- 
ment, within each of which a nucleus is found. This appearance is often observed in 
fibrous tumours — not genuine scirrhus — of the uterus and other parts. 

In the reticular carcinoma of Muller, the white network which encloses the scirrhous glo- 
bules in its meshes, is formed of round, opaque granulations, three or four times as large 
as the blood globules ; they are, occasionally, agglomerated into rounded masses. The 
genuine scirrhous tissue, of a pale grayish colour, is composed of globules that, on the 
whole, resemble those of the first stage of an encephaloid formation. These globules are 
either round or somewhat oval ; along with them, according to Vogel, we find free nuclei 
with their nucleoli. 

From a variety of observations, it may be reasonably concluded that the cells of scir- 
rhus are formed around the nuclei of which M. Vogel speaks ; their contents are at first 
granular and almost opaque. When the process of softening commences, the granulations 
disappear, the globules become transparent, and within them are formed new cells, which 
at first are few in number and gradually multiply, until they entirely fill the parent cell. 
M. Valentin, who, in part at least, admits this account of the progress of the cell, declares, 



140 



INFLAMMATION. 



This very agreement, if it really be so complete, shows that in classifying 
morbid growths we must reject the aid of the microscope, and attend to their 
grosser and more palpable features. And, inasmuch as cancerous formations 
have, by some pathologists, been ascribed (very erroneously, in my opinion) to 
inflammation as their cause, I shall scarcely be going out of my way if I state 
here some of the broad facts which have been ascertained upon this very interest- 
ing subject. 

Cancer, or carcinoma, considered as a genus of disease, comprehends two or 
three species, which present among themselves very striking differences, and of 
which the varieties have received a puzzling multiplicity of names ; scirrhus, stone 
cancer, medullary sarcoma, encephaloid or cerebriform disease, soft cancer, fungus 
haematodes, colloid or gum cancer, and several more. The simplest division, 
founded upon the consistence of the morbid growth, is into hard and soft cancer. 
But the most modern and scientific system recognizes three species, viz., scirrhus ; 
encephaloid, or brain-like cancer; and colloid, or gum-like cancer. The physical 
characters of these three species offer strong points, not merely of difference, but 
even of contrast. 

Scirrhus, as that word implies, is remarkable in its early stages, for its hard- 
ness. It is as firm as cartilage, and creaks when divided by a sharp knife. The 
surfaces exposed by its division present a glistening, satiny appearance, and a 
white, or gray, or bluish-white colour. Athwart this grayish and semi-trans- 
parent substance run opaque intersecting bands, having a fibrous aspect. By 
strong pressure a thin juice may be made to ooze from a slice of the scirrhous 
tumour. 

Encephaloid cancer is also well named. It is composed, in great measure, of 
a soft, white, opaque pulpy substance, very closely resembling, both in colour 
and in consistence, that of the healthy brain. This cerebriform pulp is traversed 
and circumscribed by fibrous septa, which are sometimes extremely thin and deli- 
cate. In both these species of cancerous growth, therefore, there is a contained 
and a containing element. 

The same feature is still more distinctly marked in the third species, the colloid 
cancer, which exhibits the appearance of small portions of a greenish-yellow 
transparent gum, or jelly, arranged in regular cells. Hence it is sometimes de- 
nominated alveolar cancer. 

You may ask upon what principle structures so dissimilar in their physical 
appearance have been assigned to the same genus? Why, for these reasons. 
They are all strictly destructive or malignant forms of disease. Although in any 
shape they are of somewhat rare occurrence, yet when they do occur, two, or all 
three of the species are often found to coexist in different organs of the same indi- 

that the parent cells eventually burst and discharge their cellules : we may^thus account 
for the presence of young free cells in scirrhous formattons that have become softened. 

The inter-cellular substance seems to undergo certain modifications corresponding with 
the evolution of the cells ; the granulations or granular points which it often contains, 
usually disappear, and it becomes limpid, while, at the same time, the space which it occu- 
pies is diminished by the enlargement and multiplication of the cells. 

The fibrous network does not appear to follow, in its alterations, the development of the 
cells: it may remain firm and resisting while the cells are far advanced in their evolution. 
Even when a scirrhous tumour has become completely softened, this tissue sometimes forms 
shreds that retain their original character. 

In alveolar cancer, the basis of the morbid tissue consists of white fibres and lamellae, 
which cross and intercross with each other, containing, between the meshes thus formed, 
limpid cells, either closed or communicating with each other, of various sizes, from that 
of a grain of sand to that of a large pea, and filled with a transparent, gelatinous substance. 
In this substance there are cells, which contain other cells more minute. The smallest of 
these cells exhibit, at one point of their parietes, a distinct dark yellowish nucleus, and 
sometimes, also, many free and unattached granules floating within them. To this species 
Muller refers the gelatinij or m and areolar cancers of Laennec and Cruveilhier. The cells 
of this species of the disease appear to be only an advanced or more mature degree of the 
cells of scirrhus.— C] 



CANCER. 



141 



vidual ; nay, in contiguous parts of the same organ. More than this : if a tumour 
consisting of one species be amputated, and a fresh growth springs (as too often 
it does) from the same spot, this secondary growth is frequently of another spe- 
cies. There can be no doubt that all are connected by some very intimate bond 
of union; and the facts I have just stated suggest the question, whether instead 
of being different species of the same genus, they ought not rather to be regarded 
as mere varieties of the same species. 

Of all three it has been ascertained, by much and fatal experience, that occur- 
ring in any one part of the body they are prone to multiply in various other parts ; 
that they are commonly attended, during some part at least of their progress, 
with very severe pain ; that they are incontrollable by any known remedy ; and 
tend always, sometimes slowly, sometimes with frightful rapidity, to augment in 
bulk ; eating away contiguous parts by their invasion and pressure ; breaking 
out, when near the surface, into foul and repulsive ulceration; producing often the 
most ghastly disfigurement ; and ultimately destroying life. Sometimes vital parts 
are slowly disorganized by the corroding extension of these tumours ; sometimes 
large blood-vessels are laid open, and death is suddenly brought about by hemor- 
rhage; and sometimes the powers of life sink gradually under the wearing 
influence of the disease, and that degeneracy of the blood which it causes or 
accompanies. 

There is scarcely an organ or texture of the body which is not liable to be 
attacked by this terrible foe : the brain, the eye, the lip and face, the lungs, the 
stomach, the intestines, the liver, the kidneys, the breast, the womb, the testicle, 
the bones. But some parts are more often the seat of cancer than others. Among 
these may be reckoned the female mamma, the uterus, the stomach, the liver, and 
the testicle. 

The mode in which cancer originates is uncertain ; the modes in which it 
spreads and multiplies are better understood. An individual tumour may enlarge 
by the progressive insinuation of the cancerous matter into the interstices of the 
neighbouring tissues, which, thus fastening upon, it consolidates. The disease 
may be communicated, by imbibition, from one organ to another which is in mere 
contact with it. But how does it come to occupy at the same time, or in quick 
succession, several separate and distant organs ? This is a question of the great- 
est interest and importance, and it admits of a distinct reply. 

Cancer often makes its appearance in a single spot on the surface of the body ; 
in the female breast, for instance. We see and feel it there while it is yet small, 
and while the general health of the patient seems to be otherwise perfect. By 
degrees the tumour increases, and at length it softens in some places ; the glands 
of the axilla become swollen, hard, painful, and filled sometimes with cancerous 
matter ; the tumour breaks perhaps through the skin, and presents the shocking 
spectacle of " open cancer ;" the general health gives way, and the skin assumes 
a straw-coloured tint. During this process, unless the patient dies prematurely, 
or the original disease is removed by a surgical operation, cancerous tumours form 
in one or in several of the internal organs, and give notice of their presence by 
appropriate symptoms. There is an original morbid growth, and there are sub- 
sequent morbid growths; a primary tumour, and secondary tumours; and the 
latter are caused by the former. This is a most important fact, if indeed it be 
true. 

Now Miiller has discovered, by means of the microscope, and the discovery has 
been confirmed by other observers, that the contained matter, in the several spe- 
cies or varieties of cancer, consists of very minute cells, with nuclei attached to 
their walls, and of granules still more minute, which are supposed to be the rudi- 
ments of new cells. It is (apparently) by the amplification of these granules into 
cells, and by the development of the nuclei into other cells, and by the growth and 
evolution of young cells, which in some instances, are included generation after 
generation within parent cells, that the original tumours enlarge and extend them- 
selves ; and it is by the transference of certain of these cells and granules from 



142 



INFLAMMATION. 



the original tumour that a crop of secondary tumours is sown in remote parts of 
the body. The cells, and probably the granules also, are endowed with the 
power of self-increase and propagation, whenever they find a fitting nidus. Pos- 
sessing, like the seeds of plants, an inherent vitality of their own, they merely 
require, in order to germinate, to be placed in contact with some living tissue, 
wherewith they may form vascular connections, and wherefrom they may draw 
the materials of their nourishment. Cohering together, for the most part, with 
but little force, they are easily detached from the parent mass. It is matter of 
fact that the secondary tumours form most surely and most rapidly when the 
primary tumour is of a soft kind; and that when they succeed to scirrhus, it is 
after the process of softening has commenced in that originally hard structure. 
These germs — which present in their forms and mode of generation, striking 
analogies to those of some of the lower animals, as well as to those of plants — 
these germs are probably carried sometimes through the lymphatic vessels to 
absorbent glands in the vicinity of the primary growth ; but there can scarcely be 
a doubt that the blood is the main channel by which the seeds of this dreadful 
malady are conveyed from its first to its subsequent sites, and thence perhaps, if life 
continues long enough, to tertiary locations. The gross matter of cancer is often to 
be found in the veins that proceed from the primary tumour — nay, in large venous 
trunks at a distance: so that some distinguished pathologists have too hastily 
conjectured that it may originate in the veins. You are probably aware that 
foreign substances, circulating with the blood, stop or are entangled more often in 
some organs than in others. Minute globules of mercury, where that metal has 
been introduced into the veins, are found strewed through the substance of the 
lungs, and of the liver. Pus, received into the blood in phlebitis, is arrested, and 
forms scattered points of inflammation and abscess, in the same organs ; and it is 
in the liver and the lungs that separate tumours of secondary cancer are most 
commonly met with. If this be the true theory of secondary cancerous forma- 
tions, I need scarcely point out to you the urgent importance of the rule which 
prescribes to the surgeon the most complete extirpation of the primary tumour, at 
the earliest possible period of its existence. 

Of these primary formations the origin is involved in much obscurity. It 
seems, however (and this, after what has just been stated, you might expect) that 
the germs of the disease are capable of being transferred from one human being 
to another; and even to an animal of a different species. Langenbeck injected 
cancerous matter, just taken from a living body, into the veins of a dog. After 
some weeks the dog began to pine away, and was then killed, and cancerous 
growths were found in its lungs. Several instances have occurred — I have myself 
known of two — of cancer of the penis in men whose wives laboured under cancer 
of the uterus. Here it is presumable that the cancerous germs, received upon a 
delicate and vascular surface, and suffered perhaps to lodge there through neglect 
of cleanliness, might fasten upon the part, take root there as it were, and grow. 
One very curious circumstance connected with this subject is, that the frequent 
contact of common soot seems to have the power of producing cancer. There is 
a form of carcinoma, affecting chiefly the scrotum, and familiar to surgeons as 
the chimney-sweeper's cancer. A case is recorded of cancer of the same variety 
occurring in the right hand of a gardener, who for years had been in the habit of 
sprinkling soot over his flower beds with his hands. 

There are not wanting, then, plausible grounds for the hypothesis, that the 
seeds of cancer may be introduced, in some way which eludes observation, from 
without ; that cancerous growths are strictly parasitic, and independent of the 
body, excepting so far as they derive their pabulum from its juices. The diffi- 
culties involved in this supposition are not greater (as we shall see hereafter) than 
those which hang over the source and origin of certain entozoa, whereby the body 
is liable to be infested. But whether this hypothesis be true, or whether the 
cancer cells and germs are merely morbid elements of the native tissues of the 



ENCEPHALOID CANCER. 



143 



body, developed by some perverted energy of the formative process, remains yet 
to be determined. 

From the tables contained in the Reports of the Registrar-General, it would 
appear that women are more subject to this fearful disorder than men, in the 
large ratio of five to two. It fixes chiefly upon the female organs of reproduction ; 
the mammae and the uterus. 

The mortality from cancer, estimated with due reference to the whole number 
of persons existing at different ages, increases steadily as life advances. 

There are still some general habitudes of the different varieties of cancer, with 
which I should wish you to be acquainted. 

The secondary formations are most commonly of the encephaloid kind, what- 
ever the primary form may have been. 

Encephaloid cancer, as compared with scirrhus, is abundantly furnished with 
blood-vessels ; and upon this difference in their degree of vascularity other 
remarkable differences between the two varieties seem to depend. First, ence- 
phaloid tumours generally augment with much greater rapidity, and attain a much 
larger size, than scirrhous tumours. Occasionally their magnitude comes to be 
enormous. Again, cerebriform growths seldom happen singly, but occupy several 
organs of the body at once. Scirrhus, increasing slowly, occurs also in fewer 
sites ; it is sometimes even solitary. More tissues, too, appear to be obnoxious 
to the soft than to the hard variety. 

Now (as Dr. William Budd has well remarked) a large apparatus of blood- 
vessels, bringing a proportionally plentiful supply of nourishment to the parasitic 
tumour, accounts sufficiently for its rank and rapid growth ; and the same condi- 
tion, especially when conjoined with softness of the parent mass, affords obvious 
facilities for the liberal dissemination of its germs through numerous returning 
channels. In fact, the soft varieties alone have, as yet, been found in the veins. 

The same multitude of its blood-vessels, and slender cohesion of its component 
parts, serve to explain another peculiarity of the cerebriform species. Intermixed 
with, or diffused through, the brain-like substance, there is often to be seen a 
quantity of extravasated blood ; and when the disease breaks out into ulceration, 
red, ragged, and bleeding growths, of fungous aspect, sprout rapidly from the 
open surface. To these accidents of cancer the term fungus hasmatodes is to be 
traced. We do not find scirrhus to be the seat of similar interstitial hemorrhages. 

Encephaloid cancer has less tendency to contract adhesions with contiguous 
parts than scirrhus has. 

Of the alveolar variety, which has been more lately discriminated from the 
others, and less studied, less is known. It occurs principally in the abdomen, 
affecting the pyloric orifice of the stomach, and the omentum. It appears also 
occasionally in the bones, and in the breast and testicle. Although sometimes 
combined with the two other species in the same person, it is often alone, and 
limited to a single organ. I believe it has not been met with except in adults. 

For more minute information upon this subject, so interesting and important 
both in its pathological relations and in its practical bearings, I must refer you to 
a very able and elaborate article on cancer, in the Cyclopaedia of Surgery, by 
Professor Walshe, and to a shorter but admirable essay on the same topic, by Dr. 
William Budd, published in the Lancet. From these sources has been derived 
much of what I have now been stating. [We may also refer the reader to the full 
and excellent paper of Dr. Carswell, on Scirrhus, in the Cyclopaedia of Practical 
Medicine. — C] 

Returning to our current theme, I proceed, in the next place, to speak, in a 
general manner, of the measures to be adopted when we are called upon to 
administer to the relief of a person labouring under inflammation : of what is 
sometimes called the cure; but, more correctly, of the treatment of inflammation. 

In describing the phenomena and progress of inflammation, I took external 
inflammation as a type, and I shall keep that type principally in view in what I 



144 



INFLAMMATION. 



have to say respecting its treatment : making, however, such reference to the 
inflammation of internal parts as the subject will permit. You will bear in mind 
that my design at present is merely to explain the principles of treatment, gene- 
rally : I shall point out, by and by, the application of those principles, and the 
modifications they may require, in respect to particular cases. I speak also, now, 
of common inflammation, occurring in a previously healthy person. There are 
many observations that concern all inflammations alike, whether external or 
internal, and by despatching these in the outset, I hope to avoid much repetition 
hereafter. 

In all cases of inflammation, our first object is, if possible, to obtain resolution: 
and if that be not possible, we next aim at securing that event of inflammation 
which would be the most fortunate in the particular case before us. In external 
inflammations good suppuration will generally, next to resolution, be the most 
desirable event: in internal inflammations it will be sometimes suppuration, 
sometimes adhesion. 

It is necessary to keep in view the distinction between the treatment proper for 
the inflammation itself ; and the treatment that may be required for the effects of 
the inflammation. At present we are concerned only with the inflammation 
itself. 

I stated to you in a former lecture, that a knowledge of the cause of a disease 
might help us in its treatment. Knowing the cause, our first care must be to 
remove it, if we can. In the case formerly supposed, we should extract from the 
inflamed arm the fragment of glass. If the inflammation has been excited by the 
extremity of a fractured bone, of a broken rib, for example, we take measures for 
bringing the separated bones into their proper places, and for keeping them there : 
if the mere displacement of a part has occasioned the inflammation, as the dislo- 
cation of a joint, the protrusion of the bowel in hernia, the first thing to be attended 
to is the restoration of the part to its natural situation : if there be any chemical 
source of irritation, (in the stomach, for instance, threatening or producing inflam- 
mation there,) we eject, neutralize, or dilute it. 

I know of but one exception to this rule, and it belongs to surgery : to wit, 
when a bullet or a splinter is so lodged in the interior of the body, that its extrac- 
tion would be more hurtful or hazardous than its remaining where it is. 

A knowledge of the cause of an inflammatory disease may help us in another 
way. We do not treat a joint that is inflamed in consequence of external violence, 
as we should treat the same joint when inflamed in rheumatism. 

But it is very seldom, except when the inflammation is external, that we can 
accomplish the removal of its cause. In most internal cases, either it cannot be 
got at, or it has already ceased to be applied; as when the inflammation has been 
excited by exposure to cold. But it may be possible, and it is of the utmost 
importance when possible, to prevent any re-application or repetition of the same 
cause, which would be likely to frustrate our endeavours to bring about resolution. 

Next in importance to the removal and avoidance of the exciting cause, must 
be placed in most instances, the observance of what is called the antiphlogistic 
regimen. This may seem an old-fashioned phrase, but it is a very convenient 
one; being a brief form of expressing the sum of several distinct provisions for 
the welfare of the sick, and for the conduct of their attendants. The word anti- 
phlogistic is derived, indeed, from an obsolete theory ; but we retain it as a useful 
arbitrary term, without reference to its etymology, or to its original meaning. 

The object of the antiphlogistic regimen is to put and keep the patient in that 
state which is most favourable for the spontaneous subsidence of the disease, or 
for the sanative influence of remedies. This regimen consists in the avoidance 
of every stimulus that can he avoided, whether external or internal. Common 
sense will suggest to you the details. It implies a total abstinence from animal 
food, and from strong drink of all kinds. It prescribes the exclusion of all that 
might excite or exercise the mind, or produce a strong impression upon the senses : 
noise; bright light; great heat or cold. The patient should be kept in a tempera- 



ANTIPHLOGISTIC REGIMEN. 



145 



ture of about 62°, and in a well-ventilated apartment. He must not be allowed 
to converse, nor to attend to matters of business ; unless, indeed, his mind happens 
to be disturbed and anxious about some point which one short interview with a 
friend may effectually settle. All causes of strong emotion, and mental agitation, 
should be strictly guarded against. Whatever tends to quicken the circulation is 
to be shunned; and therefore not only those influences which operate through the 
nervous system, but also all needless bodily effort and exertion, must be prohibited. 
The patient (in the serious cases I am now contemplating) must remain in bed : 
and in a position which facilitates, or at least does not impede, the free return of 
blood by the veins from the suffering organ. If the inflammation is seated in or 
about the head, that part should be elevated by pillows. If one of the lower 
extremities is affected, even when the disease is not so intense as to require con- 
finement to bed, the limb must be sustained horizontally, or be even still more 
raised up. On the same principle it is that we suspend an inflamed hand or fore- 
arm in a sling. In some cases of internal inflammation — in pleurisy, for example 
—•the patient will choose his own position. He is admonished, by the pain and 
distress they occasion, that certain postures would be hurtful or dangerous, and 
he carefully avoids them. We often derive much information from this instinctive 
caution on the part of our patient. 

The function of the organ inflamed should also be spared its exercise whenever, 
and in as great a degree as that can be done. As you would not allow a patient 
to move an inflamed joint, so you must not permit him to use an inflamed eye ; 
to speak more than may be absolutely necessary with inflamed lungs ; to exert by 
thinking, and by attention to external excitements, an inflamed brain. This last rule 
is essential, even when the brain is not the seat of the inflammation : it is to be 
observed in all febrile disorders. 

The adoption of this antiphlogistic regimen is not, indeed, necessary, nor even 
proper, in all cases and stages of inflammation. The inflammation may be so 
slight as not to require it ; particularly in external cases, of which the causes and 
the extent are known; as slight contusions, trifling wounds, and some kinds of 
eruption. But this exception must always be applied with great caution to cases 
of internal inflammation, about the causes and extent, and tendencies of which we 
may be less sure. In chronic forms of inflammation again, as in scrofulous 
inflammation of the lymphatic glands, or of the eyes, attended with but little pain 
or heat, the antiphlogistic regimen would often fail to be beneficial : the state of 
the general system being such as to require support and strengthening measures, 
more than the local symptoms call for an opposite treatment. So also when sup- 
puration or gangrene have supervened, the antiphlogistic regimen must generally 
be modified, or abandoned. 

But in the outset of all cases of serious inflammation, when the strength is 
entire, and the inflammation intense enough to produce pyrexia, all the pariiculars 
of the antiphlogistic regimen may require to be observed. 

Of all the direct remedies of inflammation, the abstraction of blood, bleeding, 
or h\QO&-letting, as it is called, is by much the most effectual and important. We 
should, I think, be prepared to expect this, prior to any experience of it. Blood 
being the natural stimulus of the heart, we should deem it probable that the 
removal of a portion of that fluid would diminish the force with which the heart 
contracts: and as an inflamed part contains a preternatural quantity of blood, and 
as (with the exception of resolution and mortification, which really are termina- 
tions of inflammation — as with these exceptions) all the events of inflammation 
depend upon the effusion of certain parts of the blood from its containing blood- 
vessels, we should be inclined, a priori, to believe that the amount of those effu- 
sions would be checked and limited by lessening the supply of blood to the 
inflamed organ, as well as by abating the force with which the blood reaches it. 
And we find it in fact to be so. The results of experience confirm, in this matter, 
the suggestions of our reason. Blood forms the pabulum of the whole process. 
"If," (says Mr. Lawrence), " we may be allowed to use figurative language, the 



146 



INFLAMMATION. 



obvious increase of heat in the part is analogous to that of fire ; and blood is the fuel 
by which the flame is kept up: in fact, if we could completely take away its blood 
from the part, we should be able entirely to control or arrest the increased action." 

But it is not every case of inflammation that requires or warrants the abstrac- 
tion of blood : and when blood-letting is requisite, the mode of taking away the 
blood, the proper quantity to be taken, and the propriety of repeating the bleeding, 
all vary greatly in different cases. It is obviously of vast importance that you 
should learn so to use this valuable remedy as not to abuse it. Its power is great 
for evil as well as for good ; and in rash or inexperienced hands it too often 
becomes an instrument of fatal mischief. 

There are, as you are all aware, several modes of abstracting blood : phlebotomy, 
arteriotomy, scarification, cupping (which is merely a variety of scarification), the 
application of leeches. Bleeding performed in either of the first two of these 
methods is called general bleeding. The rest are, in most instances, topical or 
local: but they are not merely topical in all cases. The main object of general 
bleeding is to diminish the whole quantity of blood in the system, and thus to 
lessen the force of the heart's action. The object of local bleeding is, in most 
instances, that of emptying the gorged and loaded capillaries of the inflamed part. 
Sometimes the blood is thus taken directly from the turgid vessels themselves ; 
more often, I fancy, topical blood-letting produces its effect by diverting the flow 
of blood from the affected part, and giving it a new direction, and so indirectly 
relieving the inflammatory congestion. General bleeding has also incidentally a 
similar tendency to deplete the vessels concerned in the diseased process : and, 
on the other hand, a dexterous cupper, under favourable circumstances, will take 
away blood from a part as copiously and rapidly as if it were made to flow from 
an opened vein: and then the effect upon the system will be alike in the one case 
and in the other. The same may be said of leeches, when they are applied in 
the enormous numbers which our neighbours, the French, are fond of using. In 
whatever way the blood is drawn, whether from a vein or from an artery, or by 
the pressure of a cupping glass around a surface previously scarified, or by the 
suction of leeches, the general effect upon the system will be in proportion to the 
quantity of blood abstracted in a given time. The most convenient and effectual 
mode of general bleeding, upon the whole, is certainly the common one, from 
the veins at the bend of the arm. But sometimes those veins are small or deep, 
especially in fat people ; and we fail in our efforts to get the blood to flow from 
them in a full stream: and then we may open some other vein or an artery, or 
call in the cupper to our assistance, or cover the neighbouring surface with leeches ; 
according to the situation of the part inflamed, and other circumstances. 

Let us now briefly consider what the indications are by which we judge of the 
expediency of taking away blood. We are guided very much by the degree of 
pyrexia ; by the quality of the pulse ; by the importance of the organ affected ; 
by the intensity of the inflammation, in what manner soever that may be mea- 
sured ; by the period or stage of the disease ; by the age, and sex, and general 
condition of the patient; and frequently also by the ordinary character and course 
of the disease, when inflammation happens to be, or to accompany, an epidemic 
disorder. It is not one of these circumstances alone, but several of them, that we 
have to take into the account, in most cases : and what I have now to say in 
reference to them must needs be very general. 

The presence of pyrexia, especially when the febrile disturbance is well 
marked, admonishes us, indeed, to search after other indications of the propriety 
of blood-letting, and confirms them if they are found ; but is not, of itself, a suffi- 
cient reason for resorting to that remedy. There may be high febrile symptoms 
without any inflammation at all ; as in the hot stage of an ague fit : and a smart 
attack of fever may spring out of local inflammation, and yet the known course 
of the disease, or the nature of the part affected, may render the abstraction of 
blood unnecessary, and therefore improper. 

Our judgment is more often determined by the quality of the pulse, although 



BLOOD-LETTING. 



147 



we are by no means to be wholly directed by this. The quality of the pulse 
which— other things being the same — bespeak the necessity of blood-letting, is 
hardness. I .described this quality to you in a former lecture : it may coexist 
with a large or a small, a slow or a frequent pulse. Most commonly (and yet 
the exceptions are numerous) in acute inflammations the pulse is full and frequent 
as well as hard. The hardness is ascertained and measured by the resistance 
which the throb of the artery makes to the pressure of your finger. The pulse is 
sometimes said to be incompressible; which means that, although you apply 
your finger with considerable firmness, the blood still forces its way through the 
vessel beneath it. 

Now this hardness of the pulse is sometimes our best warrant for active deple- 
tion by means of the lancet : yet I say we must not trust to this alone ; for a hard 
pulse may habitually exist, where there is no inflammation. Certain chronic 
diseased conditions of the heart may occasion it; and it probably results also 
sometimes from some unnatural state, which is not inflammation, of the whole of 
the circulating system. When you happen to know your patient, and have 
ascertained what kind of pulse he has when he is well, and are previously aware 
that his pulse during health is not a hard pulse, you learn from that circumstance 
that the new quality it has now acquired denotes the presence of inflammation ; 
and usually of active inflammation, likely to go on, if not controlled, to the 
destruction of the part it has seized upon. 

Many persons, and young practitioners in particular, are apt to look to the fre- 
quency of the pulse, when they wish to ascertain the expediency of blood-letting : 
but really its frequency is very subordinate in importance to its hardness or soft- 
ness : and this is very unlucky, because any body with his stop-watch in his 
hand can count a pulse : but it is not every one who can tell a hard pulse when 
he feels it. The finger requires a certain education for that purpose ; and there 
are some persons who seem never to attain the t actus eruclitus. I should advise 
you to attend particularly to this quality of the pulse, and to compare your per- 
ceptions of the hardness or softness of the pulse in individual cases, with those of 
other medical men. 

The frequency of an inflammatory pulse ranges for the most part between 90 
and 120. When the hard pulse is much more frequent than this, it commonly 
occurs either in young children, or in persons who are more than usually nervous 
and susceptible ; or in persons who were previously labouring under some chronic 
and wasting complaint, in which the pulse was already frequent, though not hard : 
as, for example, in phthisical patients, when acute pleurisy supervenes upon 
tubercular disease of the lungs. 

As the hardness of the pulse is, with certain exceptions at which I have just 
glanced, our lawful warrant for general bleeding, so the disappearance of that 
hardness is a token that the blood-letting has been carried far enough. 

Again, the nature and importance of the organ affected will influence our judg- 
ment in respect to the question of abstracting blood. If the organ inflamed be a 
vital organ ; or if we are not sure about that, but have any reason to suspect that 
it may be a vital organ ; I need scarcely say that we must act upon the worst sup- 
position, and bleed. But if the part be of less importance in the economy of the 
body ; or if inflammation is known ordinarily to run its course in that part with- 
out producing any abiding damage ; it may not be worth while, even though the 
fever be high and the pulse hard, to have recourse to this potent remedy, for the 
sake of subduing inflammation which is attended with so little danger. In this 
predicament may be placed many instances of cynanche tonsillaris, and of acute 
rheumatism. The subsequent debilitating effects of the loss of blood upon the 
system may be more certain and more hurtful than the effect of the bleeding upon 
the local inflammation is likely to be beneficial.* 

* [Without pretending to advocate the employment of blood-letting in every case of 
cynanche tonsillaris and of acute rheumatism, we must dissent from the correctness of Dr. 
Watson's position, that " even though the fever be high and the pulse hard," it may not be 



148 



INFLAMMATION. 



The period or stage of the disease forms a most important element in the ques- 
tion before us. It is of inflammation while yet in its early progress, that blood- 
letting may emphatically be pronounced the cure ; while the disease is still within 
the possibility of resolution ; before there is any great amount of effusion, or any 
serious disorganization of structure. The sooner we bleed, the more surely will 
the inflammatory process be moderated and limited, even when it cannot be whollv 
quenched. In no case within the range of medical practice is the maxim " prin- 
cipiis obsta" more imperative. Those among you who happen to be attending 
the wards of the Middlesex Hospital may wonder, indeed, after hearing my esti- 
mate of the power of blood-letting over inflammation, that I so seldom prescribe 
venesection there. The truth is, not that I undervalue the remedy, but that the 
time for its employment has generally gone by. The poor are unwilling to re- 
linquish the occupations by which they subsist : they struggle on as long as they 
can, and resort to hospitals only when they are compelled to do so by the exi- 
gency of their malady. Many of them, labouring under inflammation, have been 
freely bled before admission. It is commonly too late, when they present them- 
selves, to expect that the course of the disease can be so arrested. The first effect 
of blood-letting is to deplete and relieve the labouring circulation. But when it is 
again and again repeated, it becomes (as the French say) spoliative ; it robs the 
vital fluid of its nutrient and plastic materials. Pushed still further, it produces a 
peculiar state of the nervous system, marked by great weakness and irritability. 
Now although blood-letting is the summum remedium for inflammation at its 
commencement, there is a point beyond which it not only does no good, but is 
positively injurious. And this point it is not always easy to hit. On one side is 
the danger that the inflammatory action may continue and extend: on the other 
the danger that the strength of the system may be so reduced as to prove unequal 
to the process of restoration ; for, to remove the interstitial extravasations, and to 
repair the damage that has accrued, a certain degree of vital power is requisite, 
and a sufficient quantity of healthy blood. Bleeding will cure inflammation, but 
it will not always cure the effects of inflammation ; nay, it may render them 
lingering in their departure, or even determine their fatality. I cannot too often, 
or too strongly inculcate the precept, that in order to check and extinguish acute 
inflammation, you must, above all, bleed early. 

We judge that the bleeding has been carried far enough when the inflammatory 
.fever subsides, or changes its character; when the pulse regains its softness, or 
.undergoes some marked alteration ; when any of the signs (already specified) of 
suppuration appear. Upon these points I hope to give you more explicit in- 
struction when w;ecome to special instances of inflammation. 

Whenever inflammation supervenes on other chronic disease: whenever it 
Arises is the progress of idiopathic fever, or whilst the constitution is contaminated 
by some specific poison: whenever suppuration is inevitable, or even probable : 
in all these cases general blood-letting may be necessary, but it must be employed 
with great caution. 

Nor can we, safely, neglect the age, and sex, and general condition, of the sick 

worth while to bleed "for the sake of subduing inflammation which, in these affections, is 
attended with so little danger." When acute rheumatism occurs in young, robust, and ple- 
thoric habits, and is attended with considerable fever and a hard and accelerated pulse, we 
know of no remedy from which such decided advantage is to be obtained as from a well-timed 
resort to the lancet. The extent to which the bleeding is to be carried and the propriety of 
its repetition, must be determined by the circumstances of each case, and the effects pro- 
duced by the first operation. We are no advocate, under any circumstances, for the pro- 
fuse and repeated bleedings recommended by, M. Bouillaud as a means of cutting short an 
attack of acute rheumatism ; we have had, however, ample experience of the very decided 
relief obtained by a prudent and well timed use of the lancet in this disease. 

In many cases of cynanche tonsillaris, also, an early and full bleeding will have the 
effect of arresting the inflammation, and thus of saving the patientfrom much suffering, if not 
danger. Even when the arrest of the disease is not effected by it, the inflammation is 
reduced in violence and shortened in duration.— C] 



BLOOD-LETTING. 



149 



person, when we are turning in our minds the propriety of bleeding. The very 
young, the old and the feeble, do not bear well the loss of much blood. This 
consideration is not to deter you from bleeding such persons when they are 
attacked by dangerous inflammation; but it especially enforces, with respect to 
them, the general rule, that no more blood should be abstracted than is absolutely 
requisite to control the disease. 

It is also very necessary to study the character and tendency of the reigning 
epidemic: whether that may depend upon some predisposition silently and gra- 
dually produced in men's bodies by the agency of causes that are but little under- 
stood : or whether it may result from some peculiarity in the exciting cause of a 
particular epidemic disease. I have been long enough in practice in London to 
have learned, in common with others, how much the character of continued fever 
may alter. Since about the time when the virulent form of cholera made its 
first appearance among us, continued fever has neither required nor borne the 
abstraction of blood as it did bear and require it for some years prior to that 
period. Perhaps some variation in the intensity of the poison may partly explain 
the comparative malignity — the greater tendency, I mean, to the typhoid type — 
which marks certain epidemics of scarlet fever, small-pox and measles. The 
influenza, or epidemic catarrh, which was almost universal in this town and king- 
dom in the years 1833 and 1837, afforded a striking illustration of the point I am 
endeavouring to set before you. The inflammatory symptoms — the bronchitis, 
and sometimes pneumonia — were in many cases strongly marked, and it was 
necessary to abstract blood ; but persons suffering under influenza bore bleeding 
exceedingly ill, and where the use of the lancet could not be avoided, it was never 
resorted to without reluctance and misgiving. 

When we bleed in acute inflammation of an important organ, we endeavour, I 
say, to effect our purpose as speedily as possible, and with as little expenditure 
of the vital fluid as possible. It would be quite ridiculous to pretend to give any 
precise direction as to the number of ounces of blood that should be taken. You 
must stay by the patient, and bleed, in such cases as I am now contemplating, 
until you produce some distinct impression by the bleeding; and one of the best 
guides in this matter is the state of the pulse. If you find, as you sometimes 
will do, that the most pressing symptoms give way while the blood is still flowing 
— that the pain, for instance, is mitigated — that the respiration (when the lungs 
are concerned) becomes easier and deeper — that (in affections of the brain) the 
patient emerges from a state of stupor or delirium — you may be sure that you are 
doing right in bleeding; but you must keep your finger upon your patient's wrist, 
and suffer the blood to flow, until the hard pulse is sensibly softer, or until symp- 
toms of impending syncope appear; and then you had better tie up the arm, and 
wait a* few hours, and repeat the bleeding if the symptoms which at first demanded 
it again become urgent. 

As it is desirable to produce the necessary effect upon the system as quickly as 
may be, the blood should be taken pleno rivo ; i. e., a sufficiently large orifice 
should be made in the vein : and sometimes it may be right to open a vein in both 
arms : and the patient should be bled in the upright position. Faintness and syn- 
cope depend upon a defective supply of blood to the brain ; and therefore will be 
likely to occur the sooner when the force of gravity facilitates the descent of the 
blood from the head through the veins, and retards its ascent towards the head 
through the arteries. And conversely, the first thing to be done towards reme- 
dying syncope is to lay the person flat in a horizontal posture, or. even with his 
head lower than his trunk. 

If you neglect these smaller matters, and make an insignificant slit in the vein, 
and suffer your patient to lie down whilst you are bleeding him, you will be 
obliged to take much more blood in the end ; or you may drain him of his blood 
and of his strength by repeated bleedings of this sort, and make no impression 
after all upon the disease. It is one of the numerous cases in which parsimony 
is not true economy. 



150 



INFLAMMATION. 



The quantity of blood requisite to be taken in order to produce the due effect 
is exceedingly various. It is a remarkable circumstance, well worth attending 
to, and much insisted upon of late years, especially by Dr. Marshall Hall, that a 
patient under the influence of mere inflammation will bear to lose a far greater 
quantity of blood without becoming faint, than he could bear in health : that the 
state of the system produced by the presence of inflammation protects it from the 
ordinary consequences of loss of blood. The amount of the bleeding necessary 
to occasion syncope will be in proportion to the exigency of the case. This fact 
— if it be really a fact, as, indeed, I believe it is — is evidently one of the highest 
value and importance, for it furnishes, what is always so desirable, especially in 
an uncertain art like ours, a simple rule of practice. Yet it is not a rule so firmly 
established as not to admit of exceptions. If the mere state of syncope was the 
curative influence required, we should have no difficulty. That the faintness does 
constitute a part of that influence I fully believe. Dr. M. Solon even relates a 
case in which it sufficed to the cure of erysipelas of the head and face, attended 
with high fever. The patient fainted from alarm, before the vein was opened. 
The inflammatory symptoms thereupon ceased: but with returning animation 
they presently recurred. Again, preparation was made for venesection ; and again 
the young lady lapsed into syncope: and this time the inflammation and fever dis- 
appeared, never .to return. She is described as having been quite well the next 
day. I cannot, however, entertain a doubt that the withdrawal of a certain quan- 
tity of blood is, in almost every case, essential to the permanent control of common 
acute inflammation, attended with pyrexia: and it may be advisable to keep per- 
sons who, like M. Solon's patient, are of a timid disposition, and liable to syncope 
from slight causes, in a recumbent posture, in order that the requisite discharge of 
blood from the system may be obtained. 

In equivocal cases (and there are many such), where it is questionable whether 
the symptoms proceed from inflammation or not, the diagnosis may often be settled 
by observing the quantity of blood which, taken in the upright posture, suffices to 
bring on incipient syncope. 

Dr. Hall's book, On the Effects of Loss of Blood, is well worth your attentive 
perusal. He suggests that a scale of diseases might be formed, representing the 
protective influence of some maladies against the effects of blood-letfing ; and the 
opposite influence of some others in producing preternatural susceptibility of those 
effects. " It would begin (he says) with congestion of the head, or tendency to 
apoplexy ; inflammation of the serous membranes, and of the parenchymatous 
substance of various organs, would follow ; then acute anasarca ; and lastly, in- 
flammation of the mucous membranes. This part of the scale would be divided 
from the next by the condition of the system in health. Below this would be 
arranged fever ; the effects of intestinal irritation ; some cases of delirium ; reac- 
tion from loss of blood ; and disorders of the same class with hysteria, dyspepsia, 
chlorosis, and cholera morbus." 

With respect to the propriety of repeating venesection, it is his remark, that if, 
at the first blood-letting, much blood flowed before any tendency to syncope mani- 
fested itself, an early repetition of that remedy will probably be required — and at 
any rate an early repetition of our visit to the patient will be proper. But this 
last precept is of universal obligation in all cases of serious inflammation. 

I am almost afraid to tell you how much blood I have seen taken at one bleed- 
ing, lest I should seem to encourage you to imitate such heroic practice. I once 
stood by and saw, not without trembling — although I was quite free from respon- 
sibility in the matter — a vein in the arm kept open until seventy-two ounces (four 
pints and a-half) of blood had issued from it: and then, and not till then, did the 
patient become faint. The event of the case quite justified the bleeding in that 
instance, for the man got perfectly well. It was a case of general dropsy, which 
had come on suddenly, in a young and robust man. It occurred in the clinical 
wards of the Infirmary at Edinburgh ; the physician had desired the clinical clerk 
to bleed the patient in the erect posture, until some sensible effect was produced 



BLOOD-LETTING. 



151 



upon his pulse : and no such effect could be perceived until the enormous quantity 
I have mentioned had been abstracted. It is very seldom that such large bleed- 
ings are required; you will generally find that five-and-twenty or thirty ounces, 
taken properly, will be sufficient to accomplish the purpose of the measure. Some- 
times one such bleeding will extinguish, as it were, the inflammation ; sometimes 
two or three, or half-a-dozen may be necessary : and we judge of the propriety of 
repeating the venesection by the effect of the former bleeding ; by the character 
of the pulse ; by the appearance of the blood already drawn. It would be impos- 
sible, in a general account like the present, to lay down any minute directions on 
this head. 

I have hitherto been speaking of bleeding as we perform it for the cure of active 
inflammation, occurring in a person previously healthy, affecting an important 
organ, and attended with febrile disturbance of the system. But the abstraction 
of blood is scarcely less valuable as a remedial measure in chronic inflammation, 
when the system at large scarcely sympathizes at all with the local disease. And 
here it is that what is properly called local bleeding is so useful — by cupping 
glasses, or a moderate number of leeches. The object is always the same, viz. : 
to unload and relieve the turgid capillary vessels of the part : and this we could 
not do by general bleeding without carrying it to an extent which would be dan- 
gerous to our patient's existence. These local bleedings for chronic inflammation 
usually require to be often repeated. Considered as a remedy, blood-letting resem- 
bles some other remedies in this, that it must be proportioned and adjusted to the 
rate of progress, and the duration of the disease. The remedy must be used chro- 
nically when the malady is chronic. A patient may lose, on the whole, much 
more blood for the cure of a chronic inflammation, than for the cure of one that 
is violent and acute ; but then the bleeding must be spread over a larger space 
of time. 

With respect to the relative merits and advantages of cupping and of leeches, 
as topical remedies for local inflammation ; it may be said in favour of cupping, 
that the precise quantity of blood taken away is more accurately determined in 
that manner, and the operation is sooner over, and is less fatiguing, than the suc- 
tion of leeches. But on the other hand, the leeches seldom bungle in the operation, 
while the surgeon often does. It requires a good deal of practice to become handy 
and dexterous in the application of the glasses — to avoid torturing and burning 
the patient — and therefore it is that in large towns, as in this metropolis, cupping 
is an art carried on by a distinct class of persons. You may apply leeches also 
to parts where the cupping glasses could scarcely be used. 

General bleeding, then, is best adapted to acute inflammation ; and topical bleed- 
ing is most appropriate in that which is chronic and slow. But a combination of 
the two is often highly proper and useful. You may lessen the force of the gene- 
ral circulation by venesection ; but the small vessels of the inflamed part may 
remain unable to rid themselves of their excess of blood, and continue dilated and 
full. Such, at least, we may reasonably suppose to be sometimes the case ; and 
certainly we often act successfully upon that theory; that is, we bleed from the 
arm, and at the same time, or presently after, we empty the capillaries of the 
labouring organ, or the neighbouring vessels, by the help of leeches, or by the 
scarificator and exhausted cup. The goo(l effect of local bleeding, after the gene- 
ral febrile disturbance has abated under venesection, is often very marked in the 
relief of pain. 

I have recommended blood-letting to you when, among other circumstances, 
the pulse is full and hard ; and have stated that the blood should be suffered to 
flow -until some distinct impression is made upon the system. But I wish also 
to apprise you, that you ought not to be deterred from bleeding merely because 
the pulse is small. It is very apt to be so in dangerous inflammations within the 
abdomen ; and it is a very curious thing that the pulse will often rise, and the 
artery develop or expand itself, during the time the blood is flowing. Now you 
must look upon that circumstance as a distinct impression made upon the system? 



152 



INFLAMMATION. 



although it is one of a rather different kind from what I spoke of before. You had 
better, in. my opinion, pause when this effect is fairly obtained: for so great is the 
tendency to death by syncope in abdominal inflammation that it would not be 
prudent to urge the influence of the blood-letting further, at one time, than the 
change I have just mentioned. Wail, therefore, and repeat the venesection if the 
circumstances should again render it necessary. 



LECTURE XIV. 

Treatment of Inflammation, continued. Recapitulation. Bleeding. Purga- 
tives. Mercury. Antimony. Digitalis. Colchicurn. Opium. 
Local Remedies. External Cold. External warmth. Counter- Irritation. 

After pointing out to you, yesterday, the necessity of guarding your patient, 
as much as possible, from all stimulants or sources of irritation, both internal and 
external, the avoidance of which constitutes what is called the antiphlogistic 
regimen, I began to speak of the remedies of inflammation. 

Now the great remedy in acute and dangerous inflammation is blood-letting: 
and when this remedy is used at all, it should be used freely, and so as to produce 
a decided impression: and its efficacy will always be the greater, in proportion as 
it is applied in the earlier stages of the inflammation. The objects of the abstrac- 
tion of blood are two-fold: to lessen the force of the heart's action is one object; 
to empty the gorged capillaries of the part inflamed is the other. We effect the 
first of these objects, or both of them at once it may be, by making an orifice with 
a lancet, in the trunk of some convenient vein or artery, and allowing the blood to 
escape; we accomplish the second by making little incisions with a scarifier 
through the skin as near the inflamed part as we can, and forcing the blood 
through these little wounds by the pressure of the atmosphere: i. e., we take off 
the pressure from the part scarified, by placing over it a glass cup, from which 
the air has been in great measure exhausted, and then the unbalanced weight of 
the atmosphere upon the surrounding surface forces out the blood: or we suffer 
leeches to scarify the skin, and to suck out the blood. These two modes of 
drawing blood, from the trunks of the blood-vessels on the one hand, and from 
the capillaries on the other, we call, respectively, general bleeding, and topical 
bleeding. 

I say the main point to be achieved in general bleeding is so to manage the 
operation as to make a decided impression, as quickly as possible, upon the pulse 
or the heart: and to do this we place our patient in an upright position, and make 
a free orifice in the vein of one or both arms. 

And when the force of the general circulation has been thus abated, it will in 
many cases be proper and necessary to take away blood from the capillaries also, 
in the neighbourhood of the suffering organ; this is almost always safe and good 
practice; there can seldom be any reason for abstaining from it, except when the 
general bleeding has brought the patient so low that the abstraction of a few more 
ounces in any way might be hazardous. But the employment of local depletion 
presently after general is then especially indicated, when the local symptoms 
remain unrelieved ; when, although the indirect symptoms which manifest them- 
selves through the medium of the system at large have been moderated by the 
general blood-letting, yet the direct symptoms belonging to the part, and disturbing 
its functions, the pain for example, or the labouring breath, or the stupor, have 
not undergone a proportional improvement. Under such circumstances, the 
unloading the oppressed capillaries by means of leeches or cupping-glasses will 
often be attended with the happiest effects. 

I mentioned that the most common way of performing general blood-letting in 



BLEEDING. 



153 



this country is by venesection ; and that the veins chosen, as the most suitable for 
that purpose, are the cephalic and basilic veins at the bend of the arm : but 
that when, from accidental circumstances, blood cannot be obtained easily and 
abundantly from those veins, any other large and superficial blood-vessel may be 
opened. It matters little which, in my opinion, so far as regards the effect of the 
abstraction of blood upon the disease. Some persons are fond of opening the 
temporal artery when the inflammatory disease is situated in or about the head : 
and certainly, when we see this vessel starting from the surface like a cord, and 
tortuous from its fullness, and visibly throbbing, we feel tempted to give vent to 
the blood which is distending it. But arteriotomy is not so easily managed as 
phlebotomy. It is sometimes difficult to get the blood to flow properly; and it 
i$ sometimes difficult to stop its egress when we wish to do so; and sometimes 
there are after-consequences which are far from being pleasant: little aneurismal 
tumours are apt to arise. It is, besides, desirable to avoid the necessity of band- 
aging the head, in order to restrain the further efflux of blood from the artery. 
Other practitioners recommend opening the external jugular vein in head cases, 
especially in children, whose veins in the arm are small. This is a plan which I 
have very seldom adopted, and which, I am bound to tell you, I do not much 
like: first, because I think it is seldom necessary ; secondly because I think it is 
often unsafe. 

It is seldom necessary: for in children we can always get as much blood by 
topical bleeding as will be equivalent to a general blood-letting. And it is unsafe 
in two ways. In the first place, it is not always an easy matter to stop the bleed- 
ing from the jugular vein, especially in a struggling and unmanageable child; 
and the difference of a few ounces of blood may be a fatal difference. Here 
also any compression of the neck, to stay the hemorrhage, might affect injuriously 
the cerebral circulation. Again, there is a distinct and peculiar danger attending 
the incision of this vein, that, namely, of admitting air into it. You perhaps are 
aware that if air enters a large vein near the heart, and passes on to that organ, 
it kills outright. If you open the jugular vein of a horse, and blow forcibly into 
it towards the heart, the animal drops down dead. The celebrated Dupuytren 
was performing some operation about the neck, in the course of which he cut 
across one of the veins there situate : some bubbles of air rushed in at its open 
mouth, with an audible clucking noise, and, in an instant, his patient expired. 
The same frightful accident has occurred in operations performed in this country, 
and in America. I was told very lately that in one of our metropolitan hospitals 
it was thought right, for some reason or other, to bleed an adult patient by open- 
ing his jugular vein : the opening was made very near the clavicle, so that pres- 
sure between the orifice and the heart was difficult to effect. Of course the blood 
soon leaves the portion of the vein nearest the heart ; and whether by some suction 
power of the heart itself upon the veins, or how, one scarcely knows, but air 
rushed in, and the patient was presently a dead man. Perhaps misadventures of 
this kind may be capable of being prevented by using great caution in such cases ; 
but as it is the etiquette for physicians to direct but not to perform these manual 
services towards the sick, and as, therefore, I should incur all the responsibility, 
and at the same time be able to ensure none of the necessary care, I confess that 
I am shy of recommending venesection to be made in that particular place. 

Whether, all other things being the same, the abstraction of arterial blood may 
be more or less effectual in restraining inflammation than the abstraction of venous, 
is more than I can tell you. 

When topical breeding is employed with the view of disburdening the turgid 
capillaries, either in chronic inflammation, or in acute inflammation as an auxiliary 
to general bleeding, it would seem most expedient to get as near to the part affected 
as we can. To apply, for example, our cupping-glasses or our leeches to the 
temples, or behind the ears, or just below the occiput in inflammatory affections 
of the head ; to the chest or the precordia, when the lungs or heart are the seat of 
the disease ; to the surface of the abdomen, in inflammation of the liver s or sto* 



154 



INFLAMMATION. 



mach, or intestines, and so on. And this is the plan which I have almost always 
adopted; and with such satisfactory results that I have felt little inclination to try 
any other. But many persons do believe that local bleeding is more useful when 
it is performed at some distance from the affected part: they would put leeches, 
for instance, on the insteps, to relieve an inflamed throat; and they attribute the 
benefit that ensues to what is called revulsion: they suppose that the suction of the 
leeches solicits the blood, as it were, to that quarter, and diverts it from the vessels 
of the part that is inflamed. It seems to me that the revulsive influence of topical 
bleeding would be greater in the neighbourhood of the inflamed part than far from 
it. I know, however, some very practical men who have been much struck with 
the results of this distant blood-letting, which they had seen practised in the 
Parisian hospitals. Leeches are also sometimes applied at a distance from the 
seat of the inflammation, on another principle — that of drawing the blood directly 
from the veins which communicate with the diseased part. In abdominal affec- 
tions, in, inflammation of the liver or intestines, the French are in the habit of 
applying leeches in great numbers to the verge of the anus : because, they say, 
the blood is then abstracted from the very veins through which it is returning 
towards the already overloaded organs. It is right that you should be aware of 
these opinions, and of this practice. I can say but little of it from my own 
knowledge. I can well believe, however, that it is good and useful practice : but 
in this country we should find it difficult to persuade many of our patients to 
submit to have leeches planted round the anus ; and I have seldom been disap- 
pointed of the benefit I expected from topical bleeding, when it has been employed 
at the surface, as near the part inflamed as possible. 

The evacuation next in importance to blood-letting, is purging. This is an 
expedient which in cases of violent inflammation, or high general fever, should 
scarcely ever be omitted. To keep the bowels what is called open, forms indeed 
a part of the antiphlogistic regimen; but in acute inflammatory diseases, active 
purging is of very great service. These two points are gained by it. The 
stomach and intestines are freed from accumulated faeces, or other matters which, 
by their bulk or their acrimony, might prove irritating: and at the same time 
depletion is carried on by means of the serous discharge which is produced from 
that large extent of mucous membrane. There are some cases of inflammation, 
in which the operation of purgative medicines is of especial benefit; as in inflam- 
matory affections of the head, either external or internal, of which part these 
medicines assist or cause the depletion in a very sensible manner. We have an 
illustration of this in the paleness of the face, which often, during health, accom- 
panies the action of a brisk cathartic. The usefulness of repeated purgatives is 
less distinctly seen in inflammations situated within the thorax; although in 
these cases also they are often highly beneficial. They are efficient remedies, 
too, in all inflammatory conditions of the liver. But when inflammation has 
fastened upon the stomach or bowels themselves, although it may be indispensa- 
ble that they should be unloaded of their contents, which are often composed of 
irritating ill-digested food, and of morbid secretions no less teasing and hurtful, 
the propriety of going beyond this point is extremely questionable. I believe 
that much harm is often done by pressing the inflamed alimentary canal with 
active purgatives. But to all those points I shall have occasion to return. 

Next to blood-letting, as a remedy, and of vastly superior value upon the 
whole, to purgation, in serious inflammations of various kinds, is mercury. 
This mineral is really a very powerful agent in controlling inflammation; espe- 
cially acute, phlegmonous, adhesive inflammation; such as glues parts together, 
and spoils the texture of organs. It is of the greatest importance that you should 
accurately inform yourselves concerning the various effects of mercury upon the 
system : the changes it produces ; the changes it arrests or prevents ; the cases 
in which it does good ; the cases in which it does harm ; that you should learn, 
in short, how to wield a very potent, but a two-edged weapon. 

If we inquire what mercury does when it is administered to a person in health, 



MERCURY. 



155 



we find three very marked effects following its internal use. They vary, indeed, 
in different cases, and under different circumstances: but we know that the em- 
ployment of mercury under any of its usual forms of exhibition is often followed 
by increased watery evacuations from the intestines ; or by an increased discharge 
of bile ; or by an increased flow of saliva ; that is to say, it determines (as the 
phrase is) to certain secreting organs — the mucous membrane of the bowels, 
the liver, the salivary glands ; it augments their natural secretion ; and in this 
augmentation of secretion is implied an increased afflux of blood to the secreting 
part. It is probable that mercury has a similar influence on most or all the 
secreting surfaces of the body, altering the condition of the capillary circulation 
throughout. And an explanation of its curative power in inflammation has been 
drawn from this fact: it has been supposed that mercury thus tends to equalize 
the circulation ; that by causing the blood to be distributed in larger quantity than 
common upon several surfaces at the same time, it obviates, pro tanto, its exces- 
sive congestion or accumulation in any one organ. Whether this hypothesis in 
respect to the modus operandi of mercury be true or not, I will not pretend to 
say ; but it certainly is not an unreasonable hypothesis. 

If you push this remedy in healthy persons, other effects ensue : inflammation 
is actually produced; the gums become tender, and red, and swollen, and at 
length they ulcerate ; and in extreme cases, and in young children especially, the 
inflamed parts may perish : the cheeks, for example, sometimes slough internally. 
Not only the gums, but the throat and fauces, grow red, and sore and sloughy. 

Now you will do well to observe what is the character of the inflammation 
thus produced. It is superficial, spreading, erysipelatous : it leads to ulceration 
without any distinct occurrence of suppuration ; the ulcers enlarge. Of the three 
processes which I formerly pointed out as going on in different degrees, at the 
same time, in an ulcerated surface, that of absorption is vastly predominant; and 
you will find that persons in whom this local affection, this condition of the parts 
within the mouth, has been produced, get rapidly thin; their fat disappears; 
they become emaciated. That is, the absorption of the old materials throughout 
the body exceeds the deposit of new matter. Patients who are kept under the 
influence of mercury grow pale as well as thin : and Dr. Farre, who has paid 
great attention to the effects, remedial and injurious, of this drug, holds that it 
quickly destroys red blood: as effectually as it may be destroyed by venesection. 
As an example of this he was in the habit of relating in his lectures the case of a 
lady who was attacked with hematemesis : and whose gastric system and liver 
were gorged with blood. " Her complexion," said the doctor, " was com- 
pounded of the rose and the violet. Under a course of mercury she was blanched, 
in six weeks, as white as a lily." 

There are still other, occasional, effects of the continued introduction of mercury 
into the system : a peculiar eruptive disease ; a peculiar condition of the nervous 
system : but with these I do not now meddle ; they will come under our more 
particular consideration hereafter. At present I am desirous to place such facts 
before you as may help you to determine in what cases mercury is a fit remedy 
for inflammation ; in what cases it would be improper to give it. The facts I 
have already mentioned show that it has a loosening effect upon certain textures ; 
that it works by pulling down parts of the building. 

But the great remedial property of mercury is that of stopping, controlling, or 
altogether preventing the effusion of coagulable lymph ; of bridling adhesive 
inflammation; and if we, in our turn, could always bridle and limit the influence 
of mercury itself, it would be a still more valuable resource. 

From the little I have now said you will readily understand in what description 
of cases mercury is likely to be useful. In common adhesive inflammation, 
whether of the serous or the areolar tissues ; whenever, in Tact, you have reason 
to suppose that coagulable lymph is effused, or about to be effused, and mischief 
is likely to result from its presence, then you may expect much benefit from th© 



156 



INFLAMMATION. 



proper administration of mercnry ; as an auxiliary, however, to blood-letting, not 
as a substitute for it. 

On the other hand, mercury is likely to be hurtful in those forms of disease 
" where the morbid action approximates to its own action." In cases of erysipe- 
latous inflammation ha'ving a disposition to gangrene ; in scrofulous diseases ; in 
inflammatory complaints attended with general debility, and an irritable condition 
of the nervous system, or a manifest tendency to take on a typhoid character. 

When we have to contend with acute inflammation, and desire to prevent or 
arrest the deposition of coagulable lymph, our object is, after such bleeding as 
may have been proper, to bring the system as speedily as possible under the 
specific influence of mercury. How may this best be done ? and how are we 
to know that it has been achieved ? 

I will answer the last of these questions first. We know that the whole system 
has been brought under the specific influence of mercury, as soon as its effects 
become even slightly perceptible in the gums and breath of the patient; and in 
adults we cannot be sure of it before. The gums grow red and spongy; the 
patient complains that his gums are sore: and that he has a metallic taste, a taste 
like that of copper, in his mouth ; and an unpleasant and very peculiar foetor, 
easily recognized again when it has been once perceived, is smelt in his breath. 
These symptoms are enough : you need not in general look for any more decided 
affection of the mouth, such as ulceration of the gums, swelling of the glands 
beneath the jaw, and of the tongue, and a profuse flow of saliva. Formerly, 
when it was believed that the material cause of the disease was carried out of the 
body with the saliva, the mercurial treatment was continued with the view of 
producing the discharge of many ounces, and even of a pint or two, in the 
twenty-four hours: but all that is requisite is that the gums should become dis- 
tinctly tender, and that the mercurial foetor should be unequivocally manifest, and 
that these symptoms should be kept up for a certain time. 

Now this is best effected, usually, by giving some form of mercury in equal 
and repeated doses, by the mouth. For urgent cases calomel is the best form in 
which it can be administered : two or three grains, given every four or six hours, 
will generally suffice to touch the gums in the course of thirty-six or forty-eight 
hours. If it acts as a purgative its specific effect upon the whole system will be 
postponed by that circumstance; and it then becomes expedient to combine with 
it just so much opium as will prevent its passing off by the bowels. A quarter 
of a grain of opium with two grains of calomel — or a third of a grain of opium 
with three or four grains of calomel — -will generally be sufficient to restrain the 
purgative operation of the latter. When a speedier effect is desirable we give 
larger doses; such as five or ten grains every three, or even every two hours: or 
we combine mercurial inunction with the exhibition of calomel by the mouth. It 
is impossible to lay down any precise rule that will fit all cases. 

Blue pill, or the hydrargyrum cum cretd, may, in certain cases, be preferable 
to calomel ; but they must be given in greater quantity. Some practitioners believe 
that a combination of blue pill and calomel acts sooner, and answers better, than 
a proportional dose of either, given alone. 

This mode of administering mercury, so as to affect the system at large, is 
eminently useful in many instances of acute phlegmonous inflammation, after 
bleeding has been carried as far as the circumstances of the case may warrant. I 
repeat that it must not be allowed to supersede blood-letting. Previous bleeding 
renders the body more readily susceptible of the influence of mercury; and the 
operation of the mercury comes in aid of the salutary effect of the abstraction of 
blood. The two remedies accomplish by their joint power what neither of them 
could accomplish singly. 

It is important to know that different persons admit of, or resist, the specific 
agency of mercury, in very different degrees; so that in some patients the remedy 
becomes unmanageable and hazardous ; while in others it is inert and useless. It 
is most grievously disappointing to watch a patient labouring under inflammation 



MERCURY. 



157 



which is likely to spoil some important organ, and to find, after bleeding has been 
pushed as far as we dare push it, that no impression is made upon his gums by 
the freest use of mercury. Such cases are not uncommon; and unfortunately 
they seem most apt to occur when the controlling agency of mercury is most 
urgently required. On the other hand, there are persons in whom very small 
quantities of mercury act as a violent poison ; a single dose producing the severest 
salivation and bringing the patient's existence into jeopardy. This history was 
told to Dr. Farre by a medical man, under whose notice it fell. A lady, whom 
he attended, said to him, at his first professional visit to her, " Now, without 
asking why, or speculating about it, never give me mercury, for it poisons me." 
Some time afterwards she met with the late Mr. Chevalier, and spoke to him 
about her complaints ; and he prescribed for her, as a purgative, once, two grains 
of calomel, with some cathartic extract. She took the dose ; and the next morning 
showed the prescription to her ordinary attendant. " Why (said he) you have 
done the very thing you were so anxious to avoid ; you have taken mercury." 
She replied, «* I thought as much, from the sensations I have in my mouth." 
Furious salivation came on in a few hours ; and she died, at the end of two years, 
worn out by the effects of the mercury, and having lost portions of the jaw-bone 
by necrosis. 

Another medical man informed me that he knew a person so susceptible of the 
influence of mercury, that when his wife had rubbed a very small quantity of 
white precipitate ointment upon her neck for some cutaneous affection, after sleep- 
ing with her his gums were tender for three or four days, and slight salivation 
took place. This did not happen once only, but three several times. On one 
occasion this same man took two blue pills, as preliminary to a common purge, 
and he was salivated profusely for six weeks. Cases similar to these occur now 
and then to most medical men : we cannot tell beforehand in whom such effects 
are to be looked for ; but it is never prudent to neglect any warning which the 
patient gives of his own previous experience on this point. You will generally 
find that where the affection of the gums and salivary organs goes on to a trouble- 
some or distressing extent, it has supervened upon the employment of a very 
moderate quantity of mercury. 

So distressing sometimes are these effects of mercury upon the mouth, that I 
may pause a moment to tell you what I know about the means of remedying 
them. You will constantly be called upon to do something for the relief of this 
disease (for so we must call it), which you yourselves, or some of your brethren, 
have with the best intentions inflicted. I have tried all sorts of expedients ; and 
I have asked a great number of my friends what is the best plan to adopt in such 
cases : but I never could get much satisfactory information from them. Some 
thought purging was the best thing. Others recommended alum gargles; or 
gargles made with the chloride of soda ; and these last certainly have one good 
effect, that of correcting the fcetor. A dilute solution of chlorine in water, much 
used at the Middlesex Hospital, is better still. Others believed that sulphur, 
which has long been prescribed in such emergencies, was really of service; and 
some advised that the patient should be as much as possible in the open air: a 
few commended iodine. All admitted that they knew of no certain remedy. 
Neither do I. But there are two or three expedients which I am confident are 
often of very great use in checking the violence of the salivation, and in removing 
the most distressing of its accompaniments. If there be much external swelling, 
treat the case as being, what it really is, a case of local inflammation: apply 
eight or ten leeches beneath the edge of the jaw bones, and wrap a soft poultice 
round the neck, into which the orifices made by the leeches may bleed ; and I 
can promise you that, in nine cases out of ten, you will receive the thanks of your 
patient for the great comfort this measure has afforded him. Pure tannin, moist- 
ened and smeared upon the spongy gums, is remarkably efficacious in rendering 
them firmer and more comfortable. But this is not always to be procured: and 
when the flow of saliva, and the soreness of the gums, formed the chief part of 



158 



INFLAMMATION. 



the grievance, I have found nothing more generally useful than a gargle made of 
brandy and water; in the proportion of one part of brandy to four or five of water. 
This last piece of practice I learned from the present apothecary to the Middlesex 
Hospital; I have tried it over and over again ; and I tell it to you as a thing worth 
remembering. These little points are by no means to be despised. A very 1 
fashionable and successful physician, now dead, used sometimes to say when he 
met others of his brethren in consultation, " It is all very well to speculate about 
the exact situation, and the precise nature of the disorder, but the question with 
me is, ' what is good for this, that, or t'other thing V " A wise physician will 
seek to combine with an accurate knowledge of disease, and settled principles of 
treatment, those practical expedients and minor appliances which are picked up 
by casual experience; which could never have been reasoned out: and which 
sometimes constitute nearly all that we can do for our patient's benefit. 

But to return to mercury as a remedy against inflammation. It is of great ser- 
vice in many cases of chronic inflammation; and I may repeat here the observa- 
tion I formerly made when speaking of blood-letting — that the treatment must 
keep -pace, as it were, with the disease. When textures have been slowly altered 
by a gradual deposition of coagulable lymph, we should gain but little by suddenly 
or speedily salivating our patient. The lymph, if it can be dispersed at all, must 
be gradually taken up again : and mercury, given with the view of promoting its 
absorption, must be slowly and gradually introduced into the system; and its 
specific influence, when at length it is felt, must be sustained for a considerable 
length of time. 

You must not expect any good, but the contrary, from the exhibition of mer- 
cury in scrofulous inflammations; and where the scrofulous diathesis is well 
marked, you should be cautious in giving mercury at" any time. But I am certain 
that many men are too scrupulous in this respect ; and that, through over tender- 
ness of your patient's constitution, you may risk his life, by withholding mercury 
because he shows tokens of scrofula. You may recollect my stating that scrofu- 
lous persons are not exempt from attacks of common inflammation ; and in some 
such cases the possible aggravation of their general ill health, by mercury, is not 
to be put in competition with the immediate danger from the local inflammation. 
I have again and again seen scrofulous patients benefited by moderate salivation ; 
which, if it proved injurious at all to their general condition, was certainly less 
injurious than the unchecked local complaint would have been. 

There are some other remedies for acute inflammation which, in this general 
account of its treatment, I must briefly notice. Antimony is one of them ; and a 
very valuable remedy it is in some forms of inflammatory disease. Antimony, 
properly administered, subdues the action of the heart and arteries, producing 
nausea, paleness, and sinking of the pulse, and frequently great relief to the local 
symptoms. You bring the circulation into that state into which it may be brought 
by free blood-letting. But when the violence of the inflammatory symptoms 
recurs again and again, you cannot again and again employ the lancet : or if you 
do so employ it as at length to extinguish the inflammation, you reduce your 
patient to a state of pitiable, and even perilous, debility. Now you may continue 
or repeat the depression of the circulation by means of antimony, without any 
dread of such subsequent weakness. Antimony, so far as my own observation 
goes, is admirably suited to cases of active inflammation, in which mercury would 
either be not so useful, or could not be brought to bear. It is in inflammation of the 
mucous membrane of the air passages that antimony is so signally beneficial. 
You will see a patient labouring for breath, unable perhaps to lie down, with a 
turgid and livid countenance from imperfect arterialization Of the blood. He has 
been ill but a short time ; it is an acute affection; and upon listening at his chest 
you hear that peculiar wheezing sound which we call sibilus, in every part of his 
lungs. I shall have to describe this sound, and its causes, and its meaning, in a 
future part of the course. You give such a patient repeated doses of antimony; 
he becomes sick, vomits perhaps, but he feels nausea: his pulse becomes less 



ANTIMONY. 



159 



forcible, his face grows pale, and he can breathe again. The nausea is not a plea- 
sant sensation ; but the want of breath is a far more distressing one ; and that is 
greatly mitigated. Perhaps free secretion takes place from the congested mem- 
brane, and then the patient is easy and safe. Now you could not effect this 
change so quickly and readily, or so conveniently, by mercury, and perhaps not 
at all. Bronchitic affections are very common in children, in whom it is usually 
difficult to induce the specific influence of mercury. 

On the other hand, antimony does not appear to be nearly so valuable a remedy 
as mercury, when serous membranes are inflamed. 

The French and Italian physicians place much reliance upon antimony for the 
cure of inflammation ; and they seem to know little or nothing of the remarkable 
agency of mercury upon that disease. For my own part I do not k see how any 
useful comparison can be made between these two substances in respect to inflam- 
mation, considered generally, as we are now considering it. There are some 
particular forms of inflammation to which the one remedy is better suited, and 
there are others in which the other is most effectual. I must content myself for 
the present with having adverted to these distinctions. 

As to the form in which the antimony should be exhibited, I apprehend that 
we shall all come at last to freshly dissolved tartar emetic. The antimonial pow- 
der is of very uncertain strength; and the antimonial wine contains too much 
spirit to allow of its being given in large and frequently repeated doses. It is a 
curious circumstance, that although vomiting and purging are apt to be produced 
by the first two or three doses, they usually cease when the same quantity is per- 
severed with. Tolerance of the remedy is established. But although these un- 
pleasant primary effects cease, the curative agency of the antimony appears to 
continue. When you desire to obtain its full influence in a short time, you may 
dissolve a grain of the tartar emetic in two ounces of hot water, and give a fourth 
part of the solution every half hour. If the patient becomes. pale and sick, you 
pause awhile and allow him to recover himself ; and if the inflammatory symp- 
toms return, you repeat the medicine. It sometimes acts violently upon the 
bowels, and then it is necessary to add a few drops of laudanum to each dose.* 

Digitalis is another powerful medicine, from which, as a remedy for active 
inflammation, much was at one time hoped ; but this hope has been in a great 
measure disappointed. It is not a manageable remedy in such cases. Its singular 
property of retarding the circulation, of bringing down the number of the heart's 
pulsations, and abating its force, led to the expectation that it might render the 
use of the lancet unnecessary ; that it might check the inflammatory process 
without permanently reducing the strength of the patient. But if you give mo- 
derate doses of digitalis, its peculiar effect upon the pulse comes on at very un- 
certain periods, and may be postponed until it is too late to be of any service. 
If, on the other hand, you give it in such quantity as speedily to affect the heart's 
action (which is what we want in acute and serous inflammation), then you are 
never secure against what may be called its poisonous effects : deadly faintness, 
frightful syncope, and even death itself. Most practitioners can tell of cases in 
which patients, who were taking full doses of digitalis, have suddenly expired; 
and when the remedy has appeared to have had more to do with the fatal event 
than the disease. There are practitioners, however, and I know one of them, 
who affirm that digitalis may be given, after due depletion, and in acute inflam- 
mation, in very large, and I should say startling doses, with the very best effects 
— doses which range from half a drachm to half an ounce, and even six drachms, 

* [The remarks of Dr. Watson upon the remedial effects of tartar emetic in inflam- 
matory affections, are perfectly correct in reference to these diseases as they occur in the 
adult; in the inflammatory diseases of infants and young children, however, the tartar 
emetic is not a remedy that can be safely employed; it produces in them always very con- 
siderable and enduring disturbance of the stomach, and in many cases a state of extreme 
and, as remarked by a late writer — Dr. Wilton, (Prov. Med. and Surg. Journ.)— even fatal 
depression of the vital powers. — C] 



160 



INFLAMMATION. 



of the officinal tincture. I confess to you that I should be very unwilling to 
sanction this mode of using digitalis. I never attempt to employ it with the view 
of knocking down acute inflammation — to which alone you will observe that my 
present remarks apply. Digitalis is often of great service in other complaints; 
but I am not at present discussing the remedial virtues of digitalis, or of any other 
drug, except so far as they relate to the cure of recent and active inflammation. 

Colchicum is a drug which is often prescribed in inflammation. It is a most 
valuable remedy in certain specific forms of inflammation. But for repressing 
common phlegmonous inflammation we have much more certain and better reme- 
dies. For this purpose colchicum is, I believe, a very unimportant medicine. 

I have formerly been asked, by students attending here — and therefore I anti- 
cipate the question now — respecting the utility of opium as a remedy in inflam- 
mation, 'tainly opium, like most of our powerful medicines, may do much 
good, as it may do much harm, in different inflammatory diseases; and it is not 
very easy to point out clearly, in a general view of the treatment of inflammation, 
the rules for its administration by which we must be guided in different cases. 
Yet there are a few general observations which I may make now on this subject. 

The administration of a full dose of opium has been strongly recommended 
after that free and effective bleeding which I have already described. It prevents 
the rekindling of the inflammation which is apt to result from irritation of the 
nervous system — a kind of irritation, you will remark, which the copious ab- 
straction of blood is calculated to produce ; or to augment, if it finds it already 
existing. The opium soothes this nervous irritability, and it must be given, when 
given at all, in doses whi^h will have that effect. It is best adapted to those cases 
in which a natural irritability is inherent in the constitution of the patient — to 
those in which such irritability has been acquired by bad habits of life — and to 
those in which the local disease is attended with much pain, which is in all con- 
stitutions a source of irritation. 

However, this is a remedy which requires to be used, in inflammation, with 
great caution and discrimination. In cases of active inflammation within the 
cranium, its propriety is very questionable. It is apt to confuse both the patient 
and his physician, who is unable to say, after a full dose of opium has been given, 
how much of the stupor that follows is owing to the disease, and how much to the 
drug. It is a very ticklish remedy in pectoral inflammations. I believe that by 
the free use of opium I saved the life of a relation of my own, an old lady, who 
was in danger of being worn out by the cough and bronchial affection which 
attended the influenza. On the other hand I certainly have known more than one 
person, labouring under extensive and severe bronchitis, so effectually quieted by 
a dose of the same medicine, that they never woke again. As a general rule I 
should say that you must be very careful how you venture upon opium in in- 
flammatory diseases that tend to produce death by coma, or apnoea. If there be 
any unnatural duskiness of the face, if ever so slight a tinge of purple mingles 
itself with the red colour of the lips, this is an appearance which (with certain 
exceptions, to be specified hereafter) should warn you against opium. It shows 
that the blood is imperfectly arterialized : and imperfect arterialization of the 
blood, as I hope you all know now, either results from, or conduces to, a state of 
coma. 

On the other hand, it is, casteris paribus, in cases where the tendency is to- 
wards death by asthenia, that the use of opium, as a remedy for inflammation, is 
most serviceable. It has a capital effect often, after free bleeding, in cases of 
peritonitis, and of enteritis. It probably does good in various ways : by quieting 
the nerves — by sustaining the faltering action of the heart — by keeping the in- 
flamed parts at rest. There are some frightful accidents in which we can expect 
little. from blood-letting, but in which the judicious employment of opium affords 
some glimmering of hope. I allude to those cases of intense and general peri- 
tonitis which arise upon the escape of irritating substances into the cavity of the 
belly; the contents of the intestines, from ulceration or from external injury; 



TOPICAL REMEDIES. 



161 



urine from rupture of the bladder ; arid soon. If there be any hope in such cases, 
it is to be found in the continued exhibition of opium in considerable doses. But 
upon all these points I shall go more into detail when we come to consider indi- 
vidual diseases. 

A very few remarks, in respect to external remedies in cases of inflammation, 
will terminate both this lecture and what I have to say, thus generally, of the 
treatment of inflammatory complaints. 

The application of external cold will aid us very powerfully, in certain serious 
cases of inflammation ; and especially in cases of inflammation within the cra- 
nium. It is really wonderful what a sedative and soothing effect this expedient 
frequently has in allaying delirium, the result of active inflammation of the brain 
and its membranes. Thin folds of linen, kept constantly moist and cold by cold 
water, are placed upon and around the shaven tyead. We often apply ice in the 
same way. But I need not go at present into any detail on this subject : I will 
only observe, that we have a most excellent and simple guide as to the probable 
usefulness of cold application to the head, in the sensations of our patients. It is 
very lucky that it is so. As long as the cold cloths, or the bags of ice, are plea- 
sant and grateful to the patient, so long we sedulously continue to apply and renew 
them ; as soon as the patient dislikes them, they had better be intermitted. 

Cold applications to the chest, and to the belly, in active inflammation of parts 
situated within those cavities, have been praised by some practitioners ; but I be- 
lieve are very seldom employed. I have no personal experience either of their 
utility, or of their hurtfu\iess. I confess that I should not like to use them. I 
should think that the effect of the cold, in driving the blood from the cutaneous 
vessels, and accumulating it in internal parts, would be likely to be injurious. 
We shall see, by and by, that the contents of the skull are somewhat differently 
circumstanced, in this respect, from those of the thorax and abdomen. 

The totally opposite measure, applying warmth to the surface, is of very great 
service in many cases of internal inflammation; especially in inflammations of the 
abdominal organs. We speak of cold lotions, and of hot fomentations. These 
last are managed in various ways, into which I do not at present enter. They 
seem to do good by determining to the surface ; they promote perspiration ; they 
mitigate pain, and persuade to sleep. 

In cases of external inflammation, sometimes cold applications are found to be 
of use, and sometimes warm. In this matter, also, the sensations of the patient 
afford the best criterion. Both of them tend, in different circumstances, to pro- 
mote resolution. We have an illustration of the beneficial agency of cold appli- 
cations for this purpose in the treatment of recent burns and scalds, particularly 
when the injury is superficial, and the skin has not been destroyed. Probably 
there is scarcely any one present who has not experienced the relief given to the 
pain of a burned finger, by dipping it in cold water; and the return of the pain 
upon taking the finger out again. The cold may be so constantly applied that the 
p^vin will cease to recur when the application is at length suspended. Dr. John 
Thomson relates a case in which a burned arm was kept immersed in cold water 
for two days and two nights incessantly; and inflammation was thereby wholly 
prevented. I have known this expedient fail, however. A nurse in the Middle- 
sex Hospital fell as she was carrying a pail of hot water upstairs, and in her fall 
thrust one of her arms into the scalding liquid. Without loss of time she plunged 
the same arm into cold water; but after a while was obliged to desist; the cold 
immersion bringing on severe rigors. 

In erysipelas I am persuaded that warm fomentations not only afford more com- 
fort, but are more effectual and safer than cold lotions. 

Independently of their occasional influence in promoting resolution, warm ap- 
plications — warm soft poultices, for instance — are often used with the view of 
forwarding suppuration. Hence this rule. Whenever resolution of the inflam- 
mation is possible — but suppuration is likely to ensue — warm applications are the 
most proper: because, under their use, we have an equal chance of obtaining 



162 



HEMORRHAGE. 



resolution, with less hazard of retarding or rendering untoward the process of sup- 
puration, in case resolution does not take place. 

Counter-irritation, by means of blisters, sinapisms, irritating ointments, setons, 
issues, or moxas, is often very beneficial. It probably operates by attracting blood 
into the neighbouring parts, and in the same degree diverting it from the inflamed 
part. It is most serviceable in chronic inflammations, and towards the decline of 
those which are acute. It is particularly adapted to scrofulous affections. There 
is an objection to the use of counter-irritation during the height of the inflamma- 
tory fever, on account of the increase of general irritation which it would then 
occasion. Neither in local inflammation should counter-irritation be applied very 
near to the inflamed part. Blisters upon the head, or neck, are not proper, there- 
fore, at least in the early stages of the disease, in acute inflammation within the 
cranium ; but they are sometimes applied in such cases, with advantage, to the 
lower extremities. To the chest, however, in thoracic inflammation, ancl to the 
belly in abdominal, blisters are often not only perfectly safe, but of the greatest 
use, as will, I trust, be apparent as we go on. 



LECTURE XV. 

Hemorrhage : — most commonly by Exhalation. Habitual Hemorrhages. Vica- 
rious Hemorrhages. Idiopathic Hemorrhages. Jlctive and Passive. Symp- 
tomatic Hemorrhages. Usual Situations of Hemorrhage. Symptoms and 
Diagnosis. Principles of Treatment. 

In the course of that somewhat cursory account which I have been endeavour- 
ing to give you of the general facts and doctrines of pathology, as a preparation 
for the better understanding of special forms of disease, we reached, some lectures 
back, the subject of local plethora or congestion. From that point our road branched 
off in three several directions. We have pursued the first and main branch to its 
termination ; that which led to the discussion of inflammation. We must now go 
back to the same point again, and follow first the one and then the other of the 
two remaining branches, which conduct respectively to the consideration of he- 
morrhage and of dropsy. These branches are shorter than that along which we 
were last traveling; but they are not uninviting; they will open to us, if I mis- 
take not, some interesting views of the country of which we purpose, in the end, 
to make a more particular survey. 

You are to observe that I treat of hemorrhage only so far as it falls to the care 
of the physician. The subject is exceedingly full of interest in its relation to sur- 
gery : and it will receive at the hands of my colleague all the attention which its 
great importance, as a surgical accident, demands. 

But we, also, as physicians, have much to do with hemorrhage ; with what, for 
distinction's sake, I may call medical hemorrhage ; which differs in kind, in cause, 
in its consequences, and in the treatment it requires, from that which surgery con- 
templates. 

In surgical or traumatic hemorrhage the blood flows from some considerable 
vessel, which has been cut or torn, or somehow ruptured. You would greatly 
mistake, if you inferred from that circumstance (as you naturally might), that it is 
usually so—the only difference being in the situation of the vessel— in medical 
hemorrhage also. 

Yet that is the popular notion. When blood gushes out from internal parts, 
through any of the natural apertures of the body, the person is said and supposed 
to have broken a blood-vessel. But this is rarely, though it is sometimes, the case. 
In nine instances out of ten, if there be any rupture at all, it is rupture of nume- 
rous capillaries only : but even of this there is often no evidence. 



BY EXHALATION. 



163 



Whence, then, and how, does the blood escape from its natural channels ? Why, 
it exudes from the unbroken surfaces of organs, without any appreciable lesion of 
arteries, veins, or capillaries ; just in the same manner as sweat oozes from the 
skin, mucus from the inner surface of the bowels, and serum or synovia from the 
membranes that respectively furnish those fluids ; and probably by the very same 
outlets. 

This certainly is a very remarkable circumstance, if it be true; and you will 
naturally ask what proof we have of its truth. 

The proof is simple, and, I think, conclusive. We examine the surface from 
which the blood must have proceeded, and we find it entire : we wash and even 
macerate it: we employ the microscope to assist our powers of vision : yet we 
fail, after this careful inspection, to discover the slightest breach of substance, or 
any appearance of erosion. 

When, for example, hemorrhage has occurred so profusely from the stomach 
or bowels, that the death which ensued could be sufficiently accounted for by the 
mere loss of blood, the whole tract of the alimentary canal has been diligently 
scrutinized, and has exhibited no ruptured blood-vessel, no abrasion even of its 
surface, nor any perceptible alteration of texture. Sometimes its mucous mem- 
brane appears, here and there, of a red colour, and, as it were, charged with blood. 
Sometimes it is pale and transparent, while the vascular net-work visible immedi- 
ately beneath it is gorged and turgid. Sometimes the whole is colourless ; the 
same net-work of vessels having been completely emptied by the previous hemor- 
rhage; and sometimes, again (and this is very illustrative of the mode by which 
the blood has issued), vast numbers of small dark-coloured masses, like grains of 
fine sand, can be made to start from the surface of the membrane by slight pres- 
sure. There can be no doubt that these are minute portions of blood which had 
remained and coagulated in the vessels or apertures forming the ultimate channels 
of the hemorrhage. 

We have absolute proof, therefore, thaj hemorrhage may transude through an 
uninjured surface : nay, in some rare cases, the process has been actually wit- 
nessed. There are well-authenticated instances on record of cutaneous hemor- 
rhage ; where a dew of blood has appeared upon some portion of the skin, has 
been wiped away, and has reappeared; and that, again and again, without any 
perceptible alteration of the affected surface, beyond some occasional variation in 
its colour. So, again, the menstrual discharge has been seen to issue guttatim 
from the healthy surface of a living but inverted uterus. I confess, however, that, 
although this analogical fact helps our conception of the manner in which blood 
may be exhaled from an unbroken membrane, I should not lay much stress upon 
it for any other purpose. It is not exactly a case in point. The process of men- 
struation cannot be looked upon as a morbid process. During a certain portion 
of the life of an unpregnant female, it is not only consistent with perfect health, 
but even essential to it; and the fluid poured out is not strictly blood. 

That the blood proceeds from the same vessels or apertures, which, in health, 
pour out the fluids natural to the part, is rendered the more probable by this fact : 
— that certain hemorrhages are ushered in and succeeded by an increased efflux 
of the fluids which belong to the surface concerned. In hemorrhages from the 
mucous membranes the following succession of events is, in some persons, 
habitual. First, there is an augmented flow of mucus alone; then of mucus tinged 
with blood ; then of pure blood : and the hemorrhage recedes by a similar but 
inverse gradation, towards a mucous drain, .which itself at length decreases or 
disappears. 

When blood thus exudes, we say that the hemorrhage takes place by exhala- 
tion. It is a convenient word, and will spare circumlocution. What the vessels 
or outlets to which we give the name of exhalants really are.; whether they be 
branches from the capillaries not large enough in the natural state to admit the red 
particles, or whether they be mere pores in the sides of the capillaries ; these are 
points concerning which we have no positive knowledge. We know, indeed, 



164 



HEMORRHAGE. 



that such channels must exist, though we cannot demonstrate or see them ; and 
we know that while every part of the body is in a state of health and integrity, 
they do not allow the blood, as such, to pass through them. 

I am aware that my learned colleague Dr. Todd objects to this doctrine of 
hemorrhage without rupture, even of capillary vessels : arguing that, if the red 
corpuscles of the blood, which measure from to 3oW tn °f an i ncn m diameter, 
could pass through lateral pores in those vessels, such pores must be large enough 
to become visible under the microscope. But on the other hand, Mr. Wharton 
Jones, who also is well versed in the use of that instrument, declares that the red 
corpuscles "can readily accommodate themselves to vessels of a diameter less 
than their own." However this may be, the distinction is broad enough between 
hemorrhage from a palpable leak in a large vein or artery, and hemorrhage from 
innumerable capillaries in which no rent can be demonstrated. Treating, then, 
this question of rupture according to the old maxim, that de non apparentibus et 
de non existentibus eadem est ratio, I shall venture to adhere to the term exhala- 
tion. 

Now, although internal hemorrhage may happen in other ways ; as from the 
bursting of an aneurism, or from an opening made in a large vessel by progressive 
ulceration; yet in by far the greater number of cases it takes place by exhalation. 
Exhalation is the rule — other modes of hemorrhage furnish the occasional excep- 
tion. 

I must exclude, however, from this general statement one very important 
hemorrhage. In the brain, the former exception becomes the rule. In almost 
all cases cerebral hemorrhage results from the rupture of a blood-vessel. 

There are various kinds of hemorrhage by exhalation. I will bring them 
before you, in succession, as clearly and concisely as I can. 

In the first place there are hemorrhages which, although they do not belong to 
the state of health, if we take mankind in general, yet when they do occur, can- 
not properly be called diseases. There are some persons — I believe I may say 
there are many persons — who are subject, during the greater part of their lives, 
to discharges of blood ; which happen again and again, commonly at regular 
intervals, without any perceptible detriment to the general health, independently 
of any obvious exciting cause, and (as it would seem) from some inherent property 
or necessity of the system. 

Hemorrhages thus occurring, I will call habitual hemorrhages. They proceed 
more commonly from the rectum, and from the nares, than from any other parts; 
although instances are recorded of their taking place from the bladder, and from 
the bronchi. Appertaining to the original constitution of the body, this disposi- 
tion to periodic hemorrhage has been sometimes observed to be hereditary. 

You will at once be struck with the analogy which obtains between these 
habitual hemorrhages occurring in either sex, and the monthly discharge which is 
peculiar to the female. The analogy is even closer than it may at first sight 
appear: but it is more distinctly marked in some individuals, liable to habitual 
hemorrhage, than in others. It was one of the singular notions of the celebrated 
phrenologist M. Gall, founded upon this analogy, that there is such a thing as 
male menstruation. The points of resemblance between the two phenomena. will 
be manifest in the following summary of the characters belonging to habitual 
hemorrhage. 

Like the catamenia, these hemorrhages do not ordinarily prevail throughout 
the whole course of life. In most cases they do not commence before the period 
of adolescence ; and they cease altogether, or recur at distant intervals only, in 
declining age. Their first eruption is sometimes preceded by a state of general 
indisposition, more rarely by slight febrile disturbance, and even (according to 
some observers) by a sort of chlorosis similar to that which affects young girls 
in whom the menstrual evacuation is delayed or suspended. The hemorrhage 
sometimes recurs at precisely regular intervals, and by monthly periods more 
commonly than any other: being announced, on each occasion, by the same pre- 



IDIOPATHIC. 



165 



ludes, proceeding from the same part, continuing for the same space of time, and 
furnishing always about the same quantity of blood. Its accidental interruption 
is almost uniformly the cause or the consequence of some derangement of the 
health: and when it becomes excessive, it becomes, like too profuse menstrua- 
tion, a disease. 

It forms a very curious part of the general history of hemorrhages that they 
are not unfrequeritly vicarious, or supplemental, sometimes of each other, but 
more often of the monthly discharge from the uterus. Females are liable to per- 
verted menstruation (so to call it) through other channels than the natural one : 
and here again the analogy between the catamenia and habitual hemorrhage comes 
into view. The hemorrhages which belong to the constitution are apt to wander 
in their seat. As bleeding from the lungs, stomach, rectum, or skin, sometimes 
follows upon the suspension of the menses, so bleeding from the bladder, from 
the mouth, and from other parts, has been occasionally observed to succeed the 
suppression of habitual hemorrhois. 

These hemorrhagic deviations take place commonly by the same organ on each 
occasion ; more seldom by different organs in succession. It is almost always 
in this supplementary manner that the rarer forms of hemorrhage occur, and 
those of the skin in particular. 

This singular migration, this interchange of place between certain hemorrhages, 
seems calculated to throw some light upon the obscure doctrine of revulsion: a 
doctrine to which I have already more than once referred, and which, though it 
is very imperfectly understood, is of frequent avail in the practice of physic. 

Vicarious hemorrhage always denotes a disordered state of the general health : 
and must be considered, in itself, as a malady. 

Again, there are certain forms of hemorrhage, not habitual, which may be de- 
nominated idiopathic: inasmuch as they are apt to arise without any perceptible 
connection with antecedent local disease. 

In other respects, however, they differ considerably, and require to be further 
distinguished : and the terms active and passive, which are in common use, will 
sufficiently express the two forms of idiopathic hemorrhage that I wish to bring 
under your notice. 

Active hemorrhage is preceded by active congestion, and therefore is akin to 
inflammation; and it often requires the treatment of inflammation. 

Passive hemorrhage often occurs without any apparent previous congestion of 
any kind. Hemorrhage of this passive character has been ascribed to some 
change — different from that which we conceive to be produced by the distension 
of plethora — in the vessels or apertures through which the healthy exhalations 
are transmitted. The change is considered as being of the nature of morbid 
debility or relaxation. That such a state may sometimes exist is not impossible, 
nor even unlikely: but as we are altogether ignorant of the natural condition of 
these outlets, it is difficult to reason about the alterations to which they may be 
subject in disease. This hypothesis derives its chief support from the occasional 
efficacy of astringent substances (either applied locally, or taken into the system) 
in checking the effusion of blood, when other remedies have failed. 

A more probable hypothesis perhaps is that which supposes some alteration in 
the consistence or composition of the blood itself ; which thus becomes attenuated, 
and capable of passing through channels or orifices that healthy blood, under 
ordinary circumstances, cannot penetrate. In support of this supposition are 
adduced the facts that hemorrhages are known to occur where the blood is more 
thin, pale, and serous than common ; and still more remarkably where that fluid 
has undergone a demonstrable change in its chemical nature, or is even visibly 
altered in its sensible qualities; as, for example, in certain cases of purpura and 
sea-scurvy. And hemorrhages of this kind are often cured by measures calculated 
to repair the blood ; to restore it to its natural condition by improvement in diet; 
or by food of a peculiar kind, as the juice of lemons. 

Whatever may be the true explanation of the differences in question, there can 



166 



HEMORRHAGE. 



be no doubt that they exist, and are often strongly pronounced in cases of hemor- 
rhage, which, inasmuch as they cannot be traced to any pre-existent local disease, 
we class together as idiopathic. And it will be worth while to run over the dis- 
tinctive characters of active and passive hemorrhage, as they are broadly and 
decidedly visible, in well-marked cases. 

Active hemorrhage (which is preceded, I repeat, by active congestion) occurs 
principally in persons who are young and robust, who live fully, and lead indolent 
lives, and are subject to the influence of those causes which tend to generate 
plethora. Occasionally the hemorrhage can be traced to some exciting cause, 
such as exposure to heat, strong mental emotion, violent exercise, or bodily 
efforts. More frequently, perhaps, no exciting cause is apparent. It is some- 
times ushered in by a set of symptoms expressive of what has been called the 
molimen liemorrhagicum. The patient experiences a general feeling of indispo- 
sition, with wandering and obscure pains that gradually settle in the part from 
which the blood is about to be discharged. A series of local symptoms, such as 
a sensation of weight, or of tension, or of heat and tingling, sometimes a slight 
degree of turgescence and redness, and a visible fullness of the larger veins, indi- 
cate the afflux of blood towards the labouring organ, and the parts in its vicinity: 
while chilliness, paleness, and shrinking of distant parts, and especially of the 
feet and hands, denote an opposite condition of the circulation in them. And to 
this state of things there often succeeds a general increase of heat, with a frequent, 
full, and bounding />w/se,—a pulse which is so characteristic sometimes, as to have 
acquired a name ; you may often hear or read of a hemorrhagic pulse. The 
blood, when at length it breaks forth, commonly escapes with rapidity ; is of a 
florid colour; proceeds from a single organ; and readily coagulates, though it 
seldom separates distinctly into serum and crassamentum. While it is flowing, 
the signs of local congestion diminish and disappear; warmth returns to the 
extremities, and the pulse regains its natural strength and frequency. The patient 
becomes conscious of a sensible relief ; and feels stronger and more lively than 
before. This kind of hemorrhage is, in some sort, its own remedy ; it ceases in 
virtue of the discharge of a certain quantity of blood, and it is followed by morbid 
consequences only when that quantity has been excessive ; or when it inflicts 
some mechanical injury upon the parts along which the blood passes. 

I said that active hemorrhage is preceded by active congestion, and is conse- 
quently akin to inflammation. Perhaps it may be more true that in some of these 
cases we actually have the initial stage of inflammation, of which the hemorrhage 
proves the natural cure: strangling it in its birth; applying that remedy, in the 
very moment when it is most effective, which I told you, in the last lecture, was 
the most potent of all the remedies of inflammation : namely, loss of blood. 

Passive hemorrhage on the other hand is characterized by circumstances of an 
exactly contrary nature. It occurs in those who are naturally feeble, or who 
have been debilitated by disease, fatigue, insufficient nourishment, great evacua- 
tions, or the depressing passions. It is not, in general, announced by any pre- 
cursory symptoms, nor attended by any re-action. The effused blood is of a 
dark colour, serous, and but little disposed to coagulate : and it often is poured 
forth from several parts of the body at the same time. If the quantity lost be at 
all considerable, the natural debility of the patient is rapidly augmented : his face 
becomes pale, and his body loses its heat. The hemorrhage leaves him in a 
worse condition than that in which it found him. The flow of a certain quantity 
of blood is not, as in the cases of active hemorrhage, suspensive of its further 
effusion ; frequently, indeed, passive hemorrhage resists the means opposed to it, 
the more, in proportion as it has continued longer, or been more profuse. 

Hemorrhages of the kind I have now been describing — that is to say, depending 
upon no palpable disease of any organ, and, therefore, idiopathic — are of no 
uncommon occurrence, whether we regard the active or the passive form in which 
they appear: but by far the greater number of hemorrhages by exhalation are 
symptomatic; that is, they result from some previous disease, either in the organ 



USUAL SYMPTOMS. 



167 



from which the blood proceeds, or in some other organ connected therewith by 
community or dependence of function. 

These secondary or symptomatic hemorrhages are preceded by congestion, bu^ 
for the most part the congestion is not of the active, but of the mechanical kind ; 
and has more to do with the veins of the part than with the arteries. 

Thus we have hemorrhage from the bronchial membrane, in consequence of 
crude tubercular matter in the lungs, filling up a portion of the pulmonary tissue, 
and obstructing the circulation of the blood through it. This is an example of 
symptomatic hemorrhage by exhalation, depending upon previous disease in the 
organ itself from which the blood proceeds. 

In some of these cases the presence of pyrexia renders it probable that the 
hemorrhage is the consequence and the relief of active congestion, provoked by 
the irritation of tubercles ; rather than the result of a mechanical obstruction of 
the circulation. 

Again, we have hemorrhage into and from the lungs, as a consequence of such 
disease of the heart as mechanically impedes the return of the blood from the 
lungs to that organ: a narrowing of the mitral orifice, for instance. Here the 
blood is barred up, as it were, in the lungs, till at length the capillaries, incapable 
of further distension, either give way, or become so dilated as to allow of the exit, 
of the blood through their exhalant openings, or through inorganic pores in their 
sides. In precisely the same way blood is poured out by the mucous membrane 
of the stomach and bowels, in consequence of disease in the liver, obstructing 
the portal circulation. These are examples of symptomatic hemorrhage by exhala- 
tion, depending upon previous disease, not of the organ itself from which the 
blood proceeds, but of another organ intimately connected with the former. 

When I say that hemorrhage into and from the lungs may result from such 
disease of the heart as implies an impediment to the circulation, you must not 
suppose that the lungs are the only channel through which the mechanical con- 
gestion can be relieved. Disease of the central moving organ of the circulation 
leads often, at length, to universal venous congestion : and the hemorrhage, which 
is apt to be the consequence of such congestion, may burst forth from any part 
where the veins are so overloaded. Hemorrhages from various portions of the 
mucous membranes are in truth very common effects of cardiac disease. 

The influence of mechanical congestion as a direct cause of hemorrhage is 
sometimes very distinctly seen in the bodies of persons who have been hanged. 
You know that when suffocation has been produced by suddenly cutting off the 
access of air to the lungs, the right side of the heart, the great veins, and indeed 
the venous system generally, become loaded and distended with dark blood. Dr. 
Yelloly examined the stomachs of five men who had been executed by hanging: 
he found them all exceedingly vascular: and in two of the five cases, blood was 
actually extravasated, and adhering to the surface of the membrane: there had 
been, in short, unequivocal hemorrhage. 

There are several things, worthy of notice, in respect to hemorrhage by exha- 
lation, of whatever kind. 

In the first place, it occurs much more frequently and readily from some tissues 
of the body than from others : and most especially of all, from mucous surfaces. 
Thus we have hemorrhage from the mucous membrane lining the nasal cavities ; 
from the pulmonary mucous membrane ; from the stomach and bowels ; from the 
urinary organs; and from the uterus ; constituting distinct forms of disease, which 
we are, by and by, to investigate more particularly. Epistaxis, hsemoptysis y 
haematemesis, melsena, hsemorrhois, hematuria, menorrhagia, are names descrip- 
tive of hemorrhage, as it is apt to occur from different parts of one or other of the 
three tracts of mucous membrane met with in the body : and you will find that 
these comprise very nearly all the complaints enumerated by nosological writers 
under the head of hemorrhage. 

Now this is a very remarkable fact: and very interesting questions arise out of 
it. Has it any relation to the manner in which these membranes, and the tissues 



168 



HEMORRHAGE. 



subjacent to them, are supplied with a capillary circulation? or may the fact be 
explained by the laxity of their attachment, which facilitates and favours the accu- 
mulation of blood in the vessels of the submucous tissue? Or has the density or 
consistence of their natural exhalations any thing to do with this disposition to 
hemorrhage in the mucous membranes? May we suppose that the vessels or 
orifices appointed to exhale mucus, afford a more easy passage to the blood than 
those which give egress to thinner fluids ; serum, for example, or the cutaneous 
perspiration ? Whatever answers may be given to these questions, you will do 
well to recollect the fact which has suggested them. 

Hemorrhages by exhalation are not, however, exclusively confined to mucous 
surfaces. They are liable to occur, but much more rarely, from serous mem- 
branes. In the majority of cases, however, in which blood is found effused into 
any of the serous sacs, it has either been an event of inflammation, or the blood 
has been poured out from an accidental opening in some considerable vessel. 
Cutaneous hemorrhage is also very rare; probably because the cuticle opposes a 
barrier to the exit of the blood : for the little red spots which characterize purpura 
are in fact hemorrhages, although the blood has not penetrated the epidermis. 
There are cases, however, as I mentioned before, in which blood has transpired, 
in a sort of dew, from the external surface of the body. 

Another important general fact in respect to hemorrhages by exhalation is, that 
they proceed more frequently from certain parts of the mucous membranes than 
others, according to differences of age. Thus in children they are most common 
from the membrane that lines the nasal cavities: in youth from the mucous mem- 
brane of the lungs and bronchi; in the middle years of life, and towards its decline, 
from the rectum, uterus, and urinary organs. I should add here, from the blood- 
vessels of the brain, in old age; except that this, as I have already intimated, is 
not (speaking generally) hemorrhage by exhalation. 

Of course when I say that, in the instances specified, the blood is commonly 
poured out by exhalation, you will understand that the hemorrhage sometimes 
occurs from the laying open of a single vessel of some magnitude. Thus hemor- 
rhage from the fauces may be the result of ulceration there, which has penetrated 
the coats of a vein or artery : haemoptysis is occasionally produced by the lacera- 
tion of a blood-vessel during the softening and expulsion of tubercles. Haemate- 
mesis sometimes is the consequence of a breach made in a considerable blood-vessel 
during the progress of cancer of the stomach, or by the extension of small corrod- 
ing ulcers ; hemorrhage from the bowels is no uncommon effect of ulceration, 
such as happens in fever, of the mucous follicles of the small intestine ; calculous 
matter in the kidneys will often lead to the rupture of some of the blood-vessels 
there, and to the discharge of blood by the urethra. Aneurisms also may burst 
into almost any part of the body. But events of this kind are unfrequent when 
compared with hemorrhage from the same parts in the way of exhalation. 

In the head, however, the ratio is reversed. Blood does, sometimes, I believe, 
exude from the membranes of the brain, but much more commonly cerebral he- 
morrhage is caused by the giving way of a diseased artery in the brain. 

How, in all these cases, to distinguish whether the blood has oozed out by many 
orifices from a surface, or has escaped from a hole in the sides of a vein or artery, 
will form matter for future inquiry. Sometimes we can make the distinction, and 
sometimes, it must be confessed, we cannot. 

You will readily understand that hemorrhage must vary greatly in respect to its 
importance, and to the danger which it implies, according to the part from which 
it proceeds, and the circumstances under which the blood is poured out. It some- 
times happens that death ensues from the 1 mere loss of blood : either at once, by 
one profuse bleeding, or more slowly, by repeated bleedings which we are unable 
to restrain : but this is comparatively rare, and when it does happen, the blood is 
generally found to have proceeded from one considerable vessel, which has been 
ruptured or eroded. The case approximates to traumatic hemorrhage, except that 
we cannot cut down upon and tie the injured vessel, Much more commonly dan- 



TREATMENT. 



169 



ger arises from the presence and pressure of the extravasated blood in and upon 
internal parts ; upon the brain, for example, in cerebral hemorrhage ; in the lungs 
in pulmonary. 

The symptoms, also, are liable to much variation in different cases. Even 
the diagnosis of hemorrhage is not always equally easy or certain. When the 
part into which the blood is directly poured communicates with the exterior of 
the body, the expulsion of some of that fluid will, generally, sooner or later, de- 
monstrate the case to be one of hemorrhage. I say generally, because cases have 
been known to occur, in which patients, previously in a state of great weakness, 
have died outright, by syncope, from the mere extravasation of the blood, and 
before any of it made its way out of the body. The stomach and bowels have 
been found full of blood, when none had passed either by vomiting or by stool. 
And when the blood does make its appearance outwardly, it is sometimes not easy 
to determine whether it has come from a certain organ, or from the parts that lie 
between the same organ and the natural outlet by which it ultimately escapes. 
For instance, it is sometimes a matter of uncertainty whether the blood, in hema- 
turia, proceeds from the kidneys, or the bladder, or the urethra. 

The blood, itself, when it reaches the exterior, will generally be more fluid, 
and brighter, in proportion as it is effused in greater quantity, and nearer the sur- 
face : more in clots, and darker in colour, in proportion to the length of time that 
it has remained within the body after its escape from its proper vessels ; and this 
length of time may depend upon the smallness of the quantity of blood effused, 
and the consequent tolerance of the organs through which it may have passed ; 
or, upon the actual space traversed. Respecting the colour, however, of the 
effused blood, I shall have some curious explanations to offer you when I come 
to speak of hematemesis as a disease. It would be superfluous to enter upon 
them now. 

If the site of the hemorrhage does not communicate with the external air, we 
are without that certainty which results from the actual spectacle of the blood. 
But in such cases we are much assisted by local disturbances of function, spring- 
ing from the pressure upon, or the laceration or distension of, the suffering organ, 
or the parts contiguous to it. And we may derive good information from observing 
the indirect symptoms which declare themselves through the system at large ; 
many of which indirect symptoms are the same whether the blood reach the ex- 
terior or not. They principally vary according to the quantity of blood poured 
out, and to the rapidity of its effusion : and some difference will occur according 
to the age and strength of the patient. 

Some of these indirect symptoms have not always been imputed to their true 
cause. Paleness of the face, feebleness of the pulse, coldness of the extremities, 
and a tendency to syncope — symptoms which are apt to be connected with hemor- 
rhage — have sometimes been ascribed to the alarm and sense of danger which the 
sight of the blood is calculated to produce in the mind of the patient. This may, 
to a certain extent, be sometimes true : but the explanation cannot apply to those 
cases in which the hemorrhage is strictly confined to the interior of the body, yet 
in which the symptoms just alluded to are often strongly marked. They then 
depend — and probably in all cases they chiefly depend— upon the actual abstrac- 
tion of the blood from the circulation. 

The management of individual cases of hemorrhage must be mainly regulated 
by the particular circumstances under which they occur. The few observations 
that I have at present to make respecting their treatment cannot be otherwise than 
very general. 

But a preliminary question, of some importance, presents itself. Is it in all 
cases of hemorrhage proper, or safe, to attempt to stop the bleeding ? 

Without going into detail, it may, I think, be laid down as a rule, that what I 
have called habitual hemorrhages ought not to be interfered with, so long as they 
have no perceptible injurious influence upon the health, and so long as they pro» 
ceed (as they mostly do) from parts of which the structure is not likely to b@ 



170 



HEMORRHAGE. 



spoiled, nor the function impaired, by the repeated passages of the blood. The 
most common seat of these habitual hemorrhages I have stated to be the rectum ; 
to which the two conditions just mentioned are, fortunately, both of them appli- 
cable. Epistaxis supplies a less frequent example of the same kind. When they 
deviate from their usual channel, and are transferred (as it were) to some more 
important organ, it will generally be right, among other remedial measui^s, to 
endeavour to recall the original hemorrhage. It is very seldom that the metas- 
tasis takes place for the better — i. e., from a part where the bleeding is attended 
with danger, to one where it is comparatively harmless. 

However, when these habitual hemorrhages happen, as they often do, in ple- 
thoric persons ; and when they are urged and kept up, as they frequently are, by- 
intemperate and luxurious habits; we ought not to content ourselves with merely 
looking on. Hemorrhois often performs the office of a safety-valve in such 
persons ; and there are many who have what are called bleeding piles, and who 
would rather continue to have them, than to submit to any change in their mode 
of life, or to the employment of other means of evacuation. Certainly these are 
cases in which nothing should be done to stop the bleeding ; yet such patients 
ought to be told that the hemorrhoidal discharge is but a precarious, and often an 
inadequate relief of the plethora: that while the plethora is suffered to exist there 
is danger of a cessation of the piles, and of the supervention of serious or fatal 
affections of other parts, and especially of the head. Apoplexy, or cerebral he- 
morrhage, has frequently been known to follow hard upon the suspension of 
constitutional hemorrhois. The patient should be admonished also that the dis- 
charge of blood from the vessels of the rectum may become excessive ; that if it 
be aggravated by exercise, or in any other way, it may lead to inflammation about 
the anus, and to great inconvenience ; and that there are safe and tolerably sure 
methods of getting rid of the plethora (which is what chiefly constitutes the danger 
of such cases), if they will submit to the observance of them. It is in the inter- 
vals between the hemorrhages that the danger of which they are in some sort the 
token, may best be met. 

Again, it will seldom be proper to employ direct expedients for stanching the 
flow of blood, in the small class of active idiopathic hemorrhages ; unless the 
quantity lost is so great as to endanger the safety of the patient. Such hemor- 
rhages have commonly a tendency to cure themselves, by relieving the general 
plethora, or the local congestion, on which they depend. For these hemorrhages, 
which bear so strong an analogy to inflammation, the treatment of inflammation 
may often be requisite, as an indirect mode in which their amount may be mode- 
rated, and their recurrence obviated. 

With these exceptions, both direct and indirect measures are to be used, for 
arresting the effusion of blood as speedily as may be. 

To this end the patient is to be surrounded as much as possible with cool fresh 
air, and kept in a state of absolute quiet. All motion of the body, and emotion 
of the mind, all kinds of stimulating food and drink, every thing, in short, which 
has a tendency to hurry the circulation, should be diligently avoided ; and that 
position of the body should be chosen which is the least favourable to the afflux 
of blood towards the part affected. The horizontal posture will be proper in 
hemorrhage from the bowels, the uterus, or the urinary organs. In epistaxis, and 
in cerebral hemorrhage, the head should be raised. 

In two words, the antiphlogistic regimen should be strictly enjoined in all 
cases of hemorrhage sufficiently severe to require medical assistance. 

Of the actual remedies used for checking the further escape of the blood, one 
of the most important has already been alluded to— -I mean venesection. Herein 
we are guilty of homoeopathy; to prevent bleeding, we draw blood. After what 
was stated respecting the use of blood-letting in inflammation, I need not dwell 
upon the objects aimed at by this measure : they are, briefly, to abate the vigour 
and force of the heart's contraction, to lessen general plethora when it exists, to 
remove local congestion, and to divert the current of the blood from the suffering 



DROPSY. 



171 



organ. The method, and the amount, and the repetition of the blood-letting, must 
of course be regulated by the circumstances of each particular case. And the 
same objects may sometimes be effected by other modes of general depletion, 
especially by the use of purgative medicines. 

Another important remedy for inward bleedings is mercury. Whatever may 
be the modus operandi of that mineral, the fact is certain, that hemorrhage, which 
had resisted other modes of treatment, has, in very numerous instances, ceased at 
once upon the occurrence of a moderate degree of salivation. 

Next to blood-letting and mercury, astringents constitute the great resource 
against actually existing hemorrhage : and among these, cold is one of the chief. 
It may be placed in direct contact with the bleeding surface : as when ice is 
swallowed to restrain hematemesis ; or cold water injected into the rectum in 
excessive and exhausting hemorrhois ; or into the vagina, in flooding from the 
uterus. Or it may be applied to the surface of the body, as near as possible to 
the seat of the hemorrhage ; as to the nose and forehead in epistaxis ; to the 
chest in hemoptysis; to the epigastrium in hemorrhage from the stomach; to the 
lower part of the abdomen or to the perineum in hemorrhage from the intestines, 
uterus, or urinary organs. But the influence of cold in constringing the smaller 
vessels is not confined to the part with which it is in contact ; it will stop hemor- 
rhage by the sympathetic shrinking which it produces in distant parts. Epistaxis, 
for example, has often been arrested by the sudden apposition of cold water to 
the neck, back, or genital organs. The nursery remedy consists in slipping a 
cold key down the back between the clothes and the skin. 

Of the mischievous power even of cold in this way we have continual illustra- 
tion in the suppression of* the catamenia by cold and wet accidentally applied to 
the feet. 

There is a long catalogue of medicinal substances which are esteemed to pos- 
sess more or less of a specific virtue, when taken internally, in checking the flow 
of blood. Most of these are of an astringent nature, and some of them are emi- 
nently useful. The acetate of lead enjoys, in this country, a higher character, 
perhaps, than any other of these substances. 

Many vegetable matters, and some artificial compounds, frequently employed 
in internal hemorrhages, seem to owe their astringent and styptic properties to 
the gallic acid which enters into their composition. Such are the rhatany root, 
uva ursi, bistort, tormentil, the pomegranate, kino, catechu, the several prepara- 
tions of gall nuts, and the nostrum called RuspinVs styptic. 

The power of arresting internal hemorrhage has also been confidently ascribed, 
by different persons, to nitre given in large doses, to the mineral acids, to the 
muriated tincture of iron, to alum, to the oil of turpentine, to the secale cornutum 
or spurred rye, and to various other substances, a more particular account of the 
rules and indications for administering which, I may return to, when I have to 
speak of individual hemorrhages. 



LECTURE XVI. 

Dropsy : its General Pathology . Passive Dropsy ; Cardiac and Penal. Active, 
Jlcute, or Febrile Dropsy. Prognosis ; and General Principles of Treatment 
in Dropsies. 

There remains now only one subject, of the pathology of which it will be 
convenient and, I hope, instructive, to take a short general view, before we enter 
upon the consideration of special diseases. I proceed to speak of dropsies : by 
which I mean collections of serous liquid in one or more of the shut cavities of 
the body, or in the areolar tissue, or in both, independent of inflammation. 



172 



DROPSY. 



We have already considered serous effusion as occurring as an effect or event 
of inflammation. We are commonly able to say of this, that it has originated in 
inflammation ; either from its being mixed with some of the less equivocal products 
of that disease, such as coagulable lymph ; or from its having taken place while 
symptoms of inflammation existed. But there are numerous examples of serous 
accumulation, which cannot with any show of reason be regarded as events of 
inflammation. It is to these that I would apply the simple term dropsy. 

It has been said — and said with much truth — that dropsy is rather a symptom 
of disease, than a disease in itself. And it has been affirmed that it would be 
more philosophical and scientific to treat of the original malady upon which the 
effusion or accumulation depends ; to erase dropsy from the list of substantive 
diseases, and to place it in the catalogue of mere symptoms. 

But this, in my mind, is a very mistaken view of the matter. For, first, it is 
oftentimes uncertain, while the patient is yet alive, what or where the primary 
disease may be; and even after death we sometimes can discover no organic 
change that would satisfactorily account for the effusion. Practically speaking, 
in such cases the dropsy is the disease, and the sole object of our treatment. 

And, secondly, dropsy is, in fact, to a medical eye, in all cases, something 
more than an effect or symptom of disease. The imprisoned liquid is often a 
cause of various other symptoms ; embarrassing, by its pressure, important func- 
tions, and even extinguishing life. The removal of the dropsy (although its 
original cause, of which it was a symptom, may remain behind, untouched, to be 
again productive of effusion under circumstances favourable to its operation) — the 
removal of the dropsy will often restore a person to comparative comfort; or even 
to what, so far as his sensations, and powers, and belief are concerned, is, to him, 
for the time, a state of health. 

You see then, already, that in a dropsical person, whose dropsy depends upon 
organic disease, there are two sets of symptoms to be distinguished: viz., those 
which depend on the primary disease ; and those which depend on the collected 
fluid. The latter, often the most grievous, are often to be got rid of : the former, 
frequently permanent, are frequently also but little complained of or felt by the 
patient, except when effusion is the result. 

Some persons, I fancy, have regarded dropsy as a less attractive subject of 
investigation than it might be if it were less frequently, in its nature, incurable. 
But as far as the dropsy itself is concerned, the complaint often is curable ; and 
there are some forms of dropsy that are curable in a more absolute sense : that is, 
both the effusion, and that condition which was the physical cause of the effusion, 
are sometimes remediable. 

Besides, it is our business to cure when we can ; but whether we can cure or 
not, to relieve and palliate human suffering ; and this, under Providence, we are 
able to do, in many or most cases of dropsy, to a very considerable extent. 

Wherever there is a shut sac, or wherever there is loose and permeable areolar 
tissue, there we may have dropsy. 

Thus there may be dropsy of the ventricles of the brain, or of the meshes of 
the pia mater, leading to death by coma ; of the pleurae, of the areolar texture of 
the lungs, or of the submucous areolar tissue of the glottis, any of which may 
cause death by apnoea ; of the pericardium, producing death by syncope. I men- 
tion these instances in particular, to show that almost every mode of dying may 
result from dropsical effusion ; and to win your attention to a disorder so full of 
peril. 

When the cerebral ventricles are distended with water, we express the diseased 
condition by the term hydrocephalus. Wjien serous liquid collects in the pleurae, 
or in the pericardium, we say that the patient has hydrothorax, or hydropericar- 
dium. If the cavity of the peritoneum be the seat of the effusion, we call the 
complaint ascites. When the areolar tissue of a part becomes infiltered with 
serous fluid, the part is said to be cedematous ; and anasarca is the name given to 
the more or less general accumulation of serum into the areolar tissue throughout 



DROPSY. 



173 



the body, and especially to visible subcutaneous oedema of considerable extent. 
Finally, the term general dropsy signifies the combination of anasarca with dropsy 
of one or more of the large serous cavities. 

Other local dropsies indeed there are, but, as they belong entirely to surgery, I 
need not enumerate them. 

Now what reasonable account can be given of these remarkable conditions ? 
How is it that the hollows and interstices of the living body, or of parts of the 
body, become thus water-logged? 

To solve this question, we must carry in our minds some physiological recol- 
lections. 

The closed cavities, or the interstitial tissues, within which the fluid of dropsy 
is confined, are kept moist, during life and health, by a continual serous secretion 
from their surfaces : and they are kept merely moist, for the fluid thus constantly 
secreted is as constantly reabsorbed into the circulation. 

When these tissues or cavities, without having undergone inflammation, become 
filled and distended with the serous fluid which they habitually secrete, one of 
three things must have happened. Either tjie quantity of fluid exhaled has been 
augmented, the absorption remaining the same; or the absorption has been dimi- 
nished, the exhalation continuing the same ; or else the exhalation has been 
increased, while at the same time the absorption was either lessened or not pro- 
portionally increased. 

The last is a mixed case ; and we need only consider the two others. 

Now the balance between exhalation and absorption is often deranged, and 
dropsies do actually arise, in each and all of these ways. 

It will best suit my purpose to speak first of those dropsies which are occa- 
sioned by defective absorption, and which are usually called chronic or passive 
dropsies. 

The direct agency of the blood-vessels in the production, as well as in the 
removal of dropsy, although indicated by many common and obvious facts, has 
not been generally recognized till a comparatively recent period. Perhaps I 
should rather say that more importance used to be assigned, in these respects, to 
the agency of the lymphatic absorbents, than they are really entitled to. You 
will find that pathologists, even in modern times, speak of a want of tone, of 
deficient energy, in the absorbents, as a cause of dropsical accumulations; the 
superfluous fluid of the part is not adequately taken up (they say) by the enfeebled 
absorbents, meaning the absorbents strictly and anatomically so called. And this 
view of the matter, connecting dropsy always with debility as its cause, has led 
to a corresponding plan of treatment: the object aimed at being the stimulation of 
the absorbents to more energetic action. 

But to the doctrine that dropsy is a consequence of the deficient action of the 
absorbents, this obvious difficulty presents itself, — that absorption really goes on, 
and goes on, very actively, in dropsical patients: their adipose matter disappears, 
they become wretchedly thin. There is no complaint in which wasting and 
emaciation go to a greater extent than in dropsy. You will find also that per- 
sons labouring under anasarca are readily enough affected by mercury ; which 
must of course be absorbed before it can produce any of its specific effects. 

It must be confessed that our knowledge respecting the mechanism of absorp- 
tion is neither complete nor certain ; but there is good reason for supposing that 
the process is shared among the lacteals, the lymphatics, and the veins ; and it is 
probably distributed between these sets of vessels somewhat in this manner; — 
that the lacteals absorb the chyle from the surface of the alimentary canal, and 
convey into the blood the materials .of its renovation ; that the office of the lym- 
phatics is to take up and carry into the blood those old and effete portions of the 
solid constituents of the body, whichjrequire to be removed to make way for a 
fresh deposit; while the veins imbibe the serous fluid exhaled from the surfaces 
of serous membranes, and into the meshes of the areolar tissue, as well as poisons 
and other substances that are soluble and dissolved in that fluid. 



174 



DROPSY. 



If this be so, the difficulty just now mentioned vanishes. Of the two sets of 
absorbing vessels, the lymphatics and the veins, one set may continue to perform 
its functions, while the other fails to do so. This theory is quite consistent with 
the actual phenomena of dropsical disease; and whether it be altogether true or 
not, a part of it is certainly true ; that, namely, which assigns to the veins a large 
share in the whole process of absorption. The experiments of Magendie and of 
others are quite conclusive upon that point. 

It has also been fully established, that fluids may and do pass into or out of the 
veins, in the living body, not by any vital process, but by mere physical imbibi- 
tion and transudation, through the coats of those vessels ; that when the veins are 
distended to a certain degree with watery fluid, the entrance of more of the same 
fluid through their sides, is impeded or prevented ; that, when the distension is 
still greater, the aqueous part of the blood may even pass in the other direction 
out of the vessel; and that, on the other hand, when the veins are comparatively 
empty, the surrounding serous fluid passes readily into them, or, in common lan- 
guage, is absorbed. The venous absorption is explicable therefore upon the 
principles of endosmose and exosmose, as laid down by Dutrochet; or I would 
rather say, according to the more general and more simple laws of heterogeneous 
attraction, as explained by Professor Daniell. 

Imbibition, being a form of that attraction, belongs in various degrees to all the 
tissues of the body. Its rapidity — and even its direction in respect to the elastic 
coats of a vessel surrounded by fluid, and also carrying fluid of a certain consist- 
ence — will vary with the' varying distension of the vessel. When the vessel is 
moderately full, the exterior fluid passes uninterruptedly inwards, and is conveyed 
away by the internal current. When, on the other hand, the vessel is kept much 
distended by its contents, the contained fluid, or its thinner part, passes continu- 
ally outwards ; and there is an intermediate degree of distension, at which the 
pressure is just sufficient to prevent the transit of fluid in either direction. Ma- 
gendie found, accordingly, in a well-conducted and conclusive series of experi- 
ments, that by regulating the conditions of comparative emptiness or fullness of 
the circulating system, he could accelerate, or retard, or suspend altogether, the 
operation of a poison dissolved in the humours of the body. In other words, he 
could thus accelerate, retard, or prevent, the process of absorption or imbibition 
through the blood-vessels. 

Bearing these physiological truths in remembrance, we shall have no difficulty 
in showing that the chronic forms of dropsy are attributable partly, and chiefly, 
and in many instances entirely, to undue plenitude of the veins ; and that this 
venous repletion is produced, almost always, by some impediment to the free 
return of the blood towards the heart. 

When the areolar tissue of a limited part of the body becomes filled and dis- 
tended by serous liquid, we call the swelling oedema; but this is exactly the same, 
in its nature, as anasarca. Now oedema is often the consequence of some me- 
chanical obstruction to the venous circulation. We can produce it whenever 
we will. Our countryman Dr. Lower, 170 years ago, tied the jugular vein of a 
living dog. When a few hours had elapsed, he observed that all the parts be- 
yond the ligature, reckoning from the heart, were much swollen : and upon dis- 
secting the animal after death he found that the areolar tissues of the head and face 
were rilled, not with red blood, as he had expected it might be, but with clear and 
limpid serum. On another occasion he placed a ligature upon the vena cava, just 
above the diaphragm : death soon ensued, and a large quantity of water was dis- 
covered in the cavity of the peritoneum, " non aliter quam si ascite diu (canis) 
laborasset." 

These experiments were not instituted with any reference to the pathology of 
dropsy ; yet that Lower perceived their bearing upon that subject is plain from 
this sentence : " Quantum haec ad ascitis et anasarcae causas investigandas con- 
ducant, aliis judicandum relinquo." He even explains the extravasation of the 



PASSIVE DROPSY. 



175 



thinner or serous part of the blood as taking place by infiltration, " velut in filtro," 
through the pores of the vessels. 

Precisely similar phenomena succeed the compression or obliteration of a large 
vein in various parts of the body. In operating for popliteal aneurism, Mr. Tra- 
vers was obliged to tie the femoral vein ; the areolar tissue of the limb was speed- 
ily infiltrated with serous fluid. Long-abiding oedema of one foot and ankle has 
been cured at once by the reduction of a crural hernia, which had been pressing 
for the same length of time upon the femoral vessels. You have heard, most 
probably, of the disease called phlegmasia dolens ; a disease that is very common 
in women soon after childbirth, although it is not peculiar to them, nor to the 
female sex. The foot, leg, and thigh, become enormously cedematous. The 
essence of this disorder is inflammation of the femoral vein ; blocking up that 
vessel near the groin, and retarding or precluding the return of the venous blood 
from the limb. One arm often swells in the same way, and from a similar cause, 
in women who are afflicted with cancer of the breast. In pregnancy, the gravid 
uterus sometimes presses upon the iliac veins, and obstructs the current of blood 
within them: the consequence is, anasarca of the lower extremities, which dis- 
appears as soon as the pressure is removed by the delivery of the woman. The 
flow of blood through the vena portse is frequently hindered, by disease in the 
liver, or by other causes; and serous liquid accumulates in the peritoneum, con- 
stituting ascites. A French physician, M. Tonnelle, narrates several cases in 
which serosity was found in the cavity of the arachnoid, in conjunction with ob- 
literation of the venous sinuses of the dura mater. In all these instances we have 
retardation of the venous current, undue plenitude of the veins, and dropsy of the 
part from which they proceed. The natural exhalation goes on, and the exhaled 
fluid collects and stagnates because the channel through which it ought to be 
drained away is choked up. The larger the vein, and the nearer we approach the 
heart, the more extensive is the dropsical accumulation : and if we could plant an 
obstacle at the very termination of the venous stream, we should dam up the blood 
in the whole system of veins, and produce a general dropsy. 

Such an obstacle is frequently placed there by disease. The returning blood 
is checked at its entrance into the heart ; at the confluence of all the veins of the 
body, where they unite to empty themselves into the right chambers of that organ : 
and then anasarca of the universal areolar tissue comes on, and water collects in 
all or most of the great serous cavities. 

It is no part of my present purpose to inquire how such disease of the heart 
as is productive of dropsy, arises. Commonly we find the right auricle and ven- 
tricle enlarged in capacity, the opening between them unnaturally wide, and the 
tricuspid valve unequal to its office of closing that aperture. Such a morbid state 
of the right heart may be occasioned by any cause which impedes the flow of 
blood out of its cavities. The diseased condition of those cavities may be pri- 
mary ; but it is oftener, perhaps, consecutive to other disease. It may be produced 
by disease of the lungs, preventing the right ventricle from freely delivering its 
contents into the pulmonary blood-vessels. Or the retarding cause may be still 
more distant, in the left side of the heart, keeping the pulmonary blood-vessels 
unduly full, and thereby hindering indirectly the escape of the blood from the right 
ventricle. The dropsy may ultimately depend, therefore, upon some bar to the 
circulation, placed even at the mouth of the aorta. Obstacles situated anywhere 
in the circuit formed by the right heart, the lungs, and the left heart, have the 
effect of producing secondary changes in the parts behind them. But disease, 
thus propagated in a direction retrogade to the course of the blood, is propagated 
gradually, and sometimes very slowly. These are points of much interest, which 
we shall investigate together by and by. I allude to them now, that you may not 
be perplexed by a knowledge of the fact, that diseases of the heart often exist for 
a long while without inducing dropsy. It is with disease of the right side of 
the heart, whether primary or secondary, that passive dropsy is especially asso- 
ciated. 



176 



DROPSY. 



As if to furnish the experimentum cruets in respect to this doctrine, disease 
does sometimes, with a curious precision, dam up one only of the two great venous 
trunks, at the junction of which the right auricle is placed : and then the dropsy- 
is as curiously limited to that half of the body in which the tributary veins of the 
obstructed trunk originate. The first example of this which I ever saw was a most 
remarkable one. The patient was dropsical in his upper half only. His arms 
were so hugely anasarcous that he could not bring his elbows near his sides ; his 
neck and face were hideously bloated and exaggerated, and his eyes prominent 
and staring; while his lower limbs were of their natural size, and appeared pre- 
posterously small and out of proportion. The poor man looked as if the upper 
part of his body had been stuffed, for acting some ridiculous part upon the stage. 
The cause of this strange and distressful state was found to be the obliteration of 
the vena cava superior, close to the auricle. Its sides had been pressed together 
by a large aneurism of the aorta; and a portion of the vein was fairly sealed up. 
I have seen two similar cases since. 

Objections have, however, been taken to the accuracy of the conclusions drawn 
from such cases as I have related ; and it is fit that you should be aware of them. 
Thus it is stated that veins have been found obliterated, and yet there was no dropsy. 
Now to this objection it may be answered, in the first place, that it is not every 
vein, the obliteration of which would cause manifest oedema. It must be the prin- 
cipal venous trunk of the part concerned. When some of the secondary and smaller 
veins alone become impervious, the blood may reach, and return by, the primary 
branches, with sufficient readiness to relieve the turgid capillaries, and prevent any 
serous accumulation. 

But (it may be said) the principal vein itself has been found converted into a 
solid cord, and still there was no dropsy. Granted : but it does not follow that 
there never had been dropsy. You know that when a large artery is tied, the 
circulation is carried on in the corresponding limb, by means of collateral arterial 
branches: imperfectly, indeed, at first; but, at length, as the supplemental chan- 
nels become more numerous and free, the supply of blood to the limb is as copious 
as ever. It is precisely the same, mutatis mutandis, with the veins; only that 
the anastomosing venous tubes are not (perhaps) so readily developed as the arte- 
rial. Now I am not aware of any instance in which it has been shown that the 
principal vein was obliterated, and yet there neither was, nor had been, any oedema 
of the limb. The recorded cases have been met with in dissecting rooms, and 
the previous history of the subject has been unknown or unregistered. Mr. 
Kiernan has told me that he once examined the body of a woman who had ex- 
cited much curiosity among the medical men by whom she had been seen during 
life, on account of a remarkable and enormous dilatation of the superficial veins 
of the abdomen. She was not dropsical, and the cause of the huge varix was 
sought for with great interest after her death. The inferior cava was obliterated. 
Here the compensating result was obvious to the sight; the new channels had 
answered their purpose, and performed the functions of the original channel. 
The history of this case was incomplete: it was not ascertained whether the 
woman had always been free from dropsy. 

I hold this objection therefore to be invalid, until some authentic instance shall 
be brought forward of the obliteration of a large venous trunk, without a corre- 
sponding accumulation of serous fluid, either at the time when the observation is 
made, or at some previous time in the life of that individual. It is, besides, pos- 
sible enough, that the obstruction of a large vein may be effected gradually, by 
the slow encroachment, for instance, of a growing tumour; and the collateral cir- 
culation may begin to be enlarged with the first impediment in the vein, and may 
keep pace with and counterbalance that increasing impediment, till the closure of 
the vessel is complete; so that, from first to last, there may be no noticeable 
dropsy. 

Again, it is affirmed, and truly affirmed, that anasarca often occurs, without any 
obliteration of veins, and independent of any discoverable organic disease in the 



PASSIVE DROPSY. 



177 



heart or anywhere else. We see this every day, in weak chlorotic girls, with 
bloodless cheeks, and pale lips. Some of $bu saw a case of this kind which was 
lately under my care in the hospital ; besides the anasarca, the systolic sound of 
the heart was accompanied by a loud, unmistakeable bellows sound. This girl 
got quite well, and left the hospital without bellows sound, or any other trace of 
disease. There could not then have been an organic change : in fact there was 
not. Yet was there, virtually, a retardation of the venous circulation ; not by 
any mechanical obstacle opposed to its course, but in consequence of the debility 
of that hollow muscle, the office of which is to propel onwards, with a certain 
degree of force, the blood that reaches it. Girls of this description have weak 
and flabby voluntary muscles; and it is reasonable to presume that the involuntary 
muscle, the heart, partakes of the general debility of the muscular system, and 
becomes incapable of sending the blood forwards with the requisite energy. Nay, 
I believe that a heart thus feeble may yield a little and dilate under the resisting 
pressure of the blood that enters its chambers ; and that so an occasional but tem- 
porary bellows sound may arise, from the altered relation between the cavities of 
the heart and their outlets. Certainly this view of the matter is strengthened by 
the juvantia and Icedentia. If you are tempted, by the pain complained of by 
your patient, or by the violence with which her heart is throbbing, to take away 
blood, you find that she is ultimately made worse by the depletion ; on the other 
hand, if you give her steel, feed her well, keep her bowels free, and place her 
every morning under a cold shower bath, you find that she recovers her lost 
strength, that colour returns to her lips and cheeks, that her palpitations cease, 
and her dropsy vanishes. In proportion as the muscular system in general re- 
ceives fresh tone and vigour, does that particular muscle, the heart, also regain the 
degree of power necessary for the effectual discharge of its proper function, which 
is very much that of a forcing-pump. Such is the way in which I should explain 
both the cause of the dropsy, and the cause of its cessation. In such cases our 
patients do not simply recover ; they are cured. I should apply a similar expla- 
nation to some other forms of dropsy. Andral describes a certain cachectic dispo- 
sition of the body as being a cause of dropsy ; persons may be bled into a dropsy, 
or starved or weakened into a dropsy. These are genuine instances of dropsy 
from debility, which is what the ancients conceived all dropsies to proceed from. 
It maybe that the thin and watery quality of the blood induced by frequent bleed- 
ings, by insufficient nourishment, by certain poisons, or by other causes, may 
facilitate its passage through the coats of the veins. But admitting this as a con- 
current cause, I am disposed to the belief that all passive dropsies occurring under 
the circumstances just adverted to, and without any apparent organic disease or 
change, are mainly to be ascribed to debility of the heart : and viewed in this 
way, they are all brought under the same general principle ; viz., the retardation 
of the blood in the veins. 

A large class, then, of passive dropsies, depending upon mechanical congestion, 
and defective absorption by the veins, are traceable, in their origin, to the heart ; 
and we call them, accordingly, cardiac dropsies. But another class, perhaps as 
numerous, are connected in a remarkable manner with certain diseased conditions 
of the kidneys; and these, for the sake of distinction, we style renal dropsies. 
I shall say a few words respecting them, after I have briefly considered the other 
source of dropsical swellings, adverted to in the commencement of this lecture : 
namely, excessive exhalation of serous liquid. Dropsy so caused comes on sud- 
denly and tumultuously, and is spoken of as being acute or active. It borders 
closely upon inflammation, and sometimes can scarcely be discriminated from 
inflammation with serous effusion. The condition of the capillary circulation is 
supposed to be intermediate between that in which the ordinary amount of secre- 
tion is maintained, and that in which inflammatory effusion takes place. The 
excessive increase of secretion is analogous to what we observe in other parts and 
predicaments of the body ; to the abundant perspirations, for example, that are 
12 



178 



DROPSY. 



occasioned by violent exercise ; to the plentiful flow of tears caused by any irrita- 
tion of the eye, or by the passion o&grief ; to the augmented watery discharges 
from the mucous membrane of the bowels produced by purgative medicines; all 
of which may be independent of inflammation, but all of which are attended with 
congestion that might readily be pushed into inflammation. In point of fact, if 
the secretions to which I have now referred were poured into close cavities, instead 
of proceeding from the surfaces that are situated on the exterior of the body, or 
that communicate readily with the exterior, they would constitute dropsies. 

The phenomena of active dropsy are of this kind : a labourer is engaged in 
some employment, which, while it requires considerable bodily exertion, and 
causes copious perspiration, necessarily exposes him also to the influence of exter- 
nal cold and moisture : he has been digging (perhaps) in a wet ditch, in winter 
time, and he pauses to take his meal ; or he has been unloading a waggon, and 
rides home, some miles, in a heavy rain that wets him to the skin ; or he has 
been mowing, in the heat of summer, and lies down to sleep upon the damp 
grass. All these suppositions are derived from actual occurrences. The perspi- 
ration is suddenly checked ; and in the course of a few hours he becomes univer- 
sally anasarcous. Again, a patient recovering from scarlet fever ventures out into 
a cold atmosphere, while the process of desquamation is yet going on ; and he is 
attacked with dropsy of the areolar tissue ; and, it may be, of some of the larger 
cavities also. The urine at the same time is observed to be scanty, troubled, 
mixed with blood. 

To comprehend this rapid change from a state of health to a state of dangerous 
disease, we must again have recourse to the findings of physiology. 

Besides the constant exhalation that takes place from the inner faces of the shut 
serous cavities, a large amount of watery fluid is continually thrown out of the 
system, by all those surfaces that communicate with the air — by the skin, the 
lungs, the bowels, the kidneys. Now it is well ascertained that when the excre- 
tion of aqueous fluid from one such surface is checked, the exhalation from some 
other surface becomes more copious. It is probable that the aggregate quantity 
of water thus expelled from the system in a given time, cannot vary much, in 
either direction, without deranging the whole economy. But we are sure that 
the amount furnished by any excreting surface may vary and oscillate within 
certain limits consistent with health, provided that the defect or excess be com- 
pensated by an increase or diminution of the ordinary expenditure of watery liquid 
through some other channel. Sound health admits and requires this shifting and 
counterpoise of work between the organs destined to remove aqueous fluid from 
the body. This supplemental or compensating relation is more conspicuous in 
regard to some parts than to others. The reciprocal but inverse accommodation of 
function that subsists between the skin and the kidneys affords the strongest and 
the most familiar example. In the warm weather of summer, when the perspira- 
tion is abundant, the urine is proportionally concentrated and scanty. On the 
other hand, during winter, when the cutaneous transpiration is checked by the 
agency of external cold, the flow of dilute water from the kidneys is strikingly 
augmented. All this is well known to be compatible with the maintenance of 
the most perfect health. But supposing the exhalation from one of these surfaces 
to be much diminished, or to cease, without a corresponding increase of function 
in the related organ, or in any excreting organ communicating with the exterior, 
then dropsy, in some form or degree, is very apt to arise. The aqueous liquid 
thus detained in the blood-vessels, seeks, and at length finds some unnatural and 
inward vent, and is poured forth into the areolar tissue, or into the cavities bounded 
by the serous membranes. 

Dropsy of one part sometimes supervenes suddenly upon the rapid disappear- 
ance of a watery collection from another part. It is no uncommon thing to see 
the swollen unwieldy legs and thighs of an anasarcous patient quickly unload 
themselves, and resume their natural bulk and symmetry. His friends congratu- 



ACTIVE DROPSY. 



179 



late him, and each other, that his disease is. leaving him ; but as his legs are 
emptying, he becomes drowsy, forgetful, comatose, apoplectic ; and after his 
death we find the ventricles of the brain distended with serous fluid. 

Or the dropsical accumulation may be transferred from its place through a safer 
channel. The best instance of this that occurs to my recollection I heard related 
by Dr. Farre. A gouty individual had hydrocele ; dropsy of the tunica vaginalis. 
After the disease had lasted for some time he got very drunk one evening; with 
rack punch, which greatly disordered his alimentary canal, and brought on a kind 
of cholera. He had profuse vomiting and purging, which quite exhausted him : 
and at length he fell asleep. When he awoke in the morning he found that his 
hydrocele, which had been a large one, was gone: and it never returned. Such 
an accidental cure is most instructive. 

If water be injected, in some quantity, into the blood-vessels of a living animal, 
the animal soon perishes ; dying generally by coma, or by suffocation : and when 
the carcass is examined, the lungs are found to be charged with serous liquid, or 
water is discovered in the areolar tissue of some other part, or in the shut serous 
membranes. If, however, the animal be first bled, and then a quantity of water 
be injected equal to the quantity of blood abstracted, the injection is followed by 
no serious consequences. \ 

Facts like these throw, as it seems to me, a strong light upon a confessedly 
obscure part of pathology. It appears that under various circumstances the blood- 
vessels may receive a considerable and unwonted accession of watery fluid ; and 
that they are very prone to get rid of the redundance. When they empty them- 
selves through' some free surface, their preternatural distension is relieved by a 
flux. If, on the other hand, the surface be that of a shut sac, in discharging their 
superfluity they cause a dropsy. Why sometimes this organ, and sometimes 
that, is selected as the channel by which the superabundant water shall be thrown 
out of the vessels, we can seldom tell. We often find it difficult to determine 
which of the two facts in question is to be considered the antecedent, and which 
the consequent. For not only is it true that when the blood-vessels become 
overloaded with serous fluid, they readily deposit a part of it : but also that when 
they are in the opposite condition of comparative emptiness, when they contain 
less blood than is natural, they are equally ready to replenish themselves by ab- 
sorbing fluids from any source to which they can find access. In the case of the 
man who was cured of his hydrocele upon the occurrence of profuse watery dis- 
charges from the stomach and bowels, it seems clear that the expenditure of serous 
liquid from one part led to its absorption into the blood from another. When 
anasarca suddenly leaves the extremities, and fatal coma follows, it appears proba- 
ble that the absorption is the first of the changes, and the effusion the second: 
and had this effusion been determined to the mucous membrane of the intestines, 
to the skin, or to the kidneys, it would have brought relief and safety to the 
patient, instead of causing his death. 

We have obtained, then, a glimpse of one or two most important principles in 
respect to the pathology of dropsy. The blood-vessels, when preternaturally 
full of aqueous fluid, have a strong tendency to empty themselves : when pre- 
ternaturally empty, they readily drink up watery fluid wherever they come in 
contact with it. From the discharge of their superfluity of water arises a 
dropsy, or a flux. The cause and the cure of many dropsies lie in these pro- 
positions. 

The application of these principles to the supposed case of active dropsy must 
be obvious. No doubt, in some such cases, actual inflammation takes place ; 
but in many of them there is merely the dropsical effusion, without any other 
trace or evidence of inflammatory action. The two facts which it chiefly con- 
cerns us to remark are these — first, that the aqueous portion of the blood which 
in health is habitually carried off to a very considerable amount by the skin, is 
suddenly diverted from that tissue ; the perspiration, sensible and insensible, is 



180 



DROPSY. 



suppressed: and secondly, that the areolar tissue, or the large serous bags, or 
both, become filled with serosity. 

It is not by any necessity, however, that the vicarious excretion is turned upon 
these serous surfaces. In truth, the intercepted perspiration more often escapes, 
or labours to escape, from some free surface ; and then we have, not a dropsy, but 
a flux. Diarrhosa, for example, is more common, under the supposed circum- 
stances, than anasarca or ascites : apparently because there is a closer analogy of 
structure, and a more direct consent or agreement in function, and a stronger 
reciprocal influence, between the skin and the mucous membrane of the alimentary 
canal, than between the skin and the serous tissues. 

Brief allusion has been made to a large class of chronic dropsies, connected with 
and dependent upon a peculiar renal disease. This important species of dropsy 
will require a detailed examination hereafter. It is more complex, and of more 
obscure pathology, perhaps, than cardiac dropsy. It certainly has a more direct 
relation also to what I have just been describing as active dropsy : of which it 
may almost be regarded as the chronic form. Sometimes the kidney disease, of 
which the dropsy is an incidental and not an essential symptom, springs up 
silently, and without obvious cause. Sometimes it may distinctly be traced back 
to its origin in an attack of acute dropsy : in which complaint the kidney always 
and manifestly labours, its functions being violently deranged, and the urine being 
small in quantity, and mixed with blood. 

In this chronic and renal dropsy, the watery accumulation is accounted for by 
the deficient excretion through the customary channels. The blood-vessels deposit 
that excretion in a wrong place. The urine, in the outset of the dropsy at least, 
is scanty. The skin is almost always dry, harsh, and unperspiring. The ana- 
sarca usually increases or decreases, as the quantity of urine diminishes or aug- 
ments. Remarkable alterations take place also in the qualities and composition 
of the urine itself : it has a very low specific gravity, contains albumen, and is 
deficient in urea. The blood degenerates too ; and other organs of the body, and 
especially the heart, are apt to fall into disease. The suppression of perspiration, 
and the appearance in the urine of blood or serum, unchanged by the secerning 
power of the kidney, form striking links of connection between acute and renal 
dropsy. 

In the sketch that I have been endeavouring to give you of the pathology of 
dropsy, I have taken extreme cases to elucidate the two varieties of that disease 
which have been respectively denominated active and passive. Let me once more 
present to you, in a summary view, the points of resemblance, and the points of 
distinction between them. 

They resemble each other in the result : namely, in the collection of serous 
liquid in the circumscribed cavities and vacuities of the body. They differ in the 
rate at which the collection augments. 

In the well-marked acute dropsies the liquid is rapidly effused, in quantity 
much beyond the natural amount of exhalation. In the well-marked passive 
dropsies the exhalation goes on as usual, but the fluid exhaled is not taken back 
again into the circulating vessels with sufficient facility. In the one case the cir- 
culation is disturbed and tumultuous ; in the other, it remains tranquil. It is 
probable that in the more acute forms, the serum transudes through the coats of 
the arteries, or of the capillary vessels next adjacent to the arteries. In the com- 
pletely chronic and cardiac forms, there is a defect of absorption by the veins. 
Active dropsies are sometimes spoken of as belonging to the left side of the heart ; 
passive dropsies to the right. 

But there are intermediate degrees, in which the full veins are not only unable 
to admit any addition of aqueous liquid, but also # to retain that which they already 
hold ; and serosity gradually exudes through their parietes. 

What connects all these forms of dropsy is a preternatural fullness in some part, 



DROPSY. 



181 



or the whole of the hydraulic machine. And this seems to be the grand key to 
the entire pathology, as well as to the remedial management of the disease. 

I scarcely need point out to you the fact, that the water of dropsy is liable to 
change its place, in obedience to the force of gravity. In general anasarca, when 
the serous accumulation slowly augments, it first becomes visible about the feet 
and ankles. There are two causes for this ; the one occasional in its operation, 
the other general. The veins of the lower extremities are apt, when the patient 
is erect, to be more turgid than other veins ; for unless the action of their valves 
be quite perfect, those vessels sustain the weight of a large superincumbent column 
of blood, which concurs with other causes to retard the upward current, and to 
keep the depending capillaries unduly full. Under such circumstances the effu- 
sion, or the arrest of absorption, may take place around the insteps earlier than in 
any other part. But in general it is not so. In most cases, the truer and simpler 
reason of the earlier manifestation of dropsical swelling about the ankles, is merely 
that the serous liquid which fails to be removed from the areolar tissue in all 
parts of the body, gravitates towards the lowest part ; and being thus collected 
into a comparatively small space, is rendered more perceptible. During the 
night, when the horizontal posture is maintained for several hours, the oedema of 
the ankles disappears, but the neck and face, perhaps, become bloated and puffy. 
And it is obvious why, in these cases, the feet towards evening, swell more than 
the hands. The hands receive the serous fluid from the areolar tissue of the 
arms alone; the feet, that which sinks down, not only from the legs and thighs, 
but from the head and trunk also. The limbs may be looked upon as bags, which 
fill up in proportion to the quantity of liquid detained. And the lungs are simi- 
larly bags : and in these cases we commonly may hear the crepitation of pulmo- 
nary oedema in their lowermost portions. 

I mentioned an instance in which one-half only of the body was anasarcous, 
and that the upper half. The descent of the dropsical fluid was prevented by the 
dress of the patient; the waistband of his trowsers having compressed the areolar 
tissue through which alone the gravitating liquid could seek a passage. So some- 
times, it is stopped at a lower point of its descent by tight garters, and the thighs 
swell earlier than the insteps. It is not at all uncommon to see persons who, in 
the daytime at least, and in the erect posture, are anasarcous in the lower half 
only of the body. We do not so often meet with anasarca of one moiety of the 
body, the division being made by an imaginary plane drawa through its axis. 
Yet this does occasionally happen. This curious phenomenon is usually the 
result of a mere accident, the anasarcous patient being unable to leave his bed, or 
to lie at all except on one side ; and then the accumulating liquid gravitates to that 
side. I have, however, seen one case to which this explanation would not apply. 
I believe that some local obstruction to a large vein in the neighbourhood of the 
shoulder caused oedema there, and the fluid sank down and filled the areolar tissue 
of that side alone. As the man recovered, I had no means of verifying the truth 
of this conjecture. 

Cxteris paribus those parts of the body become the most loaded with serous 
fluid, and show the anasarca the plainest, of which the areolar tissue is plentiful 
and loose ; as the eyelids, and the scrotum. But in extreme cases the liquid 
pervades the same tissue, where it is much more dense and compact: as where, 
for example, it is subjacent to mucous membranes. In the examination of a drop- 
sical corpse, the mucous coat of the intestines may sometimes be seen to be ele- 
vated by the water collected beneath it. It then looks like jelly, and the valvulse 
conniventes, which are flat and thin in their ordinary state, become round and 
convex. Dropsy of the submucous tissue of the air-passages is frequently a cause 
of death. 

Many persons seem disposed to ascribe these anasarcous swellings, especially 
when they make their appearance suddenly, to inflammation ; and much is said 
about the frequency of inflammatory dropsy. But the facts we have just been 



182 



DROPSY. 



considering sufficiently refute this theory. If the serous liquid be the product of 
inflammation, what is the,part inflamed ? It cannot be, as some appear to think, 
the distended areolar tissue itself; for if so, the inflammation must shift its quar- 
ters under the influence of gravity. The term inflammatory dropsy may not, 
perhaps, be indefensible when applied to that class of dropsical affections that 
have been spoken of under the head of active dropsy. I am far from denying 
the frequent agency of inflammation in producing changes which, in their turn, 
lead to dropsy, but we shall do well not to confound those collections of serum 
mixed with blood or with coagulable lymph, which are distinctly events or pro- 
ducts of inflammation, with other collections of serum which resemble the former, 
in that respect only, but differ entirely from them in every other particular. To 
the class denominated active, which occur suddenly, from defect of some one or 
more of the usual channels of aqueous excretion, and which are usually attended 
with much disturbance of the whole system, the epithet febrile would not be 
inappropriate. There may be some few cases in which it is impossible to deter- 
mine whether the effusion be inflammatory in its origin or not. If the serum be 
turbid, if we can discover in it the smallest admixture of pus, or of flakes of 
lymph, or if the disease has been marked by the ordinary signs of internal inflam- 
mation, we need not hesitate in our opinion. One of the latest systematic 
writers on dropsy in this country holds that all dropsies are more or less inflam- 
matory. We can see one reason for this mistake (for a mistake it surely is) in 
the relief and amendment which often ensue upon the employment of blood-letting 
in dropsy. 

The general prognosis in this disease may be readily gathered from what I have 
said of its causes and conditions. The anasarca which occurs in chlorotic young 
women is the least perilous, and the most curable. Of the rest, febrile dropsies 
are more obedient to treatment, and oftener admit of complete recovery, than the 
passive or chronic. Local dropsies are to be regarded with hope, in proportion as 
the obstruction on which they depend is capable of being removed, or compensated 
by the development of fresh channels for the delayed blood. As far as the mere 
water is concerned in the chronic forms of the disease, cardiac dropsies are more 
readily dispersed for a time, but more likely also to return, than dropsies which 
are complicated with renal disease. It is obvious also that the immediate danger 
of dropsical accumulations will depend much upon the place the liquid may occupy. 
The difference in this respect is immense between the tunica vaginalis, and the 
pericardium; between the areolar tissue of a limb, and that which lies beneath 
the mucous membrane of the glottis. 

It remains that I should offer a very few final remarks concerning the principles 
upon which dropsies are to be treated. 

The first object is to get rid of the preternatural accumulation of watery fluid: 
the second is to prevent its collecting again ; in other words, to remedy the dis- 
eased conditions which gave rise to the dropsy. Indeed, if we can accomplish 
this second object without delay, the dropsy will generally disappear of its own 
accord. Now venesection will often sensibly reduce the dropsical swelling. In 
what has been called active or febrile anasarca, general blood-letting is advan- 
tageous in several ways. It helps to relieve the congestion, akin to inflammation, 
upon which the effusion depends : it tends to abate the undue action of the heart: 
and by emptying the blood-vessels, it facilitates the re-absorption of the effused 
liquid, and its ultimate ejection from the system. 

But although blood-letting is the most direct and certain way of unburdening 
the loaded veins, and therefore, in many instances, the most effectual remedy for 
the dropsy, it is by no means adapted to all, nor even to manj^, forms of the 
malady. It will always, indeed, remove a portion of the aqueous ingredient of 
the blood, but it expends at the same time its fibrin and its red particles. It 
impoverishes the circulating fluid, and thus enfeebles the patient more than would 
the indirect measures, to be mentioned presently, for evacuating the collected 
liquid. Perhaps, by rendering the blood more watery, venesection may indi- 



TREATMENT. 



183 



rectly favour the transuding of its serum outwards whenever the venous current 
happens to be retarded. It certainly weakens the central organ of the circulation; 
and to muscular debility of the heart we have already seen that certain forms of 
general dropsy may owe their origin: and thus it is that ill-timed or excessive 
bleeding may be the cause of dropsy. In these forms of anasarca, instead of 
robbing the veins of their blood, we seek to repair the quality and richness of that 
fluid, and so to restore the deficient tone and vigour of all the muscles, and of 
the heart among the rest. 

In many cases, then, it is inexpedient to let blood ; and we endeavour to empty 
the vessels indirectly, and in such a manner as to withdraw from them the more 
watery parts only of their contents. In other words, it becomes our object to 
augment the discharge of watery fluid from one or more of the secreting surfaces 
of the body : but it must not be the inner surface of a shut sac. 

I noticed before the close analogy that obtains between dropsies and fluxes. 
Dropsy is a flux into a closed cavity. Fluxes would be dropsies if the fluid poured 
forth did not escape. And you are to observe that we frequently try to cure a 
dropsy by producing a flux. 

By what surface or channel this artificial' drain shall be attempted, is often a 
matter of great nicety and importance. In some cases we strive to promote the 
discharge of the superabundant water by the way of the kidneys: in others, by 
the mucous lining of the alimentary canal: in others, by the external skin. The 
circumstances by which our choice must be determined will come under review 
hereafter. 

Passive dropsies are much more difficult of cure than active, and will often 
baffle our best directed efforts. You are not, however, to regard those passive 
dropsies which depend upon the obliteration of a large vein as necessarily incura- 
ble ; for if a collateral venous circulation be accomplished, the dropsy will per- 
manently disappear. But we must give nature the credit of the cure in such 
cases. Time is the best remedy ; and all that we can sometimes do is to allevi- 
ate in the meanwhile the most distressing or threatening of the symptoms. 

I mentioned, in the outset of the lecture, that the presence of the dropsical fluid 
may constitute nearly all the suffering of the patient, as well as much of his dan- 
ger. Now, when we cannot get rid of the water by bleeding, or by internal reme- 
dies which excite serous discharges, we may often afford great present comfort to 
our patient, and prolong his days, by letting the water out by a slight mechanical 
operation. Paracentesis is the scientific, and lapping the vulgar name, for this 
proceeding. It has been performed successfully, by means of a small trocar, to 
evacuate the water from the brain in chronic hydrocephalus ; it is often resorted 
to for the purpose of emptying the peritoneal cavity, and the tunica vaginalis 
testis ; and it is not seldom practised to let out the fluid of anasarca ; for acupunc- 
ture of the legs and thighs and scrotum, is only another form of tapping. 

In the local variety of dropsy that is called hydrocele, the re-accumulation of 
the liquid is sometimes prevented by exciting just so much inflammation of the 
membrane as may cause its opposite surfaces to cohere ; whereby the cavity itself 
being abolished, any return of the disease is rendered impossible. 

This is an expedient which we do not dare to employ in other species of dropsy; 
in ascites, for example: first, because the inflammation itself would place the 
patient's existence in imminent peril ; and secondly, because if it could be safely 
conducted, the adhesion and obliteration would seriously embarrass and impede 
the functions of important organs. 

The circumstances which require and justify this mechanical remedy; the rules 
and precautions to be observed in its performance ; and the measures to be adopted 
for preventing the recurrence of the accumulation, by the removal of its efficient 
cause, will all be considered in detail when we come to treat of the special forms 
of dropsy. 



184 



DISEASES OF THE EYE. 



LECTURE XVII. 

Diseases of the Eye. Catarrhal Ophthalmia. Purulent Ophthalmia of Adults. 

Having brought my observations on general pathology to a close, I next pro- 
ceed to the consideration of individual diseases ; and I shall take them up, one by 
one, in that anatomical order to which I adverted in the introductory lecture of 
this course. That is to say, I shall go a capite ad calcem : interpolating those 
disorders which, although they have a name, have as yet no ascertained local 
habitation, wherever it may seem most convenient to introduce them. I men- 
tioned before one advantage, as it seems to me, of bringing together, in juxta- 
position, all the diseased conditions to which the same part, or the same neigh- 
bourhood, of the body is liable — namely, the facility thus afforded of comparing 
the phenomena by which they are characterized, and of discriminating one dis- 
order from another. In taking the parts in succession from the head downwards, 
we adopt a sort of order, definite enough for the purpose of aiding the memory, 
and yet free from the trammels which belong to all attempts at arranging diseases 
according to their essential nature and affinities. 

I propose then to speak, in the first place, of certain diseases of the organ of 
vision. Diseases of the eye occupy a sort of neutral ground, upon which the 
surgeon and the physician may both lawfully enter. For some of them there are 
no means of relief but in manual operations of the most delicate kind. On the 
other hand, many of the internal parts of the eye require, when diseased, exactly 
the same species of general treatment which the physician adopts in diseases of 
other internal parts. We seek to change the condition of a small portion of the 
body, by remedies which act upon and through the system at large. My real 
and only motive, however, for beginning with a few of the numerous morbid 
states to which this little part is liable, is this : — that we find, in the eye, more 
satisfactory and plain illustrations of the general facts and doctrines of pathology, 
as I have been endeavouring to set them before you, than in any other single 
organ of the body. "Here" (to use the words of Dr. Latham, in his little 
volume on Clinical Medicine — a book which I strongly recommend you to study) 
" here you see almost all diseases in miniature : and from the peculiar structure 
of the eye, you see them as through a glass ; and you learn many of the little 
wonderful details in the nature of morbid processes, which but for the observation 
of them in the eye would not have been known at all." 

" Within the small compass of the visual apparatus," says Mr. Lawrence, 
" we meet with a greater variety of structures than in any other part of the body. 
Indeed the eye, with its appendages, exhibits specimens of every one of the ani- 
mal tissues. We find in it bone, cellular and adipose substance, and blood-ves- 
sels ; mucous, fibrous, and serous membranes ; the conjunctiva exemplifying the 
first; the sclerotica, the sheath of the optic nerve, and the lining of the orbit, the 
second; the surfaces containing the aqueous humour, the third: muscular, ner- 
vous and glandular parts ; common integument and hairs. Besides these, it con- 
tains several tissues of peculiar nature, to which there is nothing strictly analogous 
in other parts." 

The eye itself, taking it apart from its appendages, the spheroidal eyeball 
itself, is scarcely an inch in its longest diameter. Yet it seldom happens that 
disease, of any kind, occupies the whole, even of this small space, at once. In- 
flammation, for example, is often confined to one of the tunics of the eye, external 
or internal; and when it affects more, it is usually in consequence of the exten- 
sion of the inflammatory process, from some one texture in which it took its 
rise. You will not expect me to treat of the vast number of disorders to which 
the several parts of the eye are liable. I shall bring, I repeat, a few of them only 



CATARRHAL OPHTHALMIA. 



185 



under your notice ; and I shall select those concerning which the physician is 
most frequently consulted ; which every one, whatever branch of the profession 
he may follow, ought to be competent to treat; and, more particularly, which 
are calculated to elucidate other diseases, and, above all, other internal diseases, 
that are usually assigned to the care of the physician. With the anatomy and 
physiology of the organ, I may take for granted that you are already acquainted. 

I will first briefly inquire into the inflammatory affections of what may be con- 
sidered the mucous membrane of the eye. Like other mucous membranes, it 
forms a surface communicating with the external air. Some of these affections 
are very trifling : some are very severe. 

There is a mild form of inflammation of the conjunctiva, which constitutes the 
most common disease of the eye to which adults are subject. It results, in most 
cases, from vicissitudes of temperature ; or from certain conditions, or sudden 
variations, of the atmosphere. It is very apt to be excited by exposure to a stream 
or draft of air, especially in the night, and during sleep. It has a strong analogy 
— indeed it is the same disease, except in situation — with that moderate degree 
of inflammation, produced by the action of the same causes, in the mucous mem- 
brane of the nasal cavities, the throat, and the bronchi, which in common parlance 
we style a cold in the head, or in the chest, as the case may be : and accordingly 
that inflammation of the conjunctiva of which I speak is often called by the un- 
learned, a cold in the eye : and the same analogy is expressed in its technical 
appellation: the cold in the head or chest is termed by nosologists a catarrh; and 
the cold in the eye of the vulgar, is with them, catarrhal ophthalmia. The sud- 
denness (sometimes) of its accession has procured for it also the denomination of 
a blight in the eye. 

The term ophthalmia is at present used to denote inflammation of the eye gene- 
rally; it conveniently expresses in one word what would otherwise require more. 
Formerly, when the diseases of the eye were not so well understood in this country 
as they are at present, almost all the inflammatory conditions to which that organ 
is subject were lumped together under the common appellation of ophthalmia, or 
the ophthalmia. That word now requires some epithet to distinguish the seat or 
the kind of inflammation that is meant. 

It can scarcely be otherwise than interesting to mark the phenomena which 
occur in catarrhal ophthalmia, when we know that in its cause and nature, it is 
the same with inflammation of a similar surface, in parts which we cannot so well 
inspect as we can the conjunctiva. This membrane, as you know, lines the eye- 
lids, and covers about a third part of the globe of the eye anteriorly. The inflam- 
mation, in catarrhal ophthalmia, is confined to the conjunctiva and the meibomian 
follicles. Its leading symptoms are redness of the surface of the eye ; some pain 
and uneasiness there ; an increased discharge from the affected membrane and 
the follicles : and a sticking together of the eyelashes and lids. 

The redness is worth notice, both in respect to its tint/and to the arrangement of 
the vessels in which it appears. It is superficial, and of a bright scarlet colour ; 
and usually irregular, or diffused in patches, some fasciculi of vessels being more 
distended than others. When, however, the inflammation is more intense, the 
whole surface, except that of the cornea, becomes of a scarlet red. The vessels 
of the conjunctiva, thus rendered visible by inflammation, anastomose continually 
with each other, and form a network, which can be slipped and dragged about 
over the subjacent surface by moving the eyelids with the finger. Frequently 
some of the meshes of this network are filled up with little patches of extrava- 
sated blood ; the eye is what is called blood-shot, or, to speak learnedly, there is 
ecchymosis ; and sometimes all distinction of separate vessels is nearly lost. In 
the commencement of the complaint the redness is confined to that part of the 
conjunctiva which lines the lids ; and it afterwards advances gradually, from the 
angle where it is reflected over the eyeball, towards the cornea. 

Now all these particulars are of consequence, since they are diagnostic of the 
seat of the disease; and to show this I must mention, by anticipation, the appear- 



186 



DISEASES OF THE EYE. 



ance and the arrangement of vessels that are observed when inflammation affects 
some of the textures which lie deeper than the conjunctiva, and especially the 
sclerotica. The sclerotic redness is seen through the conjunctiva. It is of quite 
a different tint from that of the conjunctiva. Instead of showing a bright scarlet 
colour, it is pink, or sometimes of a slight violet hue. The vessels are much 
smaller and finer than those belonging to the conjunctiva, like hairs. They are 
straight also, and arranged regularly, after the manner of radii in a circle. They 
lie in the sclerotic, round the cornea, like what is called by painters a glory, or 
like a halo, or zone surrounding the central cornea ; and they cannot be made to 
shift their place by any dragging of the lids. These are very important distinc- 
tions. They are such as are easily recognized when two eyes are examined in 
which the two membranes in question are separately inflamed and vascular ; and 
they are still more palpable perhaps when both membranes are simultaneously 
inflamed, as they often are, in the same eye. Then, unless the conjunctiva is so uni- 
versally red as to prevent our seeing the sclerotica through it, the contrast between 
the larger, more tortuous, scarlet, and reticular vessels of the conjunctiva, and the 
fine, straight, rose-coloured, radiating vessels of the sclerotic, is exceedingly 
striking; and those of the conjunctiva, which lie naked on the loose mucous mem- 
brane, admit of being slipped about over the fixed zone of vascularity which is 
presented by those of the fibrous tunic. 

The pain which attends catarrhal ophthalmia is slight and trifling. At the out- 
set there is generally some uneasiness when the eye is exposed to the light; but 
there is no intolerance of light when the disease is fairly developed. The patient 
complains rather of a sensation of stiffness and dryness, and feels as though there 
were some foreign substance in the eye, between the globe and the lids, especially 
when the eye is moved ; a grain of sand, or gravel, or a little fly. So exact is 
the resemblance of this feeling, that you can with difficulty persuade the patient 
that there is nothing of that sort in his eye. No doubt this sensation is produced 
by the inequality and roughness of the surface, consequent upon the irregular 
distension of the vessels of the inflamed membrane; irritating the organ mechani- 
cally, just as a piece of dust would irritate it. 

Now in this respect, again, there is a marked difference between conjunctivitis 
and sclerotitis. In the latter disease, the pain is much more severe, of a dull aching 
character, with a sense of tightness : the part inflamed is denser, and less yielding 
than the conjunctiva. The pain is attended also, frequently, by throbbing, and 
it is felt in the surrounding parts more severely perhaps than in the eye itself; in 
the brow, temples, and head. It is a very remarkable circumstance, too, that the 
pain is distinctly aggravated towards night; increasing in violence from the even- 
ing till after midnight, abating towards morning, and ceasing in a great measure 
during the day, to be again renewed in the evening. I am speaking now particu- 
larly of inflammation of the sclerotica produced by the same causes as give rise 
to catarrhal ophthalmia; of what is generally called rheumatic ophthalmia. 

The increased discharge that takes place from the eye in catarrhal ophthalmia 
is not a discharge of tears. In the beginning of the complaint there is sometimes 
a slight degree of lachrymation. But this soon ceases, and the mucous secretion 
from the surface of the membrane is augmented in quantity, and changed in 
quality. At first it is somewhat thin, but it soon becomes thicker, and it is often 
puriform ; i. e., opaque and yellow: sometimes it retains more exactly the cha- 
racters of mucus, is transparent and viscid ; so that the eye looks moist to a 
bystander, while to the patient it feels gummy. The puriform secretion is not, 
in general, in any great abundance. You may see it lying in the angle between 
the eye and the lower lid, by pulling them apart ; or it makes itself visible at the 
corner of the eye, or between the eye-lashes along the edges of the lids, which it 
glues together at night. Sometimes, however, the discharge is more copious, so 
as to approximate to what is observed in the less severe forms of another disease 
I shall presently mention; viz., purulent ophthalmia. 

There is seldom much swelling of the conjunctiva. If there be any, it results 



CATARRHAL OPHTHALMIA. 



187 



from an effusion of serous fluid into the meshes of the areolar tissue that connects 
the membrane with the subjacent sclerotica: by which effusion the conjunctiva 
is partially raised and separated. This kind of effusion often goes to a very great 
extent in purulent ophthalmia, or in violent inflammation of the external mem- 
branes, as I shall show you by and by. 

So much, then, for the symptoms and causes of catarrhal ophthalmia. It is 
necessary that you should be familiarly acquainted with them ; not so much 
because the complaint is very serious in its nature, but because it is common; 
because you are sure to be again and again consulted about it, and because it is of 
great importance to distinguish it from other forms of ophthalmia, in order to adopt 
the proper treatment. A. mistake of diagnosis might lead to mischievous activity 
on the one hand ; or to still more pernicious inertness on the other. 

When the inflammation does not extend beyond the mucous membrane, it will 
run a certain course, and then, under favourable circumstances, subside. But if 
it be improperly treated, or if the patient cannot guard himself against a repetition 
of its exciting causes, it may continue for weeks, and harass him a good deal, and 
even produce such a change in the inflamed lids as may prove a source of perma- 
nent irritation, and of chronic disease, of the cornea over which thSy sweep. 

Remedies of an active kind, such as influence the whole economy, are scarcely 
ever necessary. The patient should observe the main particulars of the antiphlo- 
gistic regimen, and avoid exposure to drafts or currents of air, and to cold and 
moisture generally. When the external weather is inclement, he should remain 
in rooms of a uniform temperature. It will be right to purge him in the outset 
with calomel and jalap, or with calomel followed by a black dose. 

If the system at large sympathize with the local disease, it may become neces- 
sary to take blood from the arm, or to apply leeches ; but neither of these mea- 
sures is requisite, except the inflammation is unusually severe, or the disease has 
been neglected or mismanaged. 

After the bowels have been thoroughly cleared by an active purgative or two, 
remedies which encourage moderate perspiration will be likely to forward the 
cure; such as warm diluent drinks ; five grains of Dover's powder, and immer- 
sion of the feet in warm water, at bed-time ; and saline draughts containing two 
or three drachms of the liquor ammonix acetatis, taken at intervals during the 
day. 

But in this complaint local measures are of greater importance than those which 
are addressed to the general system : stimulating or astringent applications to the 
affected membrane itself. Almost all modern writers on diseases of the eye agree 
in this. Dr. Mackenzie, of Glasgow, states it as the result of his observations on 
Beer's practice in Vienna, and of his own subsequent experience, upon an exten- 
sive scale, at the Glasgow Eye Infirmary, that " general remedies in this disease 
are inferior to local ones ; that violent general remedies are worse than useless ; 
and that a local stimulant treatment may almost entirely be relied on." Mr. 
Melin, in a report of ocular diseases at the General Hospital, Fort Pitt, states that 
he had treated nearly 300 cases, some of them severe, upon the same principle, 
without either local or general bleeding : and that he had satisfied himself of the 
efficacy of this plan of management. And Mr. Lawrence, who for ten years was 
one of the surgeons to the Ophthalmic Infirmary, in Moorfields, and who during 
that period had ample opportunities of studying this disease of the eye as well as 
others, says that it is one to which the use of powerful astringents is more par- 
ticularly applicable. In disorders which manifest a strong natural tendency to 
terminate in recovery, it is only by taking advantage of the conclusions derived 
from extensive observation that we can be quite sure of our ground ; and when 
the same result is reached by different and independent observers, we may safely 
place confidence in their concurrent testimony. 

Dr. Mackenzie and Mr 'Melin both employ and recommend the same applica* 
tion, viz., a solution of the nitrate of silver in distilled water, in the proportion 
of four grains to the ounce. A large drop of this solution is to be applied to the 



188 



DISEASES OF THE EYE. 



membrane once or twice, or three times, in the course of the day. If the patient 
recline his head backwards, and the drop be placed in the hollow formed at the 
internal angle of the eye, it will be diffused over the globe upon the separation 
and subsequent winking of the lids. After a minute or two this causes a pricking 
or smarting sensation, which subsides in from ten to twenty minutes, and the eye 
then feels much easier than it did before the drop was applied. Dr. Mackenzie 
says that the feeling as if of sand in the eye, is uniformly relieved, and the inflam- 
mation abated, by the use of this solution, which he speaks of as a remedy of 
sovereign utility in the puro-mucous inflammations of the conjunctiva. The eye 
continues easy, after its application, for five or six hours perhaps ; and when the 
symptoms return, they are again to be met by the introduction of another drop. 
As the disease subsides the remedy gives less and less pain, till at last it is scarcely 
felt. He tells us that " he has sometimes alarmed other practitioners by proposing 
to drop upon the surface of an eye highly vascular, affected with a feeling as if 
broken pieces of glass were rolling under the eyelids, and evidently secreting puri- 
form matter, a solution of lunar caustic; and that he has been not a little pleased 
and amused at their surprise when, next day, they have found all the symptoms 
much abated by the use of this application." He declares, also, that the acetate 
of lead, and the sulphate of zinc, substances which are much used in what are 
called collyria or eye-washes, are greatly inferior, as local applications, to the nitrate 
of silver, in this disease. 

There is another expedient that requires to be attended to in these cases. When 
the eyelids are gummed together by the viscid discharge, much hurtful irritation 
is often produced by the hasty attempts which the patient makes to separate them. 
Now all this may be obviated by smearing their tarsal edges at bed-time with any 
mild ointment; the spermaceti ointment, or a bit of lard. There is no necessity, 
as I believe, in this form of disease, to use medicated or stimulating salves : the 
object is to prevent the mutual adhesion of the lids ; and this is accompanied by 
simple grease. 

Purulent ophthalmia is another disease of the conjunctiva; differing from 
catarrhal ophthalmia in degree, in the severity of its symptoms, in the danger 
which it implies to the sense of vision, and in its exciting causes. It takes its 
name from the profuse discharge of pus, or of altered mucus which cannot be 
distinguished from pus, that pours from the inflamed surface. There are three 
remarkable varieties of purulent ophthalmia, called respectively — 1, purulent 
ophthalmia of adults, or Egyptian ophthalmia, or contagious ophthalmia; 2, go- 
norrhoeal ophthalmia; and 3, purulent ophthalmia of newly-born children. 

The symptoms of the two first-mentioned varieties, especially in their severer 
forms, are so much the same that it would involve us in mere repetition if I did not 
take them together. In truth it appears to me much the simpler and better mode to 
look upon purulent ophthalmia as one disease ; and then to specify, as we go on, 
the differences by which its several forms are characterized : and not to split it 
into three different diseases, and to give a separate description of each. 

Although purulent ophthalmia is inflammation of the very same part that is 
inflamed in catarrhal ophthalmia, from which it differs chiefly in degree, it is a 
hideous complaint, either to suffer or to treat: on account of the rapid progress it 
frequently makes, and its destructive tendency. The inflammation is greatly 
more intense; the surface becomes, in the worst cases, highly vascular through- 
out. A copious discharge of thick, yellow, puriform matter is speedily established ; 
this flows out from between the swollen lids, and runs over the cheek which it 
often excoriates. At the same time considerable effusion takes place into the 
areolar tissue that connects the sclerotica and the conjunctiva. You are aware 
that the conjunctiva extends over the whole anterior face of the globe; adhering, 
however, so much more closely to the cornea than to the sclerotica, that we might 
doubt at first whether it did not stop at its margin. This close and firm adhesion 
over the cornea, and the looser attachment to the sclerotica, give rise to a very 



PURULENT OPHTHALMIA. 



189 



singular phenomenon. The conjunctiva is raised to some distance from the sub- 
jacent sclerotica by the effusion that takes place between them ; and it projects 
around the cornea in the shape of a large thick ring, leaving the cornea buried, as 
it were, in a pit ; nay, sometimes, the swollen and prominent membrane will lap 
over, so as nearly to exclude the cornea from our sight. The same kind of effusion 
takes place, also, sometimes very rapidly, into the areolar tissue connecting the 
conjunctiva with the palpebral, producing great external tumefaction, and a livid 
red appearance of the eyelids, which project forwards in large convex masses, 
and often prevent our seeing the globe of the eye at all ; the upper lid especially 
becoming hard and stiff, and completely overhanging the lower. This swelling 
from effusion into the subconjunctival tissue is of a pale red, fleshy colour, some- 
times marked here and there with patches of extravasated blood. The appearance 
is called chemosis : not ecchymosis, as the similarity of the sound has led some 
erroneously to suppose, but chemosis. Ex^u/iwcrts, from ex^sa, signifies an effu- 
sion, and by common consent among medical writers, an effusion of blood. Xj^ssaes* 
the root of which is xw a ^ matus > means a gap or hollow. 

Now this puriform or purulent inflammation, so long as it is confined to that 
part of the membrane which lines the eyelid, is not of any serious importance ; 
but it is prone to extend itself to the cornea, and the whole anterior surface of the 
eye, and to produce ulceration or sloughing of the cornea, either in consequence 
of the actual inflammation of that part, or in consequence of the pressure made 
upon and around it by the swelling of chemosis. Frequently, when the cornea 
remains visible, a furrow or trench of ulceration may be seen at its margin ; 
sometimes forming a complete circle, sometimes portions of a circle, sometimes 
going quite through ; and when this happens, or when the cornea bursts, from 
the effects of deeper-seated inflammation, the aqueous humour is evacuated, and 
the iris protrudes through the aperture. Even when these horrible consequences 
do not take place, the eye is often as effectually spoiled for the purposes of vision 
by an interstitial deposit between the laminae of the cornea, rendering it opaque, 
and permanently precluding the passage of light towards the retina. 

And when neither of these lamentable effects of the inflammation is produced, 
it is apt to leave behind it a chronic and very troublesome condition of the mem- 
brane. The conjunctiva that lines the lids remains thickened, granular, hard, and 
rough, instead of regaining its natural smoothness, softness, and polish. One 
consequence of this is a perpetual irritation of the surface of the cornea, by the 
mechanical friction of the rough and hard lid in opening and closing the eye, and 
in the various motions of the eyeball. The continuance of this irritation leads at 
length to haziness or opacity of the cornea, which becomes traversed also by 
visible red vessels. Chronic inflammation of its investing membrane is produced, 
and kept up. 

The most severe forms of this disease are attended, at length, with a good deal 
of pain ; doubtless because the inflammation penetrates to the deeper-seated tex- 
tures of the organ. The pain then presents those characters which I mentioned 
before as belonging to certain inflammations of the sclerotica: z, e., it is pulsative; 
and sometimes sharp and lancinating, sometimes dull and aching ; and it is inter- 
mittent, or if constant, it is aggravated by paroxysms : the paroxysms coming on 
at night, and abating towards morning : and it is not confined to the eye itself, 
but extends to the parts around it. This circumorbital pain is characteristic of 
inflammation of the sclerotica and cornea, and of the internal tunics, the choroid 
and iris. When the eye is not visible, from the swelling, we may conclude that 
the inflammation is as yet confined to the conjunctiva, if the pain be only scald- 
ing or " sandy ;" and that it has extended to the sclerotica and cornea if the pain 
be severe, throbbing, and paroxysmal. In the cases in which the latter kind of 
pain is felt, the cornea generally gives way. Sometimes this event brings relief 
to the pain, and sometimes the pain continues to return after the bursting of the 
cornea. It is curious that with all this, there is seldom much intolerance of light. 

In the earlier stages of this malady, it is entirely local : the system at large is 



190 



DISEASES OF THE EYE. 



scarcely disturbed at all. But the constitution begins to sympathize and suffer 
when the local symptoms increase in severity : the pulse becomes frequent, and 
the tongue white", but there is seldom much thirst or fever ; and when blood is 
drawn from a vein, it does not, in general, exhibit the buffy coat. A good deal 
of variety in these respects has been noticed, however, in different cases. Children 
manifest more constitutional disturbance when labouring under purulent ophthal- 
mia than "adults. If there be not much fever, there is always much uneasiness 
and irritation, and the sleep is broken by the nocturnal accessions of pain. 

Such being the general features and course of the disease, at least as it occurs 
in adults, or in patients beyond the period of infancy, we may next inquire into 
the circumstances under which it has been observed to arise. 

Purulent ophthalmia has been ascertained to be a common disease in hot 
climates : in India, Persia, and Egypt. It was brought into England, from the 
latter country, by our troops in the beginning of the present century, after the 
well-known contest which there took place between the French army and our 
own under Sir Ralph Abercromby. In this way it got the name of the Egyptian 
ophthalmia. It naturally excited very great attention at that time, and it does not 
appear to have been accurately described before. 

To give you some notion of its prevalence in certain places and at certain 
periods, and of its serious nature, I may state that, according to returns made from 
the military hospitals at Chelsea and Kilmainham, there were, on the 1st of 
December, 1810, no fewer than 2317 soldiers a burden upon the public from 
blindness in consequence of ophthalmia ; and in this number those soldiers who 
had lost the sight of one eye only were not included. 

Again, in the year 1804, within nine months, i. e.', from April to December, 
nearly 400 cases of purulent ophthalmia occurred at the Royal Military Asylum; 
and within six years from that time, without including relapses, upwards of 900 
cases had taken place in the same establishment. 

You will find these statements in a paper in the third volume of the Transac- 
tions of a Society for the improvement of Medical and Chirurgical Knowledge, 
by the late Sir Patrick Macgregor. Many of our best regiments were for a time 
crippled and rendered unfit for service by this disease ; which they carried from 
Egypt to other foreign stations as well as to this country, especially to Sicily, 
Malta, and Gibraltar. Nor were the French troops less extensively affected by 
it. Assalini, who wrote an account of the ophthalmia of Egypt, states that two- 
thirds of the French army were labouring under it at one time. It occurs also, 
but fortunately not to such an extent, in civil life. It broke out, some years ago, 
in a large boys' school in Yorkshire ; and blindness of one or both eyes, or serious 
injury to sight, from opacity of the cornea, and other consequences, took place in 
nearly twenty cases. 

You perceive, therefore, that this formidable complaint has been ascertained, 
within the last forty years, to have prevailed as an epidemic ; attacking great 
numbers of persons living under the same circumstances, and having constant 
communication with each other. And one of the first questions that naturally 
arises in one's mind is, whether it is capable of being propagated from one person 
to another by contagion. Much difference of opinion has existed on this sub- 
ject. For my own part I cannot imagine how any one can doubt its contagious 
properties. 

I will give you a case or two, as related by Sir Patrick Macgregor, proving two 
very important facts; first, that the disease is capable of being excited in the eye 
of a person, previously healthy, by the direct application of the puriform discharge 
from an eye affected with this ophthalmia; and secondly, the very rapid operation 
of the poison so applied. 

One of the nurses employed at the Military Asylum, while syringing the eye 
of a boy who had much purulent discharge, found that a considerable quantity of 
the matter had spurted into her own right eye. This was at four o'clock in the 
afternoon. She felt little or no smarting at the time ; but towards nine o'clock 



PURULENT OPHTHALMIA. 



191 



the same evening her right eye became red and somewhat painful, and when she 
awoke the next morning, the eyelids were swelled, there was purulent discharge, 
and she complained of pain in the eyeball. The usual remedies were begun in 
the morning, and she recovered in the space of three weeks or a month. The 
left eye, into which none of the matter had gone, remained free from disease. 

On another occasion a precisely similar mischance befell another of the nurses, 
except that the matter spurted into her left eye, about nine in the morning. Sir 
P. Macgregor happened to be in the hospital at the time when the accident 
occurred. He desired the nurse to bathe her eye immediately with lukewarm 
water, and she did so for several minutes ; but notwithstanding this early precau- 
tion, about seven o'clock in the evening the left eye began to itch to such a degree 
that she could not refrain from rubbing it. When she awoke next morning the 
eye was considerably inflamed, the lids were swelled, and upon moving the eye- 
ball she had a sensation as if some sand were lodged beneath them. In the course 
of the same day purulent fluid issued from the eye, and other symptoms followed, 
which were similar to those of the children under her care. The disease subsided, 
under the usual treatment, in fourteen days. In this case also the other eye 
remained sound. 

A third nurse in the same institution did not come off so well. She was 
sponging, with warm water, the eyes of a boy suffering severely from purulent 
ophthalmia: and she inadvertently applied the sponge she was using to her right 
eye. This happened at eight o'clock in the morning. She mentioned the cir- 
cumstance to the other nurses, but she took no means to prevent infection. Be- 
tween three and four o'clock of the afternoon of the same day, itching of the right 
eye came on ; and before she went to bed it was considerably inflamed. Next 
morning her eyelids were swollen, she complained of pain in moving them, the 
whole anterior surface of the eyeball was in a state of high inflammation, and a 
purulent discharge began to trickle down the cheek from the inner canthus. The 
symptoms increased in severity in spite of all the means employed to check them, 
and on the fourth day the eyeball burst. The sight of the eye was irrecoverably 
lost, and the inflammation continued for upwards of three months. The left eye 
did not suffer. 

These were cases in which the poisonous matter was accidentally applied. 
But a similar application has been made intentionally and by the way of experi- 
ment, and with the same results. Dr. Guillie, of Paris, introduced the puriform 
secretion furnished by some children affected with purulent ophthalmia, under the 
eyelids of four other children belonging to a separate institution for the blind. 
These four children were amaurotic, but the external surface of their eyes was 
healthy and entire. In each instance a regular attack of purulent ophthalmia 
followed the introduction of the matter. 

Facts of this kind prove, I say, beyond the possibility of question, that the 
disease may be propagated from a diseased to a healthy eye by actual contact of 
the puriform matter. Here we have not one case (which might be considered as 
an accidental coincidence), but several: the morbid secretion is applied to one eye 
only; the symptoms of inflammation commence, and the regular form of the 
disease is fully developed within a few hours after the first application of the 
pus ; and that eye only is affected. It is impossible to get over evidence of this 
kind. 

The only questions, therefore, that can be raised respecting the sources of the 
disease are these : — whether the malady can be communicated through the medium 
of an atmosphere impregnated with the effluvia that proceed from the diseased 
part, without any actual contact of the pus in substance? — whether the disorder 
is ever produced in any other way than by contagion ? — and if so, how it is then 
excited? 

I ought to observe, that independently of such isolated examples of the direct 
communication of the complaint, by contact with the diseased matter, as I have 
just laid before you, the history and progress of ophthalmia, since it has been 



192 



DISEASES OF THE EYE. 



noticed in Europe, are very strongly indicative of its contagious nature. I have 
already stated that it was not known in Europe till the commencement of the 
present century — till after the Egyptian campaign in fact. It is not alluded to by 
any of the authors on disorders of the eye who wrote previously to that period ; 
although some of the Italian physicians and surgeons, and many of the Germans, 
had paid great attention to ophthalmic diseases. It spread from Egypt both to 
France and to this country, and to other places in which detachments of the 
Egyptian force were subsequently stationed : in Sicily to wit, and in Gibraltar 
and Malta. Whenever it has prevailed among our troops at home, this circum- 
stance has been uniformly observed: that it first broke out in soldiers who had 
come from Egypt, or had communicated with regiments which had been in Egypt. 
In all cases its origin could be traced to the introduction of fresh troops into the 
regiment or the barracks. 

Again, the manner in which it spreads is exceedingly instructive on this point. 
It diffuses itself rapidly, when once introduced, in places where a considerable 
number of persons are collected together; especially under circumstances favour- 
able to the propagation of contagious maladies ; as among soldiers assembled in 
barracks, where many of the men live in the same apartments, and use the same 
towels: while the officers, who live in larger and better ventilated rooms, and 
apart from each other, generally escape. And the good effect, in checking the 
further extension of the disease, of separating the healthy from the sick, and of 
restricting every one to his own washing utensils, and clothes, and towels and 
sponges, leads to the same conclusion. Rust, a German author, mentions this 
striking fact in corroboration of what I have just been saying. The disease broke 
out in the town of Mayence. This place was garrisoned by Prussian and Aus- 
trian troops. The ophthalmia began and spread extensively among the Prussian 
soldiery; while the Austrians, who were stationed in separate barracks from the 
Prussians, in another quarter of the town, remained quite free from it. 

Those persons who deny, or who doubt, the contagious nature of purulent 
ophthalmia, rest their opinions upon some such considerations as these. They 
hold, in the first place, that the peculiarities of the atmosphere, in Egypt, where 
the disease has been found so common, are sufficient in themselves to account for 
it. That the inhabitants of that country never dream of its being caused by con- 
tagion. Assalini, who saw the complaint raging in the French army, professes 
his belief tha f it did not arise or spread by contagion. He remarks that the atmo- 
spheric conditions which are known to occasion catarrhal affections, are very fre- 
quent and powerful in Egypt : the days are very hot, the nights chilly, and 
attended with heavy dews ; and men's eyes are perpetually exposed in the day 
time, to a dazzling glare of light from the white and arid surface, while the air is 
full of floating particles of hot sand, which are raised from the ground by the 
slightest breeze. His opinion, therefore, and the opinion of others who saw the 
disease as it prevailed in that country, was, that it consisted simply of acute 
catarrhal inflammation of the conjunctiva; and that it affected those persons most 
who were most exposed to the exciting causes of such inflammation : the com- 
mon soldiers, therefore, more frequently than the officers. 

Other circumstances adduced by the disbelievers or sceptics, in respect to con- 
tagion, are that many who have intercourse with the sick escape the disease ; and 
that when bodies of men, among whom purulent ophthalmia has been prevailing 
to a great extent, are broken up and dispersed, the complaint is not thereby dis- 
seminated, as they say it ought to be, supposing it to be communicable from one 
person to another; that, in fact, this dispersion, the disbanding of troops, for in- 
stance, and sending them to their friends and families all over the country, is the 
surest way of stopping the disorder. 

Again, many ineffectual attempts have been made to inoculate the eyes of ani- 
mals with the matter of purulent ophthalmia. Miiller, a German, with that pains- 
taking industry, for which the Germans are so remarkable, collected on a camel's 
hair pencil matter from the eyes of patients labouring under purulent ophthalmia, 



PURULENT OPHTHALMIA. 



193 



early in the morning, before they had washed them, and inserted it under both the 
lids of each eye, in a great number of animals, leaving the pencil there for a few- 
seconds, and then pressing it so as to squeeze the matter out. He also smeared 
the pus copiously and repeatedly along the edges of the lids. He served in this 
way five cats, ten dogs, two rabbits, two squirrels, two blackbirds, a starling, a 
yellow-hammer, and a cock. And in none of them did the inoculation produce 
the slightest effect. 

It is a sufficient answer to these negative experiments, however, that other per- 
sons were more successful in producing the disease in this manner. Vasani and 
Grafe have both excited it repeatedly in dogs and cats, by the application to their 
eyes of matter taken from human patients. And I have already informed you of 
many instances in which the disease was generated in men by accidental, and 
even by intentional inoculation. No amount of negative evidence can do away 
with positive testimony so often repeated. 

And with respect to the other objections, and especially the main objection, 
that persons may associate and hold close intercourse with individuals labouring 
under purulent ophthalmia without contracting the disease, I would have you 
remark that this is no more than what continually happens in regard to diseases 
which are acknowledged on all hands to be contagious, and to have no other source 
at present, however they might have originated at first, but contagion : the small- 
pox, for example. I think there is some reason for believing, from the facts which 
1 have been relating, that purulent ophthalmia, like the small-pox, is capable of 
being communicated from one person to another, not only by positive contact, but 
by transmission of the specific poison somehow for a short distance through the 
air. But many persons exposed to the contagion of small-pox escape it alto- 
gether : and more persons still, perhaps, fail to be affected, though fully exposed, 
at one time, and yet readily accept the disease at another time, even when the 
exposure may seem much more slight than on previous occasions. Now what 
is true of the small-pox may be presumed to be likely, although, perhaps, in a 
different degree, of purulent ophthalmia. 

As to the circumstance that the disbanding of a regiment infected with the dis- 
ease prevents instead of favouring its dissemination, that circumstance is really no 
argument at all against our belief in its contagious nature. We shall see here- 
after, that when fever patients are collected in numbers in distinct wards, or in 
fever hospitals, that, disease is very apt to be communicated to the nurses and 
medical attendants of the sick; whereas, when such patients are distributed here 
and there among others, in a general hospital, the disease is scarcely ever known 
to spread. In the one case the poison is concentrated and effective, in the other it 
is diluted and harmless. 

Dr. Mackenzie, indeed, has come to the conclusion, from what he has himself 
observed, that the discharge in catarrhal ophthalmia, especially when it is dis- 
tinctly puriform, if conveyed from the eyes of the patient to those of others by 
the fingers, or by towels, and so forth, is capable of exciting inflammation of the 
conjunctiva, still more severe, more distinctly puriform, and more dangerous, than 
was the original ophthalmia. And with respect to the disease which I have been 
speaking of as purulent ophthalmia, or Egyptian ophthalmia, the author calls it 
contagious ophthalmia ; he holds that the inflammation of the conjunctiva, whether 
in the mild or the more severe form, may and often does originate from common 
atmospheric influences ; but that, when so caused, it may be communicated from 
person to person, especially when it is attended with a puriform discharge. 

And this is an opinion which, I think, is fully warranted by the facts which 
we are in possession of upon this subject. There is a strange reluctance, which 
I have never been able to account for, in some medical men, to admit of the opera- 
tion of contagion, as a cause of disease. Undoubtedly there are some difficulties 
belonging to the doctrine of contagion, and I hope in the progress of the course, 
and especially when I come to speak of fever, to give that subject the careful 
attention which its great importance demands ; and to enable you to make up your 



194 



DISEASES OF THE EYE. 



minds respecting it. At present I will only remark, that there is nothing absurd, 
nor unlikely in the supposition, that diseases may first arise from some other 
source, and then become capable of spreading by contagion; and that in all cases, 
even when the contagions principle is most manifest, there seems to be something 
else required besides the presence of contagious matter; there must be a readiness 
to receive it, a susceptibility of its influence, on the part of the person exposed to 
it : a predisposition which is less common in regard to some diseases than to 
others ; but without which there is scarcely any complaint that can be so propa- 
gated. 

At any rate I would desire to impress upon you the expedience and propriety 
of acting, whatever your doubts or your belief may be, upon the safe side. We 
are bound to proceed, in all questionable cases of this kind, upon the most 
unfavourable supposition. Very great discredit and loss of reputation have fallen 
upon practitioners who, having themselves no belief that a given complaint was 
contagious, have neglected those precautions which, under a contrary impression, 
they would have thought necessary. Perhaps they may have sometimes suffered 
unjustly: but you had better not commit yourselves, especially while you are 
young in years and in experience, by strong assertions of the non-contagiousness 
of any disease, the mode of propagation of which is at all questionable. And as 
for the disease fhat we are now concerned with, you will do well to act as though 
it were certainly contagious ; whether you meet with it as a sporadic or as an 
epidemic complaint: whether it be severe in its symptoms, or mild. You should 
forbid the use of your patient's towels and washing vessels by other members of 
the family ; you should avoid employing the same instruments or sponges to any 
sound eye, which you have been using for one that is affected with this complaint; 
and you should take care to wash your own hands, after touching a diseased 
eye, before you apply your fingers to another that is yet, in this respect, healthy. 



LECTURE XVIII. 

Purulent Ophthalmia, continued. Gonorrheal Ophthalmia. Purulent Oph- 
thalmia of Infants. Strumous Ophthalmia. 

When we last met, I spoke of catarrhal ophthalmia, i. e., a mild and common 
form of inflammation of the conjunctiva, resulting from atmospheric influences. I 
described its characteristic symptoms, and explained the treatment that has been 
found most successful for its cure ; consisting chiefly in local stimulating or astrin- 
gent applications. 

I began also to speak of the severer forms of inflammation affecting the same 
part, and included under the head of purulent ophthalmia. The symptoms and 
course and consequences of the two varieties of this complaint, as it occurs in 
adults, are so essentially the same, that one description of its phenomena is 
enough. There are certain differences, however, that require to be noticed, in 
respect to its exciting causes. I laid before you the reasons which satisfy me, 
that what is called the Egyptian ophthalmia is a contagious disease : and which 
make it probable that the complaint is capable of being propagated from person to 
person, through the medium of the air, without the necessity for any substantial 
application of the morbid secretion from a diseased to a sound eye. These 
reasons, briefly stated, are as follows : that the disease was unknown in Europe 
till after the war in Egypt ; that, arising among our own and the French troops 
in that country, it was conveyed by them to various places, and extended itself to 
soldiers who had intercourse with those troops ; that when once introduced it 
spreads rapidly wherever men are crowded together within a small compass, pay 
insufficient attention to cleanliness, and use the same towels and utensils ; that it 



GONORRHEAL OPHTHALMIA. 



195 



has been propagated again and again by the direct application of the morbid secre- 
tion ; and that its progress is checked by measures that provide against such acci- 
dental application, and by separating the diseased from the healthy. 

On the other hand, it has been contended that the disease is nothing more than 
an extreme degree of catarrhal ophthalmia ; that the peculiar conditions of the 
atmosphere in Egypt and other hot countries, where it is prevalent, are enough 
to account for it; and that when troops are disbanded, they do not give the disease 
to their friends and families all over the country, but, on the contrary, the disper- 
sion of the sick in this way is the most effectual mode of -stopping the disease. 

To these arguments the proper answer is, that the same difficulties meet us in 
respect to some other diseases which are confessed by all persons to be strictly 
contagious. 

My own creed upon the matter is this — that the disease may, and often does 
arise, independently of contagion, from the agency of ordinary causes of inflam- 
mation ; and that having so originated, it acquires contagious properties, which 
develop themselves only under circumstances that favour the propagation of most 
of the contagious complaints. 

I shall next advert to purulent ophthalmia as it is observed to occur, in the 
adult, in connection with gonorrhoea. If we look to the mere phenomena pre- 
sented by the inflamed eye, we find nothing to distinguish the gonorrheal from 
the Egyptian ophthalmia. Taking the average of a large number of cases, the 
gonorrheal is the severer form of the two, and runs the more rapid course. It is 
said, also, that the inflammation usually commences on the lids in the Egyptian 
variety, while it attacks the whole conjunctiva at once in the gonorrheal. But 
comparing individual instances, these mere differences, and slight differences, too, 
in degree and situation, will not help our diagnosis. 

But other circumstances may guide us. If a patient presents himself with 
severe purulent ophthalmia, who has not been exposed to any of the known 
atmospheric causes of that disease, and at a time when purulent ophthalmia is not 
prevailing as an epidemic, and if this patient have a clap, we may conclude that 
we have to deal with a case of gonorrhoeal ophthalmia; and this conclusion will 
be further strengthened if the disease affects one eye only. For what, through 
the lack of any better nomenclature, I am constrained to call Egyptian ophthalmia, 
seldom restricts itself to a single eye. Dr. Vetch says, " there is but one case in 
a thousand in which one eye only becomes affected." Walther observes that 
contagious ophthalmia almost always appears in both eyes together, but not in 
the same degree; and Eble (another German author) states that the contagious 
ophthalmia has not confined itself to one eye in any instance. These round 
assertions require, however, some qualification; the nurses, whose cases I quoted 
in the last lecture from Sir Patrick Macgregor's paper, suffered each in one eye 
only. On the other hand, gonorrheal ophthalmia mostly, but by no means 
always, is limited to one eye. In Mr. Lawrence's instructive book On the 
Venereal Diseases of the Eye, he mentions fourteen cases of gonorrheal ophthal- 
mia. In nine of these, one eye only was inflamed. 

It is always a matter of some interest to. make out whether the disease has or 
has not any connection with gonorrhoea; even though we may gain nothing, in 
respect to the treatment, by the distinction. 

Purulent ophthalmia has been said to be connected with gonorrhea in three 
several ways; 1st, by direct contact of the gonorrheal discharge from the urethra 
with the conjunctiva; 2d, by metastasis of the inflammation from the urethra to 
the eye, without any such contact of matter; and 3d, independently of either of 
these ways; i. e., purulent ophthalmia has been supposed to occur in connection 
with clap, just as ulceration of the throat is apt to occur in venereal diseases. 

Now the last two of these three modes of origin are more or less questionable ; 
the first is certain. 

Very odd speculative opinions are apt to possess themselves of the minds of 
medical as well as of other philosophers. Some who believe that the disease is 



196 



DISEASES OF THE EYE. 



communicable by direct contact of gonorrhceal matter to the eye, yet hold that it 
must come from the urethra of another person ; that the Hudibrastic aphorism is 
true, " No man of himself doth catch." Dr. Vetch seems to have fallen into this 
opinion through the very common mistake of drawing positive conclusions from 
negative experiments. He had known a hospital assistant who, " with more faith 
than prudence," conveyed the matter of gonorrhoea from his urethra to his eyes, 
with impunity. He states also the converse experiment: a soldier in a very 
advanced stage of Egyptian ophthalmia, attempted to divert the disease from his 
eyes by applying some of the matter they were discharging to the orifice of his 
urethra : no effect followed this trial. But in another case the matter taken from 
the eye of one man, labouring under purulent ophthalmia, was applied to the urethra 
of another man ; and inflammation commenced there in thirty-six hours, and he 
had a very severe attack of gonorrhoea. Some persons, judging from such cases 
as this, and from the similarity of the discharge in the two diseases, «' have gone 
the length of concluding (according to Dr. Mackenzie) that gonorrhoea has been 
originally an inoculation of the urethra by the matter derived from the eye in the 
Egyptian ophthalmia ; whilst others are of opinion that this last disease is nothing 
else than the effect of an inoculation of the conjunctiva with matter from the ure- 
thra in gonorrhoea." 

To satisfy you that a person may " catch" the complaint from himself, or from 
others, it is right that I should bring before you one or two well-marked cases. 

It is a common persuasion, among the lower classes, that to bathe the eyes in 
human urine is good for the sight. This piece of practice has cost several per- 
sons their vision. A gentleman belonging to the class mentioned to me the other 
day two cases of purulent ophthalmia so produced, which he had seen among 
Mr. Guthrie's patients at the Ophthalmic Hospital. In the one, a young woman, 
not so healthy as she ought to have been, used her own water; in the other, an 
older woman, for what reason it did not appear, preferred her husband's to her 
own. Mr. Lawrence alludes to several similar cases. He details an instance 
also, in which partial sloughing of one cornea occurred ; the disease having been 
caused by the patient's wiping his eyes with a towel soiled with the gonorrhceal 
discharge from his own urethra. But one of the neatest and most conclusive ex- 
amples of the production of the disease in this way has been furnished by Dr. 
Mackenzie. A patient was brought to him from the country with his left eye 
violently inflamed and chemosed, and discharging a large quantity of purulent 
fluid ; the lower lid everted, and the cornea totally opaque. Thirteen days before, 
this man, who had then a profuse gonorrhoea, but whose eyes were perfectly well, 
while stooping down and shaking away the discharge from his penis, flung a drop 
of it fairly into his left eye. Violent inflammation immediately set in, was confined 
to the eye that was thus inoculated, and produced the results I have mentioned : 
the gonorrhoea going on just as before. 

Numerous authentic cases have been recorded of gonorrhceal ophthalmia pro- 
duced by the application to the eye of gonorrhceal matter from another individual. 
Mr. Wardrop met with the following example. An old lady went into the dress- 
ing-room of her son, who had gonorrhoea, and washed her face with a towel 
which he had recently been making use of. Purulent ophthalmia quickly super- 
vened, and destroyed the eye in a few days. Delpech mentions the instance of a 
young and healthy woman, who bathed her eyes with goulard water, by means 
of a sponge which had been used by a young man who had a clap : violent in- 
flammation soon arose, and the sight of one eye was lost. Several cases of puru- 
lent ophthalmia have been observed in laundresses, who had been employed in 
washing linen foul with the discharge of gonorrhoea. 

Mr. Lawrence seems to be of opinion that purulent ophthalmia is not a very 
frequent consequence of the application of the urethral discharge to the eye of the 
same person. " When we consider," he says, " how this matter is diffused over 
the linen of patients, both male and female, how often the fingers must besmeared 
with it, and how inattentive to cleanliness the lower classes are, we cannot help 



GONORRHEAL OPHTHALMIA. 



197 



concluding that the gonorrhoea! discharge must be often applied to the eyes of 
the same individual; yet gonorrhoeal ophthalmia is comparatively rare." Dr. 
Mackenzie, on the other hand, thinks that the application of the matter to the eye 
is seldom made. " The instinctive closure of the eyelids," he observes, " when 
the finger approaches the eye, making it actually difficult for a person to touch 
his own conjunctiva, unless with one finger he draws down the lower lid, and 
intentionally applies another finger to the eye, will serve in some measure to 
explain the rarity of this kind of inoculation." 

It has been noticed that women are much less frequently the subjects of gonor- 
rhoeal ophthalmia than men. 

Does gonorrhoeal ophthalmia ever occur by metastasis ? This question does 
not admit of a positive answer. Practical men are divided in opinion on the sub- 
ject. In the majority of cases of gonorrhoeal ophthalmia, we are unable to trace 
any application of the urethral discharge to the eye, either from the same or from 
another individual. Yet it does not follow that no such application took place. 
The German and Italian writers believe in metastasis. " In all the instances," 
says Beer, " which I have seen, this ophthalmia has occurred in young, plethoric, 
robust, and truly athletic men ; and it has always taken place in a very short time, 
generally in a few hours, after the suppression of gonorrhoeal discharge from the 
urethra." Mr. Lawrence never knew the urethral discharge stop upon the coming 
on of the ophthalmia ; it has generally diminished, but in some instances has 
continued as copious as before. He seems to regard the occurrence of the oph- 
thalmia as analogous to those successive attacks of distant parts that are common 
in gout and rheumatism. Dr. Mackenzie evidently doubts the occurrence of 
metastasis at all in this disease, and is inclined to refer all the cases in which it 
has been alleged, to inoculation, or to an accidental occurrence of purulent oph- 
thalmia and gonorrhoea in the same person. 

The supervention of purulent ophthalmia as a part of the gonorrhoeal malady, 
independently of inoculation and of metastasis, seems to me extremely problema- 
tical. The eye is well known to suffer, as well as other organs, in the secondary 
forms of syphilitic disease, but the conjunctiva is not ihe part that is attacked. I 
have never seen nor heard of any satisfactory example of purulent ophthalmia 
alternating with gonorrhoea, where the possibility of inoculation was excluded. 
And, upon the whole, my own opinion — (you will take it for whatever it may 
seem worth) — is against the existence of this alleged form of purulent ophthalmia. 
Whether it exists or not is of very little consequence in regard to the main ques- 
tion ; namely, what is the proper mode of treating the purulent ophthalmia of 
adults ? 

Now the two chief points to consider, so far as respects the treatment, are — 
first, blood-letting; and secondly, the application of strong astringents to the 
inflamed membrane. 

Blood-letting has been carried to a very great extent in this disease, or in these 
diseases, if you choose to consider the Egyptian purulent ophthalmia and the gonor- 
rhoeal purulent ophthalmia as two different inflammations. Its effects have not been 
very decisive or satisfactory ; indeed, we could hardly expect that they would. 
In the first place the inflammation is so rapidly destructive, that, in many of the 
worst cases, irreparable mischief is done before the patient applies for medical 
assistance. In forty-eight hours, or a little more, Mr. Lawrence tells us, the 
affection may have proceeded to such an extent as to be beyond our control. Of 
course this reason for the want of success is equally applicable to every remedy 
that has been, or could be, proposed. But independently of this, even when the 
disease is seen and submitted to treatment in its very beginning, we should have 
the less confidence in the power of general blood-letting to control it, for these 
two reasons : that the part affected is a mucous membrane ; and that there is so 
little constitutional sympathy with the local inflammation. Free venesection tells 
most upon inflammation, when it is attended with fever and a hard pulse, i. e., 
with increased action of the heart ; which the abstraction of blood tends to abate. 



198 



DISEASES OF THE EYE. 



It is also a matter of experience, that general bleeding has more influence over 
the inflammation of serous and fibrous membranes than over that of the mucous 
tissues. Accordingly, though bleeding has been even lavishly employed in puru- 
lent ophthalmia, it has too often disappointed the practitioner. There is one lesson, 
however, to be learned from copious blood-letting in this disease, even when it 
fails of its object. It clearly demonstrates what may be hoped for, by having 
recourse to that measure in internal inflammations. " You see a person," says 
Mr. Lawrence, who has both had, and used freely, very numerous opportunities 
of putting this remedy to the test, " you see a person with his eye bright red, and 
very painful; he cannot face the light, and tears gush out, with great suffering, if 
he attempts to do so. You bleed to fainting, and immediately the capillaries are 
emptied, so that the organ resumes its natural paleness ; the pain is gone, the eye 
is opened without difficulty, and the full influx of light can be borne without an 
uneasy sensation. For the time the part has passed from violent inflammation to 
a nearly natural state. With the restoration of the circulation the inflammation 
will recur after this temporary suspension ; but its violence is diminished, and it 
often gradually abates." Mr. Lawrence is here speaking of acute inflammation 
affecting the textures of the eye generally, and not of purulent ophthalmia in par- 
ticular ; but I am desirous that, in passing, you should take notice of this direct 
effect of bleeding to syncope, upon the capillaries of the eye, because it teaches 
us what the same expedient may do for the capillaries of any other internal part, 
which we cannot see, when that part is attacked with inflammation. In purulent 
ophthalmia, however, if you trusted to bleeding alone, you would often reduce 
your patient to a very dangerous, state of weakness, and after all fail of your mark. 
Dr. Vetch bears strong testimony to the usefulness of blood-letting when freely 
employed in the early stages of Egyptian ophthalmia ; and certainly it ought never 
to be neglected. In the very onset of the disease, it will aid the local expedients 
which I shall presently mention ; and if the patient be not seen till the globe of 
the eye is invisible for the "swelling, the propriety of general bleeding will be still 
further indicated by the occurrence of throbbing and circumorbital pain, returning 
in nocturnal paroxysms ; for this symptom denotes that the inflammation has 
descended deeper than the conjunctiva. The bleeding should be performed in 
the way I formerly spoke of as being required in serous inflammation : the pa- 
tient should be bled from the arm in an upright position, till fainting is about to 
ensue, or the pulse begins to falter. You will do more towards obtaining safety 
for your patient's vision in this way, and at less expense of his strength, than by 
bleeding him many times to a smaller amount. The bleedings/ deliquium may 
require to be once or twice repeated ; and when the patient begins to rally from 
his faintness, from twelve to twenty-four leeches may often be applied with ad- 
vantage ; round the eye and not upon the tumid lids, where their bites are apt to 
add to the existing irritation, and to fester. You had better bleed your patient 
from the arm, and not from the jugular vein, or the temporal artery, for reasons 
which, as I have fully stated them already, I need not now repeat. 

But of late years, more reliance has been placed by many practitioners upon 
local stimulants, for checking this horrible malady, than upon general or topical 
bleeding. Dr. Vetch strongly recommended the insertion of undiluted liquor 
plumbi acetatis ; and Mr. Briggs, in his translation of a work of Scarpa on the 
eye, advised the introduction of a very minute quantity of the oil of turpentine 
between the eyelids. But Mr. Guthrie has the merit of having applied, in its 
full extent, this principle of curing conjunctival inflammation, even in its severest 
forms, by stimulant and astringent substances. I told you, when speaking of 
catarrhal ophthalmia, that Mr. Melin and Dr. Mackenzie treat that complaint with 
a wash, made by dissolving four grains of lunar caustic in an ounce of distilled 
water. I might have added other authorities in favour of the same kind of prac- 
tice. ,Now Mr. Guthrie treats purulent ophthalmia on the same principle, but 
with a much larger dose of the nitrate of silver. The greater intensity of the 
disorder is met by increasing the strength of the remedy. He considers it to be 



PURULENT OPHTHALMIA. 199 

a local disease of a peculiar character; and, acting upon the aphorism of John 
Hunter (an aphorism, however, which requires some qualification) that two dis- 
eases or actions cannot go on in a part at the same time, he proposes to set up in 
the inflamed conjunctiva a new action, which shall supersede the original disease, 
and create another that is more manageable. In this point of view Mr. Guthrie's 
ratio medendi agrees with that of Hahnemann, about which there has been so 
absurd a noise made of late. I have never had the advantage of seeing Mr. 
Guthrie's plan tried, but, from all that I have heard of it, I believe it to be a valu- 
able discovery. A priori, we should expect that the caustic application would 
add to the existing mischief and destroy all chance of saving the inflamed eye. 
But it is not so. Even Mr. Lawrence, who was, I have reason to think, formerly 
very sceptical on this point, appears to be so no longer. In his treatise On the 
Venereal Diseases of the Eye, he uses this cautious language : — " Destructive or 
injurious consequences have so frequently resulted under the usual management 
of this disease" — he is speaking of gonorrheal ophthalmia — " that I should cer- 
tainly employ the local astringent, if I met with a case favourable for the trial ; i. e., 
where the affection had not extended beyond the conjunctiva. Blood-letting 
might be resorted to at the same time; in most cases, however, our aid is not 
sought until the cornea has become affected, and it is therefore too late for the 
astringent plan." But he subsequently added a note, to the effect that after the 
statement I have just quoted was written, he had employed the caustic solution 
in two cases of conjunctival inflammation with the best result. 

Mr. Guthrie's plan, therefore, you ought to be acquainted with. After many 
trials, he has arrived at the conclusion that the best appliance, in this formidable 
complaint, is an ointment, made by mixing ten grains of the nitrate of silver, 
reduced to an impalpable powder, with a drachm of hog's lard. This is what he 
calls his ten- grain ointment. 

Before applying it to the diseased eye, the discharge must be well cleansed 
away by a solution of alum ; then the ointment having been inserted beneath the 
lids, they are to be moved freely up and down, so that the whole conjunctiva may 
get its due share of the remedy ; and that it has done so is shown by its turning 
white. If the surface does not turn white, the ointment has not been sufficiently 
applied, and will not answer the purpose. If we wish to be quite sure, he says, 
we turn out the eyelids, and rub the ointment on them. This application gives 
pain, which lasts for half an hour or an hour, or more. " Warm narcotic fomen- 
tations may be employed to relieve uneasiness, and opium given to allay pain, 
and to obtain sleep ; while a solution of alum, in the proportion of a drachm to a 
pint, should be injected from time to time into the eye, to clear it; but should the 
patient sleep, he must not be disturbed. A mild ointment may be applied to the 
edges of the lids at night, to prevent their sticking together. The next morning 
the discharge is again to be removed, and the ointment to be reapplied ; for on no 
account should the action we are desirous of exciting be allowed to cease." Of 
course Mr. Guthrie means it is not to be suffered to cease prematurely. This, 
with free but not excessive venesection, is the substance of his peculiar mode of 
treating purulent ophthalmia ; and it appears to have been eminently prosperous 
in his hands. I have been informed, by one of yourselves, that purulent ophthal- 
mia has been successfully treated, on a large scale, in Manchester, by applying 
the nitrate of silver, in substance, to the surface of the conjunctiva ; that this gives 
less pain than the ten-grain ointment, though perhaps it may require to be oftener 
repeated. 

I say I have never seen this method of Mr. Guthrie's carried into effect ; but 
after what I have myself witnessed of the intractable and destructive nature of the 
disease, under the treatment ordinarily adopted before his ointment was devised, 
I will say also that were I so unfortunate- as to be attacked with severe purulent 
ophthalmia, I should desire to have the caustic applied as soon as possible, and to 
be freely bled at the same time. 

There are some minor points in the treatment that require a cursory notice only. 



200 



DISEASES OF THE EYE. 



Some persons, and Mr. Guthrie among the rest, recommend the exhibition of 
mercury, so as to affect the gnms. Now I believe that mercury is quite useless 
in this complaint; and if useless, mischievous. The disease is too rapid to be 
overtaken by the mercury, and if you could obtain the specific influence of that 
mineral in time, i. e., before any of the destructive effects of the inflammation 
were accomplished, you would do no good thereby. This is not the kind of 
inflammation over which mercury exercises any useful control. Mr. Lawrence 
tells us that he has seen both the ordinary purulent, and gonorrhoeal ophthalmia, 
proceeding apparently unchecked, under the full mercurial action. 

Practical men are not agreed about the propriety of scarifying the conjunctiva 
when it is swelled and elevated by chemosis. Mr. Lawrence objects to it, as 
likely to increase the local irritation ; a disadvantage not compensated by the 
quantity of blood discharged from the divided vessels. Dr. Mackenzie recom- 
mends it, stating that the incisions will bleed copiously, and greatly allay the 
symptoms. Who shall decide in this puzzling discrepancy of opinion ? Mr. 
Guthrie's caustic ointment would, I presume, supersede any other meddling with 
the inflamed surface. But when the question happens to lie between scarifica- 
tion and no scarification, I should give my vote for scarifying; not because I 
think any useful depletion of the blood-vessels could be brought about by that 
measure, but because, if properly performed, it would evacuate the serous effusion 
from the areolar tissue between the conjunctiva and the sclerotic, which effusion 
constitutes the chemosis, and hastens, if it does not cause, the sloughing of the 
cornea, by the mechanical pressure that it exerts around it. 

Are blisters of any use? Hear Dr. Mackenzie. " Counter-irritants are highly 
serviceable in this disease, and ought always to be employed. There is generally 
a marked change in the quantity and appearance of the discharge from the eye, 
as soon as a counter-discharge is established by blisters on the temples, nape of 
the neck, or behind the ears." But listen to Mr. Lawrence. " Experience does 
not warrant us in ascribing much efficacy to blisters." Now the truth is, I be- 
lieve, that during the active stage of the disease, blisters are not of any use ; but 
that in the more advanced and chronic periods, they are. Indeed, Mr. Lawrence 
admits that they may be regarded as auxiliary measures, and resorted to after 
antiphlogistic means. 

I agree with the same gentleman in thinking that no reliance is to be placed, in 
gonorrhoeal ophthalmia, upon any attempts to reproduce the urethral discharge ; 
indeed, in most cases it is not suspended. 

Although I have not mentioned purgatives, you will conclude that they form a 
very proper and necessary part of the treatment during the activity of the com- 
plaint. 

After what has already been said of purulent ophthalmia in the adult, and of 
gonorrheal ophthalmia, it will not be necessary for me to take up very much of 
your time in speaking of purulent ophthalmia as it occurs in newly-born children. 

This is a very common disease : it is very serious when neglected : it is very 
easily managed when it is seen and treated in time. These are all reasons why 
you should make yourselves familiar with the complaint, and with the mode of 
curing it. You may perhaps never have occasion to treat a case of purulent oph- 
thalmia in the adult: you are sure to be consulted about the purulent eye of 
infants, the ophthalmia neonatorum. 

The importance of the disorder te apt to be overlooked by mothers and nurses ; 
they say the baby has a cold in the eye, which will go off ; and they wash it 
perhaps with a little of the mother's milk, or some such insignificant fluid. 
Meanwhile the eyelids swell, the mischief that is going on beneath them is con- 
cealed from sight, and when at last a medical man is consulted, he too often finds 
that one of the eyes has perished, or both : the cornea has sloughed or become 
opaque, or protrudes, and constitutes what is called staphyloma; prolapse of the 
iris has taken place ; or the coats of the organ have shrunk up. 

The inflammation usually comes on about three days after the child is born, 



PURULENT OPHTHALMIA. 



201 



although it may commence later. It is confined, at first, to that part of the mem- 
brane which lines the lids. Their edges are observed to stick together when the 
infant wakes : there is more intolerance of light, apparently, than is suffered in the 
analogous disease of adults. The little patients cannot indeed tell us their sensa- 
tions by words, but they express them significantly enough by keeping their eyes 
shut, by knitting their small brows, and by turning their heads away from the 
light. At length the inflammation extends to the conjunctiva that covers the eye- 
ball, the eyelids swell, sometimes enormously : and an astonishingly copious dis- 
charge of pus takes place. By the adhesion of the edges of the lids the puriform 
matter is sometimes pent up, causing them to protrude; and when they are sepa- 
rated it escapes in a profuse hot gush. The eyelids are sometimes everted during 
the cries and struggling of the little sufferer, and their mucous surface is then 
seen to be villous and shaggy, and of as bright a scarlet as you ever saw the 
injected mucous membrane of a fetal stomach. At last those destructive conse- 
quences to the eye take place which I have already mentioned. The disease, 
however, may continue for eight or ten days without any affection of the trans- 
parent parts; and so long as these remain uninjured, the eye is safe, provided 
that proper treatment be adopted. 

This disease is probably much the most fertile source of blindness with which 
we are acquainted. It is believed to originate most commonly, if not always, in 
contagion. We might, perhaps, expect this from the analogy of the severe 
inflammation of the same parts in adults. And it is a matter of fact, that in a 
very large number of cases the mother has been affected, at the time of her con- 
finement, with some kind of vaginal discharge — leucorrhosa, or gonorrhoea; and 
the eyes of the children are exposed to these morbid secretions, as they are 
brought into the world. The circumstance of the disease commencing so regu- 
larly on the third day, is greatly in favour of the supposition that it results from 
inoculation of the eyes by the unhealthy fluids of the mother. The discharge 
from the infant's eyes has been ascertained to be highly contagious. Dr. Mackenzie 
mentions a lamentable illustration of this fact, which fell under his observation at 
the Eye Infirmary, in Glasgow. An infant and its grandfather became his 
patients there at the same time ; the latter having been inoculated from the former. 
Both were so severely affected that the infant had one eye left in a state of total, 
and the other of partial staphyloma: while in each eye of the old man, the 
greater part of the cornea remained opaque, and adherent to the iris. 

However, the disease certainly occurs in the infants of mothers who seem to be 
healthy, and who deny that they have any unnatural discharge. It may pro- 
bably be brought on, sometimes, by bad management on the part of the nurse: 
by exposure soon after birth to draughts of cold air, or to the injurious influence 
of a hot and bright fire ; or by the introduction of soap into the eye in the primary 
ablutions, or of gin, wherewith the lower classes, in some absurd persuasion of 
its strengthening virtues, are wont to bathe the unlucky infant's head. The dis- 
order is observed to be most common in damp and cold weather; in low crowded 
places ; and among the children of the poor.* 

One striking difference between the disease as it exists in adults and in newly- 
born children I have already adverted to; viz., its rapid and often uncontrollable 
progress in the former; and the facility with which it yields to suitable and timely 
treatment in the latter. If a child is brought to you with purulent ophthalmia, 
and you are able to separate the lids sufficiently to obtain a glimpse of the cornea, 
and perceive that it is still brilliant and uninjured, you may confidently tell the 

[* The remarks of Dr. Watson on the causes of purulent ophthalmia in children, present 
a fbrief summary of all that is positively known in relation to the subject— for further 
details, bearing more especially upon the question of the production of the disease in the 
infant by a morbid vaginal discharge existing in the mother at the period of its birth, and 
the circumstances generally, under which the affection most frequently presents itself, the 
reader is referred to the Editor's Treatise on the Diseases of Children. We have not met 
with a single fact, during a long and somewhat extensive practice, in proof of the con>> 
munication of the purulent ophthalmia of infants by contagion.— C] 



202 



DISEASES OF THE EYE. 



anxious mother that, with due care on her part, her child's eye is safe. If the 
cornea has lost its transparency, it is still within the ¥each of recovery, but the 
chances are against it: if you cannot get a sight of the cornea at all, you will do 
wisely to give a doubtful prognosis, or even an unfavourable prognosis ; for such 
is the ignorance of the vulgar (and I conclude both rich and poor under this 
phrase) that if they are not forewarned of the danger, they are very apt to attri- 
bute the blindness that ensues to your stuff, as they call it. 

In the severer forms and stages of the complaint, if the lids be very much 
swelled and red externally, and especially if you are unable to obtain any satis- 
factory view of the cornea without using a degree of violence that might be hurtful, 
it will be right to apply a leech. In this case it may be placed upon the centre of 
the tumid upper lid ; and you should, whenever that is possible, stay by the little 
patient until the animal drops off, and the bleeding ceases ; for sometimes the 
bleeding is difficult to stop, and must not be trusted to the care of the nurse ; and 
the loss of blood occasioned by the bite of a single leech will often blanch the 
infant's skin, and make you fear that the depletion, slight as it is in actual amount, 
has yet been too much. The child's bowels should be emptied by a little castor 
oil; and a lotion, made by dissolving two grains of the acetate of lead in an ounce 
of water, may be applied to the inflamed organ. 

In less severe cases, and I believe in all cases in which you can see the unin- 
jured cornea gleaming through the pus that bathes it, it will be quite sufficient to 
keep the infant's bowels open with magnesia ; to apply a little lard along the edges 
of the lids, that they may not stick together; and to inject carefully into the eye, 
beneath and between the lids, a solution of alum ; in the ratio of four grains to one 
ounce of water* Such, Mr. Lawrence tells us, was the treatment in forty-nine 
cases out of fifty at the London Ophthalmic Infirmary when he was surgeon to 
it: no other means being used than magnesia internally, and the solution of alum 
locally: and out of many hundred instances he scarcely recollected one that suffered 
in any respect, if the cornea were clear when the infant was first seen. I had, 
for a considerable period, the advantage of watching Mr. Lawrence's patients 
under that treatment; and the result of it was so entirely and uniformly satisfac- 
tory, that I should never think of employing any other. If the eye became at 
length insensible to the stimulus of the alum, a solution of the nitrate of silver, 
(from one to four grains in the ounce of water,) was substituted with advantage. 
Mr. Guthrie uses, I fancy, his caustic ointment ; but I am sure that the simple 
and less severe plan I have been describing is quite sufficient. 

There is just one more disease belonging to the conjunctiva, that I wish to 
bring before you ; and then I shall have done with the morbid affections of this 
external membrane of the eye. It has received several names: sometimes it is 
culled pustular ophthalmia, from the appearance of little pustules upon the surface 
of the organ. Dr. Mackenzie, who looks upon it as an eruptive disease, affecting 
the conjunctiva not so much as a mucous membrane, but rather as a continuation 
of the skin, names it phlyctenular ophthalmia. It has also acquired the title of 
scrofulous or strumous ophthalmia, from its continual occurrence in children of a 
scrofulous habit, and its very frequent association with scrofulous disease in other 
parts. It is a disorder of childhood, and it is so common a form of disorder, that, 
of ten cases of inflammation of the eyes in young persons, nine will be of this 
kind. I shall call it strumous ophthalmia. It is a form of ophthalmia that differs 
in many striking points from those which we have been considering. 

In the first place, it is intimately connected with the scrofulous constitution; 
the peculiarities of which I formerly explained. Although a disease of children, 
it is not a disease of infants at the breast. It is most prevalent from the time of 
weaning to about the age of eight. I mentioned to you, in a previous lecture, 
the remarkable fact — showing the strong influence of unsuitable or insufficient 
nourishment in developing scrofulous disease — that when asked to prescribe for 
children having bad eyes, you will find, in nineteen cases out of twenty, that you 



STRUMOUS OPHTHALMIA. 



203 



have to deal with purulent ophthalmia if the child be still at the breast, and with 
strumous ophthalmia if it have been weaned. 

The leading symptoms of this disease are, slight redness ; great intolerance of 
light; the formation of little prominences or pustules on the surface of the con- 
junctiva ; and specks which are the result of these. The complaint sometimes 
occurs in one eye alone, oftener in both ; but then one eye is generally worse 
than the other. Mere catarrhal ophthalmia is apt to degenerate into this affection 
in scrofulous children. After seeing two or three cases of strumous ophthalmia, 
you cannot fail to recognize it whenever you meet with it again. 

The redness has this peculiarity, that it is slight and partial. Sometimes it is 
altogether confined to that part of the membrane which lines the eyelids : generally 
a few vessels, collected into little bundles, are seen proceeding from some point 
of the circumference — more commonly from the angles of the eye than from any 
other point — towards the cornea: the vessels are evidently superficial, often 
prominent. These scattered bundles of vessels (sometimes there is but one) stop 
when they reach the cornea, or occasionally encroach a little upon it ; and where 
they stop, the small elevations of the membrane may be observed, which are 
called pustules. This is the most common situation of these elevated points, just 
at the line of junction between the sclerotica and the cornea, or near that line. 
Sometimes, however, you may see one or two near the centre of the cornea. 
They are smaller in size when they appear on the cornea, than when they are 
situated near its edge. 

These pimples may be absorbed, and leave behind them a temporary white 
spot; more frequently they break and form little ulcers. t When these ulcers are 
beyond the cornea they are of less consequence : when they are situated upon it, 
they become sources of danger in two ways ; they may penetrate the cornea, and 
let out the aqueous humour, and cause prolapsus iridis and various other mischief : 
or they may leave, after healing, a permanent white opaque speck, (called leu- 
coma,) which, according to its size and its exact place, will interfere more or less 
with the patient's vision. 

The intolerance of light is a very prominent symptom of this disease, and 
sometimes it really is the only symptom that manifests itself. It is curious that 
this inability to endure a bright light bears no regular or definite proportion to 
the intensity of the other symptoms. It is not that the eye is painful when pro- 
tected from the light ; but that the access of the ordinary light of day occasions 
extreme suffering ; the eyelids being spasmodically closed and the orbicular muscle 
in such strong, and apparently involuntary action, as effectually to resist all at- 
tempts at opening them. Children that are affected with this disease, carry it 
legibly written in their physiognomy. Although you cannot tell what is the actual 
condition of the eye without examining it, you can tell, as soon as you look at 
the patient, what is the nature of the inflammation under which he, is suffering. 
The child's brow is knit and contracted, while his alas nasi and his upper lip are 
drawn upwards ; those muscles of the face (they happen to be also muscles of 
expression) are instinctively put in action, which tend to exclude the light with- 
out shutting out the perception of external objects ; producing a peculiar and 
distinctive grin. In the severer cases the child will skulk all day in dark corners ; 
or if in bed, will lie upon his face, or uncler the clothes ; and while the light is 
thus kept off, he does not appear to suffer. If brought towards a window, he 
holds his head down, and presses his hands or arms over his eyes. When you 
attempt to open his eye to examine it, a profuse discharge of scalding tears takes 
place : these pass partly into the nose, and excite fits of sneezing, and partly 
over the skin, which they sometimes inflame and excoriate ; and then, frequently, 
pustules arise, and produce a discharge that crusts over the cheek and extends to 
the forehead and temples. This is called crusta lactea, and is very characteristic 
of the scrofulous habit; it occasionally spreads over the whole body. 

You might suppose, from this extreme intolerance of light, that the retina was 
inflamed, or in danger. But it is not so. The affection of the retina is purely 



204 



DISEASES OF THE EYE. 



sympathetic, and need not of itself excite any fears about the vision. Towards 
dusk, indeed, in the twilight, the child can generally open his eyes, and then is 
quite as able to see as if he were well. Dr. Mackenzie endeavours to explain the * 
connection of intolerance of light, spasmodic contraction of the lids, and lachryma- 
tion, even when there is but little visible redness, by the distribution of the lachry- 
mal nerve; which, after supplying the lachrymal gland, goes to the conjunctiva, 
and to the orbicularis palpebrarum. We have the same set of symptoms when a 
bit of dirt gets into the eye, and fixes itself beneath the upper lid. When little 
or no redness exists, this extreme intolerance of light has been called photophobia 
scrofulosa. 

With this strumous affection of the eye there are usually present other evi- 
dences also of scrofulous disease. Swelling and redness of thealae nasi and upper 
lip ; enlargement of the absorbent glands about the neck ; eruptions upon the 
head ; sore ears ; a large and hard belly ; disordered bowels ; offensive breath ; 
grinding of the teeth ; and general debility. And the ophthalmia will alternate 
sometimes in severity with some of these other local scrofulous complaints ; get- 
ting better as they get worse, and vice versa. 



LECTURE XIX. 

Strumous Ophthalmia, continued. Recapitulation. Treatment of Strumous 
Ophthalmia. General Remarks on Conjunctival Inflammations. Iritis : its 
Symptoms and Treatment. Causes of Iritis. 

When we separated yesterday, I was about to describe the treatment which 
has been found by experience to be the best for relieving strumous or phlyctenular 
ophthalmia. Before I take up the subject where it was then dropped, let me 
briefly remind you of the character and principal symptoms of the disorder. It 
is a form of inflammation of the conjunctiva, to which scrofulous children, from 
the time they are weaned, to about the age of eight, are extremely liable. It may 
occur considerably later. Sometimes it is the first and only token of the exist- 
ence of the scrofulous diathesis ; generally it is observed in children who bear 
other marks of the strumous habit, and are afflicted with other forms of strumous 
disease. 

Its symptoms are — first, slight vascularity ; the redness being partial, and pro- 
ceeding from one or more fasciculi of superficial vessels, which advance from the 
circumference of the visible part of the eye towards the cornea, where they usually 
stop : sometimes, however, they pass a little beyond its edge. At the extremities 
of these fasciculi, upon or near the line of separation between the cornea and the 
sclerotica, small prominences appear, which are sometimes absorbed, sometimes 
break and form ulcers. Less frequently the phlyctenae are situate towards the 
central part of the cornea. Secondly, with this partial vascularity and these pim- 
ples, and sometimes even without them, there is extreme intolerance of light. 
The pain produced by exposing the eye to the influence of light imparts a cha- 
racteristic expression to the countenance of the suffering child. Tears flow over 
the cheek, and inflame it often, and give rise to the eruptive appearance termed 
crusta lactea : or, from its sometimes covering the cheek like a mask, porrigo 
larvalis. 

I may add to this summary of what was stated in the last lecture, that some- 
times the vessels which pass along the conjunctiva and over the cornea, instead 
of leading to pustules, extend laterally : so that several bundles of vessels unite 
by their mutual ramifications ; and that part of the conjunctiva which covers the 
cornea becomes thick, as if it were darned ; and more or less opaque. Indeed, 
the greater portion of the' whole of the corneal covering may thus be rendered 



STRUMOUS OPHTHALMIA. 



205 



patchy and vascular. The appearance presented by the eye under these circum- 
stances is called pannus. 

You will readily believe, from what has been said of this complaint, that it is 
an obstinate and troublesome one. Even when it has been cured it is very apt to 
recur. The scrofulous habit on which it depends we cannot get rid of ; and 
whenever the exciting causes of scrofulous diseases come into action, this form of 
scrofula is very prone to declare itself, at the period of life which I have already 
mentioned. 

More good is to be done by general treatment, applied to the system at large, in 
this form of ophthalmia, than in those we were occupied with before ; and this is 
one strong point of difference between them. 

In the first place we must endeavour to correct that unnatural condition of the 
whole system, and especially of the digestive organs, which is commonly so striking 
a concomitant of the local disease. It will be proper to clear out the bowels in the 
outset, and occasionally, by a mercurial purge ; and to regulate them at other times 
by laxatives, such as rhubarb, or the confectio sennas, or castor oil. The recovery 
will be greatly promoted, also, by those measures which are found to benefit the 
general health in such constitutions ; warm clothing, frequent ablution of the body, 
nourishing though plain food, the respiration of a pure atmosphere, change of air, 
and regular exercise. 

In addition to these measures, tonic medicines should be administered; the pre- 
parations of iron, for example, or the dilute mineral acids : but the best remedy of 
this kind is, undoubtedly, the sulphate of quina. This may be given to a child 
in grain doses, three times a day, dissolved in water, with a drop of the dilute 
sulphuric acid, and some syrup of orange-peel. Dr. Mackenzie, in particular, has 
put this medicine fairly to the test, having employed it in a very large number of 
cases with the happiest results. In most of his patients he declares that it acted 
like a charm, «.* abating, commonly, in a few days, the excessive intolerance of 
light and profuse epiphora ; promoting the absorption of phlyctenule, and has- 
tening the cicatrization of ulcers of the cornea." And Mr. Lawrence adds his 
testimony to the same effect ; and his experience in this disease, like Dr. Mac- 
kenzie's, has been large enough to make it highly valuable. 

A few words will suffice to explain the kind of local treatment that has been 
found useful. You may feel tempted to apply leeches round the eye. This is 
seldom requisite, except when there are more redness and pain than common, and 
the tongue becomes white, and the skin hot. Certainly you must not take the 
intolerance of light as a fit indication for the use of leeches. Abstraction of blood 
rather aggravates that symptom ; apparently by increasing the irritability of the 
retina. Warm fomentations are generally very comfortable to the patient's feelings. 

When the general disorder of the system has been somewhat rectified, local 
stimulants and astringents are of great service. Thevinum opii and the solution 
of lunar caustic are the best. These are often tedious cases, and therefore it is 
necessary that you should be aware of one great objection to the long-continued 
employment of the nitrate of silver wash, which objection has been pointed out 
by Dr. Mackenzie. It is apt (but only when frequently repeated for a long time 
together) to stain the conjunctiva of an indelible olive colour. For this reason 
the vinum opii is to be preferred in slow cases, and in cases where frequent re- 
lapses happen. The good effects of either of those preparations are very striking ; 
they diminish the irritability of the eye, and promote the healing of the ulcers. 
The red precipitate ointment, and the citrine ointment of the Pharmacopoeia, 
diluted, are also found beneficial.' 

Counter-irritation is another local measure, which is of undoubted utility in this 
complaint. A great change for the better in the state of the organ often occurs, 
almost suddenly, upon the rising of a blister placed behind the ear, or at the back 
of the neck. And issues in the arms are not only serviceable in promoting the 
cure, but have a marked effect in many children, in preventing relapses. Mr. Wel- 
.bank, in his notes to Frick's Treatise on Diseases of the Eye, states that he has 



206 



DISEASES OF THE EYE. 



seen chronic strumous ophthalmia, of seven years' duration, quickly and effectu- 
ally relieved by an issue in the arm. " Having once (says he), in the case of a 
boy in Christ's Hospital, directed the healing of an issue which had been made 
above twelve months, I found the immediate consequence to be a relapse of stru- 
mous inflammation and ulceration of the cornea, resisting every measure but the 
renewal of the issue. 

He suggests, also, (what parents are sometimes more willing to assent to,) the 
advantage of making counter-irritation by piercing the lobe of the ear, and insert- 
ing a ring or silk ; and " a very convenient form of vesication will be found in the 
application of a strong thread, smeared with the emplastrum cantharidis, and 
firmly tied behind the ear at the angle of its reflection." 

When ulceration is going on in the cornea, and threatening to penetrate it, the 
progress of the ulcer may be checked by touching its surface once in two or 
three days with a pencil of lunar caustic which has been scraped to a fine point. 

When the more urgent symptoms have abated, and the discharge of hot and 
irritating tears has ceased, the crusta lactea may very easily be got rid of. The 
crusts are to be removed by a light poultice, or by warm water; and then the part 
must be bathed from time to time with a lotion made by mixing the oxide of zinc 
with water; a drachm to fourounces is the proportion I am in thehabitof prescrib- 
ing. If rose-water be used instead of common pump-water, the prescription will 
be thought the more elegant. This lotion will speedily dry up the discharge, 
and in a short time no vestige of the ugly-looking crust will remain. Parents are 
highly delighted and very thankful when you thus accomplish the removal of a 
large disfiguring and disgusting scab, which they naturally enough felt apprehen- 
sive might leave behind it a corresponding scar. But it is quite superficial. 

I have now done with the exterior membrane of the fore part of the eye — with 
its mucous membrane. In examining some of its diseases, we have had the 
opportunity of noticing several things which illustrate the pathology of the mucous 
tissues generally, and which exemplify the influence of other circumstances also, 
as well as of peculiarities of tissue, upon the morbid processes to which these 
membranes are obnoxious. 

We have seen that the mucous surface of the eye readily enough takes on 
inflammation, under vicissitudes of external temperature, and from the agency of 
other atmospheric conditions ; that the inflammation is apt to spread, often rapidly, 
over the whole surface of the membrane ; and that, in some cases, it may be 
strictly limited for a long time together, or entirely, to the mucous tissue in which 
it began; but that when intense, or under special circumstances, it may dip 
through and extend to the subjacent textures : that, on the other hand, the inflam- 
mation sometimes occupies separate specks only of the membrane, and then is 
more likely to penetrate to the deeper seated tunics: that although the membrane 
is folded upon itself, so that different portions of it are mutually in apposition and 
contact, these opposing surfaces do not become adherent to each other under 
inflammation; on the contrary, that they readily pour forth pus. This tendency 
to the formation of pus I formerly showed you to be commonly observable, when- 
ever the air finds free access to the inflamed part. The pus thus poured out 
possesses the remarkable property of exciting the same kind of inflammation 
when placed in contact with any healthy mucous membrane of the same or of 
another individual: whether it be the conjunctiva of the eye, or the internal lining 
of the urethra. The pus, in short, acts locally, upon certain parts at least, as a 
poison. And we perceive, in this fact, how a disorder that originates in common 
and accidental causes may become capable of propagating itself indefinitely — may 
become, in one word, contagious. We have seen also that the most intense 
inflammation may occur in this membrane, without exciting much or any con- 
stitutional disturbance ; an illustration of the fact that the inflammation of mucous 
membranes is not so prone to light up fever, is not in general attended with so 
much pyrexia, as inflammation of some other tissues, and especially of the serous 



IRITIS. 



207 



and fibrous tissues: and in proportion as this constitutional sympathy with the 
local disease is small or absent, so the influence of general bleeding upon the 
inflamed part is slight or ineffectual. The effect of a new and strong local irrita- 
tion, in altering or superseding the original inflammation in some cases, has been 
illustrated in the treatment of purulent ophthalmia as it occurs in the adult subject. 
The influence of age in modifying the phenomena, and in qualifying the plan of 
treatment, has been made perceptible in the differences noticed in these respects 
between purulent ophthalmia in infants and in grown-up persons. We have 
witnessed, too, the remarkable characters impressed upon inflammation of the 
very same part, by the presence of the scrofulous diathesis. We shall hereafter 
meet with numerous examples of chronic inflammation, and the deposition of 
tubercular matter, and the formation of ulcers in consequence of the elimination of 
that matter, in other mucous membranes. Whether the phlyctenae, or pustules, 
which appear upon the surface of the eye in strumous ophthalmia, result from a 
similar separation of tubercular matter from the blood-vessels, near the extremities 
of which these prominences are placed, has not been clearly ascertained. One 
other lesson we have learned from this review of conjunctival inflammation, viz., 
that general bleeding, carried so far as to produce syncope, will sometimes com- 
pletely empty the capillaries of an inflamed part of the red blood wherewith they 
were, just before, so turgid. 

I shall next request your attention to a part of the organ which is strictly inter- 
nal — to the iris: that thin curtain, with a circular aperture nearly in its centre, 
which hangs between the cornea and the crystalline lens, and is bathed on both 
sides by the aqueous humour. This little part, the office of which is to regulate 
the quantity of light admitted to the retina, is of exceeding interest in respect to 
its morbid as well as its healthy conditions. It is frequently the seat of inflam- 
mation: and, small as it is, the inflammation seems to be entirely confined to it, 
or to the surfaces immediately before and behind it. No doubt, with inflamma- 
tion of the iris, there is in many cases of inflammation of the choroid and retina 
also, and of the sclerotica. But the inflammation seems to make the iris its point 
of departure, and there it works its most striking changes. We cannot see so 
well what is the actual condition of the choroid and retina; but we have this 
proof, either that they do not always participate in the disease, or that they often 
suffer less than the iris; viz., that when the natural pupil has been closed up by 
lymph, and a new or artificial one is formed, vision is frequently restored. 

The little cavity across which the iris is vertically stretched, is lined by a 
smooth membrane, the source of the watery fluid always contained in the cavity. 
This membrane is analogous in its smoothness, in its forming a shut sac, and in 
the nature of its secretion, to the serous membranes met with in other parts of the 
body ; it is analogous also to the serous membranes, in its behaviour under in- 
flammation. It is, in fact, the serous membrane of the eye. Now we have the 
means of inspecting a portion at least of several of the mucous surfaces of the 
body ; but this serous cavity, constituting the anterior chambers of the eye, is the 
only serous cavity into which we have the privilege of looking, and of noting 
what is going on, when the membrane that forms its boundary is inflamed ; and 
this it is that makes iritis, to me, one of the most interesting of all diseases. There 
is no single part of the body from which you can derive so mu.ch instruction con- 
cerning some of the minuter processes of inflammation, and concerning the power 
of certain medicines over those processes, as you may by watching a few exam- 
ples of inflammation of the iris. 

All the changes which occur in iritis depend upon the circumstance that the 
inflammation, like that of the serous membranes generally, is of the adhesive 
kind ; i. e., is attended with the effusion of coagulable lymph. By means of this 
lymph the form and the colour of the part are changed ; the size and figure of the 
pupil undergo alterations, or that aperture is completely closed up; the motions 
of the iris are limited, or entirely put an end to. 



208 



DISEASES OF THE EYE. 



The symptoms which characterize inflammation of the iris are very obvious. 
To be perceived and understood, they require only to be looked at. Yet they 
long escaped notice, and even now are not always so carefully studied as they 
deserve to be. Not a great while ago I had to convince a surgeon of some pre- 
tensions, that he did not know this disease when he saw it. And English sur- 
geons and physicians were all of them ignorant even of its existence as a distinct 
disease, until a most excellent account of it was published by a German, Schmidt, 
in the first year of the present century. 

What are these plain and obvious symptoms that were so long overlooked, or 
that were not understood when seen ? They are the following. I will first enu- 
merate them, and then speak of each rather more particularly. Redness of the 
sclerotica ; a change in the colour of the iris itself, and in its general appearance ; 
irregularity of the pupil, produced by adhesion of the iris to the neighbouring 
parts ; immobility sometimes of the pupil from such adhesion ; a visible depo- 
sition of coagulable lymph. All these changes are apparent and conspicuous. 
Scientific writers term them objective symptoms. Then there are also the sub- 
jective symptoms, of which the patient alone is conscious — impaired sight ; pain 
in the eye, and round it. 

The redness is such as I formerly described as resulting from the vascularity 
of the sclerotic. The cornea is surrounded by a zone of fine straight converging 
pink lines, very different in appearance from the tortuous, anastomosing, scarlet 
blood-vessels of the inflamed conjunctiva. These hair-like converging lines stop 
abruptly at the edge, or just before they reach the edge of the cornea; they dip 
through the sclerotic, in fact, to go to the iris. The vascular zone, therefore, is 
well defined in front, while it becomes fainter from before backwards, and is gra- 
dually shaded off ; the posterior portion of the sclerotic being generally pale. As 
the disease advances, and in violent cases, the more superficial conjunctival ves- 
sels also sometimes enlarge, and mingle their tint of redness with that of the 
sclerotic, and more or less confuse or conceal it. Now this red zone or halo 
continues as long as the inflammation of the iris continues, and disappears when 
that ceases. It is an important symptom therefore. 

The change in the colour of the iris itself is also a remarkable circumstance. 
You know that what is called the colour of the eye is simply the colour of the iris. 
"When the lymph begins to be effused into the texture of this coloured part, it 
deepens, and at the same time alters, its tint. A gray or blue eye is thus rendered 
yellowish or greenish. A dark eye presents a reddish tinge. The change is 
such as would be produced by a mixture of the colour of the lymph with that 
which is natural to the iris. But besides a variation of colour, the peculiar bril- 
liancy of the surface is spoiled. It becomes dull and tarnished, as it were, and 
the fibrous arrangement, which is usually so evident, is confused or gone. The 
change commences at the inner or. pupillary margin of the iris, and extends gra- 
dually towards the outer or ciliary edge. This is a symptom which you can 
scarcely overlook. It is rendered certain and unequivocal by comparing the sound 
eye with that which is inflamed. 

The change of colour which I have been describing is occasioned by the effusion 
of lymph. But the same event of inflammation leads to various other changes 
not less striking and more important, in so far as the functions of the organ are 
• concerned. The lymph becomes visible upon the surface of the iris. Its precise 
appearance varies considerably in different cases. Sometimes it presents little 
spots like freckles, or specks of rust: or a thin stratum of the same colour is de- 
posited. Sometimes it exhibits the appearance of drops, or (as they have impro- 
perly been called) tubercles, embossing the surface, and projecting from its pupillary 
edge. These are commonly of a yellowish or reddish-brown colour, and they 
vary in magnitude from the size of a small pin's head to that of a large shot. 
There are seldom more than two or three of these masses. The lymph thus 
effused upon, or thrusting forward the surface, is confined almost always to that 
part of the iris which is nearest to the pupil, to the annulus minor ; while its 



IRITIS. 



209 



ciliary portion, or annulus major, is dull and clouded. Sometimes, when the 
inflammation is very violent, or the disease has been neglected, actual suppuration 
takes place. A reddish-yellow prominence arises from the surface of the iris, 
and at length breaks, and discharges matter which sinks down to the bottom of 
the anterior chamber, and presents the appearance that has been called hypopyon. 
All these changes, I say, become perceptible near the margin of the iris; its free 
edge which, in the natural state, is clear and sharp, becomes rounded and blunt: 
and at the same time the pupil often begins to lose its jet-black colour. 

Another very common consequence of the effusion of lymph from and upon 
the surface of the iris (from its hinder surface, that is, which is called the uvea, 
or from its pupillary edge), is its adhesion to the capsule of the crystalline lens, 
which lies, you know, behind the iris and very near it. And the pupil itself is 
apt to become blocked up by lymph. 

The motions of the iris are seriously impeded by the mere effusion of lymph 
into its texture. At first it moves sluggishly under variations of the light ; gra- 
dually the pupil contracts, and becomes fixed and motionless. The adhesion of 
the iris to the capsule of the lens still more decidedly restrains the action of the 
part. When it adheres at one or more points of the margin, and remains free 
elsewhere, the pupil is deformed ; loses its circular shape ; becomes angular ; and 
this deformity is the most marked when the eye is examined either under a weak 
light, which allows the pupil to dilate, except at the points where the iris is tied 
down to the lens ; or under a very strong light, which forces the free portions of 
the margin, and those only, to approach the centre. Still more palpable does the 
alteration of figure become when the pupil is artificially dilated. 

Vision is always impaired in this complaint : partly because the posterior tunics 
of the eye are liable to be implicated in the inflammatory process ; partly by the 
detriment done to the proper function of the iris, which should duly measure the 
quantity of light admitted to the retina ; partly by the presence of more or less 
lymph, filling up the pupil; and partly by a change, not yet mentioned, which is 
apt to take place, especially in severe cases, in the cornea, and perhaps in the 
aqueous humour. The cornea becomes hazy and. dull, and loses its bright polish. 
It looks like a piece of glass that has just been breathed upon. It has been thought 
(on the ground of analogy chiefly) that the aqueous humour grows turbid under 
the inflammation of the membrane that secretes it; just as serous effusion into the 
pleura is often found to be troubled and thick. But there is no sure evidence that { 
this is the case. While the cornea remains transparent, the aqueous humour is 
seen to be clear; when the cornea is dim and semi-opaque, we cannot distinguish 
the state of the aqueous humour. 

Acute iritis is attended with pain and intolerance of light. To the latter cir- | 
cumstance is probably owing the contraction of the pupil during the progress of 
the inflammation : and then the lymph fixes the pupil in that state of smallness ! 
and contraction. There is pain in the eyeball itself, and in the parts about the 
eye, the brow and temple, most severe at night. There is much variety, how- 
ever, in regard to the pain. Sometimes it is constant and severe, but still more 
aggravated in nocturnal paroxysms. Sometimes, even when the quantity of mis- 
chief that is visible is very great, scarcely any pain at all has been experienced. 

The same remark applies to the constitutional symptoms. In some instances 
these are but slightly pronounced ; but in most cases, particularly in acute cases 
(for iritis, as I have hinted before, is sometimes a chronic disease) there is a good 
deal of fever and headache, the pulse is full and hard, and the tongue white, and 
the sleep is broken. 

If the progress of the inflammation be not checked, it extends itself beyond its 
original seat. It creeps from the pupillary margin to the ciliary ; and thence it 
passes on to the ciliary body, to the choroid coat, and to the retina ; and as this 
takes place, the pain and the pyrexia increase, and blindness is usually the result. 
The delicate texture of the retina is spoiled for ever. 

I have thus described the phenomena of iritis generally : and I will next con- 
14 



210 



DISEASES OF THE EYE. 



sider, in the same manner, the treatment which it requires. It will afterwards 
be necessary for me to mention certain modifications of the disease, in respect to 
its rate of progress, its causes, and the circumstances under which it occurs. I 
say it will be necessary to mention these modifications, because they require a 
corresponding adjustment of the plan of treatment. 

When we have to deal with iritis alone — that is, when the inflammation and 
the changes to which it may have led, are confined to the iris — the disease is 
always, I believe, manageable; and affords a beautiful instance of the power of 
well-directed remedial measures. We cannot always tell whether the inflamma- 
tion has been restricted to the iris or not. 

We have three powerful weapons wherewith to combat iritis; blood-letting; 
mercury ; and a remedy that hitherto has not been mentioned in these lectures, 
belladonna. 

If I were restricted to the use of one of these means, I should choose mercury; 
if to two, mercury and belladonna; but the combined employment of the three 
has the most powerful effect in curing the disease ; and cases that have seemed 
almost desperate, have been retrieved and rescued by these remedies. 

With respect to blood-letting, I shall not run the risk of fatiguing you by dwell- 
ing at any length upon the mode in which it should be employed, or the indica- 
tions for its adoption. I shall content myself with saying that the intensity of the 
local symptoms, especially of the pain, — and the degree in which the general 
symptoms, the fever, and the hardness of pulse, are present, — offer the best mea- 
sure, both of the necessity for bleeding, and of the amount to which it ought to be 
carried. Both will depend somewhat also upon the strength and constitution of 
the patient. Bleeding from the arm till some decided impression is made upon 
the circulation; cupping from the temples; or both these modes of taking blood, 
together or in succession, will often be required. At the same time active purga- 
tives should be exhibited ; and the whole of the antiphlogistic regimen strictly 
enforced. 

But bleeding, assisted by purgatives and the antiphlogistic regimen, will not 
cure the disease ; or it will not cure one case in a hundred. It will stop the inflam- 
mation probably, but not till the organ has been spoiled. Such a termination 
cannot with any propriety be called a cure. We want not only to put an end to 
the inflammatory process, but to repair the mischief which may already have been 
done. 

Yet bleeding is not to be despised or neglected because it is unequal to the cure 
of iritis. It is productive of direct benefit by abating the force of the circulation, 
and by checking the progress of the local inflammation : and it is productive of 
great indirect benefit by preparing the system to submit itself more readily and 
rapidly than it otherwise would, to the specific influence of mercury. Mercury 
is our sheet-anchor in this disease. 

After free blood-letting, then, or after such abstraction of blood from the system, 
or from the part, as the circumstances of the case may dictate, you must administer 
mercury in the manner that I formerly recommended. The object is, in acute 
cases, to affect the gums as speedily as possible; the soreness of the gums, and 
the peculiar foetor of the breath, being the tokens that the whole capillary system 
feels the specific influence of the remedy. Calomel with opium is, in most cases, 
the best form in which mercury can be introduced into the system ; the purpose 
of the opium being to prevent the calomel from running off by the bowels. Two, 
three, or four grains of calomel, with one-fourth, one-third, or one-half of a grain 
of opium, should be given every four, or six, or eight hours. Equal doses at 
equal intervals. 

Some persons prefer giving the calomel still more frequently ; one grain, for 
instance, with one-tenth or one-eighth of a grain of opium, every hour. If the 
gums do not rise in the course of thirty-six or forty-eight hours, and a speedy 
effect is desirable, inunction of the mercurial ointment should be added. And in 



IRITIS. 



211 



some cases mercurial frictions alone may be sufficient, and the most expedient. 
Or the hydrargyrum cum creta, in five or ten grain doses. 

You may have bled your patient freely, and purged him well, and yet, on look- 
ing into his eye, you perceive the mischief to be still going on, and the deposition 
of lymph increasing. But the instant that his gums and breath acknowledge the 
specific agency of mercury upon his system, a welcome change becomes visible: 
the red zone surrounding the cornea begins to fade ; the drops of lymph to lessen ; 
the iris to resume its proper tint; and the puckered and irregular pupil once more 
to approach to the perfect circle : till, at length, the eye is restored to its original 
integrity, .and beauty, and usefulness. 

I speak now of favourable cases. The changes for the better that I have been 
describing are sometimes rapidly accomplished, sometimes slowly. If the disorder 
has been long neglected, irreparable damage may have been done; the effused 
lymph may have become organized ; or firm adhesions may have been already 
contracted between the iris and the lens. But even in cases of some standing, 
when the inflammatory action has in a measure subsided, the use of mercury 
will sometimes greatly improve, sometimes altogether restore, the impaired 
vision. 

With the mercury, both before and while its specific influence is manifested, 
we combine the use of belladonna. 

Doubtless you are all aware of the singular effect of this vegetable poison upon 
the iris. It dilates the pupil. Now it is of great importance in iritis to prevent 
that tendency to contraction which the pupil manifests. If we can artificially 
dilate the pupil, we may prevent the iris from forming adhesions with the capsule 
of the crystalline lens; and if it has recently contracted such adhesions, we may, 
while the lymph is yet soft, stretch or break them. And this power of artificially 
dilating the pupil we possess in the agency of belladonna, and of certain other 
narcotic vegetables. This remarkable effect of the belladonna was first discovered, 
accidentally, by our countryman, the celebrated Ray. He tells us that a noble 
lady of his acquaintance applied a leaf of the plant to a small ulcer, suspected to 
be cancerous, just below one of her eyes. The pupil of that eye became greatly 
dilated, and the membrane remained motionless under the strongest light. This 
effect gradually subsided when the leaf was removed. But it took place on three 
several occasions, and was witnessed by Ray himself. Other vegetables have the 
same property: henbane, for example, stramonium, and the cherry laurel. And 
there are others which have it not, although we might have expected that they 
would possess it, from the analogy they bear to the former in other respects. It 
has been ascertained that neither hemlock, nor aconite, nor foxglove, nor opium, 
has any such power. 

Preparations of belladonna are chiefly, if not exclusively, employed in ophthal- 
mic disorders in this country. It is used in two ways. The extract is rendered 
soft and semifluid by admixture with distilled water, and then is smeared freely 
around the eye, upon the lids, and brow, and forehead. It is washed off after 
remaining an hour: generally it produces a marked effect upon the pupil. 

A more efficacious and speedy mode of dilating the pupil is to drop a solution 
of the extract into the eye itself. The solution is to- be made by rubbing down 
a scruple of the extract in an ounce of distilled water, and filtering the fluid 
through linen. Two or three drops of this solution are to be introduced between 
the eyelids. 

Some very interesting experiments have been made in Germany by Dr. Rei- 
singer upon this property of belladonna and hyoscyamus, of contracting the iris 
— in other words, of dilating the pupil. The result of these experiments is given 
in the 24th volume of the Edinburgh Medical and Surgical Journal. Dr. Rei- 
singer procured atropine and hyoscyamine, the active principles of the two plants, 
and made comparative experiments with these principles, and with the coarser 
extracts ; and he concludes that the former are much to be preferred to the latter. 
Thus, he dissolved a grain of hyoscyamine in ten minims of water, and introduced 



212 



DISEASES OF THE EYE. 



a small drop of the solution into the eyes of several dogs and cats. No irritation 
whatever of the eye was produced in any instance, but the pupil was so much 
widened by the application, that in an hour's time only a small ring of the iris 
could be seen beyond the edge of the cornea ; and after three hours, the pupil 
seemed as large as the cornea itself. The dilatation did not begin to diminish till 
after three days ; and the pupil did not recover its natural dimensions until the 
sixth day. Then he applied a solution of the extract of hyoscyamus, made by 
mixing five grains with ten minims of water. This evidently caused irritation of 
the organ, which lasted from five to eight minutes, and was evinced by a discharge 
of tears, by the animal's shutting its eyes, and rubbing its eyebrows with its paws. 
Much less dilatation of the pupil followed, and continued not more than six or eight 
hours in dogs, and about twenty-four hours in cats. As soon as Dr. Reisinger 
had satisfied himself that the hyoscyamine had no injurious influence either upon 
the conjunctiva, or upon the deeper-seated textures of the organ, he applied it to 
the human eye. He dissolved a grain of hyoscyamine in a drachm of distilled 
water, and inserted a drop of the solution into the eye of an old lady of seventy- 
one, who had cataract. So great was the consequent dilatation of the pupil, that 
only a narrow ring of the iris remained visible. No irritation whatever of any 
part of the eye was produced ; and the dilatation continued for seven days. 

As chemistry is now furnishing us every day, in greater abundance, and with 
more ease, the active principles of various of our medicinal vegetable substances, 
we shall soon, in all probability, adopt hyoscyamine or atropine, for artificially 
dilating the pupil, instead of the preparations now in use. Till that time arrives, 
you had better smear the surrounding skin with the moistened extract of bella- 
donna whenever the eye is painful or much inflamed. But under other circum- 
stances, the solution dropped into the eye is to be preferred for its readier action, 
and its greater power. The use of this curious virtue possessed by certain plants is 
not confined to the cure of iritis : it enables the surgeon to introduce instruments 
through the pupil with greater facility and safety ; it affords us also the means of 
examining the deeper-seated textures of the eye; and it is of great service to many 
persons who are partially blind ; to such, for example, as have central specks on 
the cornea, or central opacities of the crystalline lens; it enables such persons to 
enlarge the window of the eye; to admit more light; and to have painted upon 
the retina, and represented to the mind, the images of objects which, but for the 
mysterious agency of these poisonous vegetables, they could never hope to see 
at all. It is a very fortunate circumstance that the power of belladonna over the 
iris does not diminish by repetition. Mr. Lawrence mentions two patients of his, 
one of whom had used it habitually for four or five years, and the other for four- 
teen or fifteen ; and it dilated the pupil just as well at the end of these periods as 
at the beginning. By carefully examining an eye in which lymph has recently 
been effused, you may distinctly see the good effects of the artificial dilatation of 
the pupil; little strings of adhesion are often visible, connecting the edge of the 
iris with the surface of the lens; and these are stretched, and not unfrequently 
broken, under the influence of the belladonna : and minute black spots may some- 
times be seen upon the capsule, marking the points where the uvea had stuck, and 
where it left behind it, when it was detached by the belladonna, a portion of its 
peculiar pigment. These black points are indelible. There is one case recorded 
in which the pupil, after being dilated by belladonna, became fixed in that con- 
dition ; probably by lymph subsequently effused into its texture, and binding 
together its fibres. Even this is better than that the pupil should be contracted 
and fixed. 

These three remedies, then — bleeding, mercury, and belladonna — are the means 
by which we are to subdue inflammation of the iris, and repair the ravages it has 
occasioned. With respect to the most important of the three, mercury, there are 
some points that require to be further noticed. 

You may ask to what extent the mercury should be pushed, and how long it 
should be continued ? 



IRITIS. 



213 



Why we have, in iritis, an illustration of what I have more than once men- 
tioned before, viz., that the rapidity of a disease will require a corresponding 
haste in the use of its remedy. In acute and violent cases, the mouth should be 
made decidedly sore, as quickly as possible ; and when that has been done, the 
further administration of the mercury may be suspended. " Full salivation," 
says Mr. Lawrence, " quickly produced, cuts short recent disease, as if by a 
charm." In cases of longer standing, or of slower progress, we must be slower 
in the introduction of the remedy: it will be enough to obtain any, the smallest 
certain evidence of its action, in the gums and breath ; and we must keep up that 
moderate influence for some time. For what precise time it is impossible to say ; 
but till the redness has gone, and the natural colour of the iris returns, and all the 
visible lymph has disappeared, and the sight is perfectly restored ; and this may 
require a month or two. 

When you look from day to day into the aqueous chamber of an eye in which 
iritis has recently produced its peculiar changes, and after the due effect of mer- 
cury upon the gums has been achieved, you will be surprised as well as delighted 
to see large masses of lymph rapidly disappear, melt away, as it were, from the 
surface of the iris, while that which had been deposited in its intimate texture, 
rendering it confused and discoloured, as quickly clears off. And you will be 
inclined to believe, as many have done, that mercury has a vast influence in 
promoting and accelerating absorption. It may have such a power: I am not 
disposed to deny it: but that it really has so we cannot safely infer from such 
circumstances. It clearly has the power of arresting the deposition of lymph : 
of putting an end to the adhesive inflammation. Whether it does any thing more 
towards completing the cure, we have these reasons for doubting. When blood 
happens to be effused into the anterior chamber ; or pus ; or when, as frequently 
happens, pieces of a cataract that has been broken up pass through the pupil, and 
show themselves between the iris and cornea ; they (the blood, the pus, the frag- 
ments of the lens) disappear, L e., are absorbed, just as rapidly as the lymph in 
iritis, although not a particle of mercury is taken. Mr. Lawrence even gives a 
case of syphilitic iritis, which got well without any affection of the gums by 
mercury, and which had been marked by the deposition of a large mass of lymph 
on the iris ; and he says that the lymph was immediately absorbed, as soon as 
the inflammation ceased ; and that he never saw it disappear more quickly under 
any circumstances. 

There is one local use of mercury which I must not omit to mention, because 
though it probably has no share in curing the complaint, it is productive of great 
comfort and relief to the sufferings of the patient. It is adapted to those cases in 
which severe pain is felt round and over the orbit of the eye at night. Ten grains 
of the strong mercurial ointment, intimately mixed with two grains of finely pow- 
dered opium, and well rubbed into the temple a little while before the nocturnal 
pain is accustomed to recur, will in many cases completely prevent it. We owe 
this piece of practice to the Germans. 

Iritis is apt to occur from different causes, and in connection with different dis- 
eased states of the system. It is no uncommon accident from surgical operations 
performed upon the eye, the iris suffering mechanical injury. The inflammation 
thus excited is usually violent and acute, and requires that the whole plan of treat- 
ment that I have been sketching out should be actively prosecuted. 

But inflammation of the iris sometimes arises slowly and insidiously, without 
vascularity enough to call attention to the eye, and without, pain. This generally 
happens when the eye has been strained by over-use ; in women who occupy 
themselves with fine needle-work; in engravers, and such as are accustomed to 
look at minute objects, or at bright objects. A more common effect of continued 
exertion of the eyes in this way, is a diseased state of the retina; but (however 
the fact may be explained) the iris is sometimes the part that suffers. In this 
form of the disease mercury will often be found a successful remedy; but its influ- 
ence must be gradually brought about ; and it is not so certainly productive of 



214 



DISEASES OF THE EYE. 



benefit as when it is employed in acute iritis : — probably because the chronic 
inflammation has involved the posterior tunics also. 

But most frequently iritis is met with in combination with syphilitic, or with 
rheumatic disease, which manifests itself at the same time in other parts of the 
body. Syphilitic iritis is more common than any other. It is one of the second- 
ary symptoms of syphilis; and accordingly it is commonly associated with other 
secondary symptoms; with syphilitic eruptions, nodes, pains in the limbs, and 
ulceration of the throat. It is also one of the earlier of these secondary affections, 
and therefore is sometimes the only one to be seen ; and occasionally it declares 
itself before the primary disease is well. The pain that attends this species of 
iritis is chiefly felt at night, but at that time it is apt to be very severe and distress- 
ing, so as entirely to prevent sleep until it takes its departure in the morning. We 
cannot, I believe, distinguish syphilitic iritis with any certainty from other acute 
varieties of the same complaint, by mere inspection of the eye. However, there 
are some points worth remembering in respect of the local phenomena which it 
most commonly presents. 

Syphilitic iritis is never attended (according to Mr. Lawrence) with abscess of 
the iris, and hypopyon ; the lymph is usually deposited in distinct masses ; and 
the pupil becomes angular, and is not unfrequently displaced towards the root of 
the nose, by the adhesions which the iris has contracted with the parts behind it. 
In another variety of inflammation of the iris (which I shall mention to-morrow, 
arthritic iritis) lymph is equally effused from the margin of the iris, but it is not 
usually deposited in a distinct drop-like form. We ascertain the variety of iritis 
with which we have to do by these peculiarities; by the co-existence of other 
tokens of syphilis ; by the periodical character of the nightly pain ; by taking into 
our account the age, the constitutional habit, and the probable state of morals of 
our patient. Syphilis, you know, is not uncommon in children; it is sometimes 
even congenital: but it very seldom affects the iris at that early period of life. 
Among a large number of syphilitic children brought to Mr. Lawrence, he never 
witnessed iritis but once. 

It was in syphilitic iritis that the curative power of mercury over adhesive 
inflammation was first distinctly recognized. But you must not fall into the error 
of supposing that the success of the remedy depended upon the specific character 
of the disorder; upon its connection, I mean, with the venereal virus. Mercury 
is fully as serviceable and as sure in common acute inflammation of the iris. 
Upon this point all men of experience are agreed. " Its influence (says Mr. 
Lawrence) is not confined to the syphilitic form of the disease, but extends equally 
to the idiopathic." And Dr. Farre bears testimony to the same effect. 



LECTURE XX. 
Iritis concluded. Rheumatic Ophthalmia. Amaurosis. 

The principal theme of the last lecture was that most interesting disease, 
inflammation of the iris. 

The symptoms of iritis are these : a radiating zone of vascular redness situated 
in the sclerotica, and surrounding the cornea ; a change in the colour of the iris, 
from gray or blue to a yellow or greenish tint, from brown or hazel to a dusky 
reddish hue; a visible deposit of lymph upon the anterior and innermost portion 
of the iris; a thickening of its free edge; contraction, irregularity, and immo- 
bility of the pupil ; closure of the pupil by lymph; adhesion of the uvea to the 
membrane of the crystalline lens. All these we can see and ascertain for our- 
selves. We can ascertain also the presence of fever, which attends the acute 
forms of the disease. And we learn from the testimony of our patient that his 



RHEUMATIC OPHTHALMIA. 



215 



sight is impaired ; that the influx of light into the eye hurts him ; and that he 
experiences pain in and around the organ, especially at night. 
The grand remedies in iritis are three. 

1. Blood-letting: of which the objects are to abate the force of the heart's 
action : to moderate the febrile disturbance ; and to facilitate the operation of the 
second remedy : which is — 

2. Mercury. This is to be given so as to produce soreness of the gums, and 
the peculiar fcetor of the breath : and these effects are to be sought for rapidly or 
gradually, according as the inflammation of the iris is recent and acute, or moderate 
and chronic. The object of this remedy is to arrest the effusion of coagulable 
lymph : to put a stop to the adhesive inflammation. 

3. The application of the extract of belladonna to the conjunctiva, or to the skin 
around the eye, so as to dilate the pupil. The objects of this measure are to 
prevent the adhesion of the iris to the parts in its neighbourhood ; to detach it 
from the lens when it has already been glued thereto by soft lymph ; and to stretch 
and elongate the bands of adhesion when they cannot be broken : and thus to 
obviate any impairment of the free movements of the iris, and any deformity of the 
pupil, after the inflammation shall have ceased. 

I began to speak of the causes of iritis. 

I say it may be occasioned by mechanical injury ; as during the operation for 
the extraction of a cataract. A clean cut, however, is frequently followed by no 
bad consequences ; a portion of the iris has been shaved off by tjie knife in making 
the section of the cornea, without any injurious result. When iritis is excited by 
mechanical violence, it is acute. 

2dly. A chronic form of iritis is sometimes brought on by excessive employ- 
ment of the eye, in looking at minute or bright objects. 

3dly. The most common species of iritis is that which arises in connection 
with syphilitic disease. It is one of the early secondary symptoms of syphilis. 
It is marked by the co-existence of other secondary consequences of the introduc- 
tion into the system of the syphilitic poison, and by the periodical character of 
the nightly pain : it is never attended with abscess of the iris and hypopyon ; the 
lymph that is effused is deposited in separate masses : and the pupil is often dis- 
placed towards the root of the nose, as well as rendered irregular, by the adhesion 
of the iris to the capsule behind it. 

4thly. It is curious enough that iritis has actually been ascribed to mercury, 
as a cause. This notion can only have arisen from that loose kind of logic, and 
hasty generalization, for which, I am sorry to say, medical reasoners are too often 
distinguished. Mercury is perpetually exhibited for the cure of syphilis ; and 
people who have been treated for syphilis are very liable to iritis. This seems 
to be the only foundation for the opinion in question. When we come to appeal 
to facts, we find no ground for believing that this mineral is thus both bane and 
antidote. If it were so, Benvolio's advice to the slighted Romeo might be very 
pertinently offered to the patient in such a case : 

" Take thou some new infection to thine eye, 
And the rank poison of the old will die." 

Mr. Lawrence has seen no instance of iritis, of whatever kind, in which there 
has appeared to him any reason for attributing the occurrence of the complaint to 
this cause. I have never heard it alleged that persons who have taken large 
quantities of mercury for other diseases, as for affections of the liver in India, are 
particularly subject to inflammation of the iris. On the other hand, iritis has 
come on, in hundreds of cases, in connection with syphilis, though not a particle 
of mercury had been swallowed by the patients. 

Lastly, there is a peculiar form or variety of iritis, called the arthritic or rheu- 
matic. 

This affection is characterized by the following general features. It occurs in 
persons who are subject to gout or to rheumatism, and often forms a part of the 
attack of the one or the other of those diseases. Like them it is liable to return 



216 



DISEASES OF THE EYE. 



again and again; and this circumstance it is which makes arthritic iritis a serious 
disorder. It is seldom that much or permanent damage to vision is effected by a 
single attack ; but adhesions readily form under it, and lymph is effused: and in 
each successive attack fresh effusion takes place : the pupil becomes more and 
more contracted ; and it may be filled up, at last, by an opaque plug of lymph. 
Some patients, however, will suffer ten or a dozen recurrences of the disease, and 
recover almost completely, and enjoy perfect vision in the intervals before the 
sight becomes much impaired. 

Some of the local appearances are more or less characteristic of this variety of 
iritis. It is seldomer attended than the syphilitic variety by a deposition of lymph 
in distinct masses ; the contracted pupil keeps its central position, and is not dis- 
placed towards the root of the nose, as it is apt to be in syphilitic iritis. The 
adhesions that bind the iris to the neighbouring parts are said to be whiter in this 
variety of iritis than in others. It is also a very remarkable circumstance that 
the zone of red vessels encircling the conjunctiva does not approach so close to 
the cornea as in other species of iritis ; but a. white ring is left between the cornea 
and the anterior margin of the zone. Sometimes the circular white stripe is 
partial, being most marked towards the angles of the eye ; sometimes, on the 
other hand, it is as perfect as if it had been described with a pair of compasses. 
I believe, with Mr. Welbank, that the appearance of this bluish ring depends upon 
the less intense degree of the sclerotic inflammation. He says that he has noticed 
its coming on, when syphilitic inflammation of the iris was beginning to yield to 
the action of mercury ; although there had been no such interval during the height 
of the inflammation. Again, the colour of the zone is not so bright as in other 
forms of iritis; it is of a somewhat livid, or slightly purplish tint : and the larger 
vessels at the back part of the eye, belonging to the conjunctiva, are apt to become 
tortuous and varicose. 

Rheumatic iritis is often met with in combination with what is called rheuma- 
tic ophthalmia : a disease which I have not before mentioned. But each may 
exist alone. And as rheumatic iritis, though frequently an independent disease, 
does also in many instances grow (as it were) out of rheumatic ophthalmia, I will 
take this opportunity of shortly describing the latter complaint. 

What is called rheumatic ophthalmia, then, is inflammation affecting the 
fibrous coat of the eye, the sclerotica. We know that the fibrous tissues through- 
out the body are frequently the seat of rheumatic inflammation. Some persons 
are more liable to rheumatism than others — are more readily affected by its ex- 
ternal exciting causes, which are vicissitudes of temperature, and exposure to cold 
and wet. In such persons there seems a tendency to take on inflammatory action 
in all the structures of the same kind ; and most particularly in the fibrous mem- 
branes, and tendons, that help to form the various joints ; and as the sclerotica 
partakes of this fibrous texture, so it is apt to suffer, in its turn, from rheumatic 
inflammation. The connection of the movable eyeball with the head may be 
considered as a sort of joint. The local symptoms are not in general of a violent 
kind; and, as in other parts, the rheumatism seldom leads to any permanent 
alteration of structure ; seldom, at least, when the ophthalmia is confined, as it 
often is, to the sclerotica alone. Perhaps the best way to put you in possession 
of the features that belong to rheumatic ophthalmia will be to describe an actual 
instance of it. I will take a well-marked example, related by Mr. Lawrence. He 
was sent for to see a gentleman who was suffering from what is commonly called 
rheumatic gout: swelling, some redness, and severe pain of one foot and knee, 
and one hand ; aching of the back ; and great constitutional excitement. He got 
well under the treatment adopted. After a short interval, upon Mr. Lawrence's 
calling to inquire how he was 5 he said there was something the matter with his 
eyes ; and asked to have them examined. " I looked at them hastily," says Mr. 
Lawrence : " the room was dark, and ihe day dull ; and I saw no appearance of 
disease. When I called again, after a few days, as the complaint was repeated, I 
examined more attentively. On bringing him towards the window, he obviously 



RHEUMATIC OPHTHALMIA. 



217 



felt the light troublesome ; he drew down the eyebrows, and half closed the lids, 
to avoid it. The conjunctiva was natural ; but the whole of the sclerotica had a 
livid red, and mottled appearance, which might have been called dull, or almost 
dirty, in comparison with the red colour of common active inflammation. The 
sclerotic vessels were partially distended ; the redness terminated short of the 
cornea, so that there was a distinct white rim round the latter. Vision was per- 
fect ; there was no pain so long as the eye remained at rest; but exertion of the 
organ, particularly under strong light, brought on uneasiness. The nature of this 
gentleman's occupations, and of his tastes, which were literary, prevented him 
from giving his eye the necessary repose ; and the condition of the sclerotica just 
described lasted for three or four months ;" so that Mr. Lawrence was apprehen- 
sive that seme serious mischief would ensue to the organ. The affection re- 
mained confined, however, to its original seat, evincing only that obstinate cha- 
racter which belongs to disorders of such structures ; and at last it disappeared 
completely, leaving the eyes with their organization and powers unimpaired. 

The treatment that appears to answer best in simple rheumatic ophthalmia of 
this kind, consists in moderate topical bleedings, and counter-irritation : with 
such other measures as conduce to improve the general health ; and among these, 
change of air and scene have sometimes a decided effect. Those remedies also 
are to be given which have been found by experience to be beneficial in rheumatic 
inflammation, although we cannot always depend upon finding them useful: col- 
chicum, I mean; bark ; sarsaparilla ; the iodide of potassium. In these abiding 
or frequently recurring forms of disease, you will often be obliged to try the so- 
called specific remedies one after the other. 

Now when the rheumatic inflammation is not confined to the sclerotic, but 
creeps inward, as by their vascular connections it easily may, to the iris also, we 
name the disease according to the most important part that it occupies — arthritic 
iritis. On the other hand, when, with that affection of the sclerotic which I 
have been describing, there is combined a moderate degree of inflammation of 
the conjunctiva, this complex disorder receives a compound denomination ; it is 
called catarrho-rheumatic ophthalmia. 

Dr. Mackenzie states it as the result of his experience, that arthritic iritis sel- 
dom occurs in connection with the earlier appearance of gout, while the patients 
still retain strong powers of digestion, and have the means of indulging ther appe- 
tites ; but rather with the asthenic and irregular forms of gout and rheumatism ; 
when repeated attacks have been followed by mental depression, indigestion, 
flatulence and languor. He has generally met with the disease in subjects be- 
yond the age of fifty, very frequently in tobacco-smokers, and whisky-drinkers, 
who have often suffered rheumatic affections, who are teased by headaches, acid- 
ity of stomach, bad gums and teeth, and lowness of spirits : in persons, that is, 
whose health has been impaired and broken by intemperate habits. I believe 
you will find this to be a very correct statement ; although arthritic iritis may 
also take place in those who are more robust. 

After what has now been stated you will be prepared to believe that arthritic 
iritis neither requires nor bears those free emissions of blood, and that liberal use 
of mercury, which are necessary for the cure of other varieties of the complaint. 
Mercury, pushed to salivation, is sometimes found to do more harm to the system 
than good to the eye ; and in a disease which is so apt to recur, we must not be 
continually salivating our patient. I can only say that the treatment must be con- 
ducted on the principles already laid down, and adapted to circumstances. If 
there be any fever, and a hard pulse, and a white tongue, you should bleed and 
purge your patient, and afterwards give him from twenty minims to half a drachm 
of the wine of colchicum two or three times a day. When the symptoms are 
less active, you must be less active too: strive to set the disordered digestive 
organs right, and to correct the bad habits of the patient : give small doses of 
mercury (such as five grains of Plummer's pill) three or four times a week ; ex* 
cite counter-irritation by blisters, or by the tartar-emetic ointment. After the use 



218 



DISEASES OF THE EYE. 



of bleeding or leeches, and the regulation of the bowels, preparations of iron, the 
sulphate of quina — tonics, in short, — have been found, in not a few cases, ex- 
tremely beneficial. 

I should have mentioned another remedy, which of late years has been recom- 
mended in iritis, and especially in syphilitic iritis, by Mr. Carmichael, of Dublin : 
not as being a better remedy in itself than mercury, or so good, but as having con- 
siderable power over the disease, and as affording, therefore, a valuable resource 
when from any cause the exhibition of mercury is forbidden. This remedy is 
the oil of turpentine. He gives it in drachm doses, three times a day. He 
relates cases of syphilitic iritis in which the pain, redness and other symptoms, 
were quickly removed, and effused lymph was absorbed, and vision restored, 
under the use of this medicine. It is necessary to its beneficial action that the 
bowels should not be confined. In other instances of the same disease, Mr. Car- 
michael was not so successful. Mr. Guthrie, who has also tried this remedy, 
reports of it that " in some cases it succeeded admirably, in others it has been of 
little service, and in some unequal to the cure of the complaint." I do not know 
that it has been fairly put to the test in arthritic iritis. 

I proceed next to quite a different kind of ophthalmic disease from any that we 
have yet considered. I have spoken of inflammation of the exterior membrane of 
the eye occurring separately ; and of inflammation of certain internal parts, and 
particularly of the iris, occurring separately. Between these exterior and interior 
tunics, the sclerotica forms a sort of natural barrier or shield, the chief point of 
connection between them being near the edge of the cornea, where the sclerotic 
vessels dive through to reach the iris. Inflammation of the sclerotica itself has 
also been described. When vision is impaired or destroyed in consequence of 
any of the complaints which have hitherto engaged our attention, that effect 
results from the partial or total exclusion of light from the retina. The cornea is 
left opaque, or it bursts ; the pupil, or aperture in the iris, is shut up by a web of 
lymph ; or the capsule of the lens to which the iris adheres has undergone a 
change, and lost its transparency. In each case the retina suffers an eclipse. 

But light may be freely admitted, and yet no vision ensue. The transparent 
parts of the eye, the several media, so skilfully and exquisitely adjusted for the 
due refraction and collection of the rays of light into an image of the object from 
which they flow, may all be perfect and in order ; but the beautiful apparatus is 
useless ; the patient cannot see with it. The fault is in the nervous matter that 
should receive and transmit the impression, and render it an object of perception 
to the mind. 

Now persons in this condition are said to have amaurosis. The term is derived 
from the Greek word a/icwpoj, which signifies obscure or dark. It expresses various 
degrees of imperfect vision, from defective nervous function. The words gutta 
serena are applied to that form of amaurosis in which vision is totally lost. It 
was formerly supposed that this sort of blindness was caused by the effusion of 
some humour or fluid behind the pupil: and this was held to be a clear fluid, 
because the natural blackness of the pupil is sometimes not troubled in amau- 
rosis. Milton has literally translated this term when, speaking of his own eyes, 
he says : 

" So thick a drop serene hath quenched their orbs." 
Amaurosis is a very obscure disease. It is capable of being caused by various 
changes, the exact seat and nature of which we often have no means of deter- 
mining during life ; and which frequently leave no traces behind them in the dead 
body. It would take a much larger space than I can possibly devote to it in these 
lectures, thoroughly to discuss this difficult but interesting subject. I shall endea- 
vour to give you such a sketch of it as you may fill up and complete by future 
observation and reading for yourselves. It will be something to learn the direc- 
tion and objects of our inquiries into what is yet unknown in the pathology of this 
affection, 



AMAUROSIS. 



219 



There is one division of the disorder which immediately suggests itself. The 
cause of defect may exist in the brain, at or beyond the origin of the optic nerve ; 
or it may be situated in any part of the course of that nerve, from its commence- 
ment at the base of the brain to its termination in the retina ; or it may be confined 
to the retina itself. 

There is reason to believe that the functions of the retina may be impaired or 
suspended, by deviations from the natural quantity of blood sent to it; by disturb- 
ances of its circulation. Various degrees of amaurosis are common among per- 
sons who employ the sense of vision overmuch, and strain the eye. This over-use 
is likely to produce congestion, or chronic inflammation, in the vessels of the retina ; 
and very slight changes of that kind may seriously affect the function of a part so 
delicate and tender. I say we frequently meet with amaurosis among those whose 
occupations oblige them to look attentively at small or bright objects during many 
hours of the day ; or what is still more pernicious, during many hours of lamp or 
candle light: so as habitually to fatigue the eye. Engravers, printers, watch- 
makers, tailors and milliners, mathematical instrument makers, persons who gain 
their bread by writing, miniature painters, cooks who are exposed to the heat and 
glare of large fires, men who have the charge of forges or furnaces, and so on. 
Here a continual stimulus leads to a chronic disorder, which, increasing in in- 
tensity, may terminate in total blindness. We call these cases of amaurosis, but 
they may be justly considered to be instances of chronic inflammation of the retina; 
we cannot see the suffering part indeed during life ; and the complaint is not a 
fatal one, and, therefore, we have few opportunities, or none, of examining after 
death the condition of ihe retina while the amaurosis is yet recent. But judging 
from the nature of the causes that precede the defect of vision, and from the nature 
of the remedies that are often found to remove it, we are warranted in regard- 
ing the essence of the disease to be retinitis. The same condition, apparently, 
may be suddenly produced by the transient operation of some more powerful 
cause of congestion : such as intense light. I will illustrate this form of amau- 
rosis — amaurosis, that is, dependent upon congestion, which, perhaps, amounts 
to inflammation, sometimes slowly established, and sometimes very suddenly — 
by the narration of a few cases. I may as well premise, however, that the treat- 
ment which promises most, or I should rather say, which has performed most, in 
this form and kind of amaurosis, is very nearly the same (excepting the use of 
belladonna) that I have already recommended for chronic and acute iritis. Blood- 
letting, general or topical, according as there are more or less pain and fever, and 
fullness of the system, and according as the amaurosis is more or less recent ; and 
above all mercury, so administered as to affect the gums, and rapidly introduced 
into the system in the acuter cases : more slowly in proportion as the disease has 
crept on more gradually and lasted longer. This treatment is very often quite 
successful: the mercury is the most important part of it; and we have in this 
fact a strong corroboration of the inference drawn from the nature of the exciting 
causes, viz., that the complaint is essentially inflammatory. And again, supposing 
it inflammatory, we need not be surprised that a remedy, the curative effect of 
which we can see in inflammation of the iris, should be equally serviceable when 
the same diseased process is set up in the retina, which we cannot see. Purga- 
tives, counter-irritation, and perfect repose of the eye, are necessary parts of the 
treatment in both forms of disease. 

Mr. Allan gives the following account of the master of a printing office, who 
became blind. He had corrected the press, and was otherwise engaged in read- 
ing, for eighteen hours daily out of the twenty-four. He continued this practice 
for twelve months, notwithstanding an evident failure of his sight. At the end of 
that time the amaurosis was so complete that he could not distinguish one object 
from another, but was merely capable of just perceiving the light, so as to grope 
his way along the streets. He continued in this state for several years, but ulti- 
mately recovered his vision. 

The next instance that I shall cite is recorded, in these words, by Mr. Law* 



220 



DISEASES OF THE EYE. 



rence. " A young woman, of florid complexion and full habit, came to the London 
Ophthalmic Infirmary, complaining that she had lost the sight of one eye. She 
was a cook in a family, and occupied for several hours daily before large fires, 
supporting her strength by free living. The pupil was slightly dilated ; the iris 
motionless. A faint and scarcely perceptible pink tint was observed in the scle- 
rotica near the cornea. Vision was dim, and had been so for three days. There 
were headache, flushed countenance, heat of skin, whitish tongue, and thirst. I 
considered the case to be pure retinitis ; and to afford a favourable opportunity for 
showing whether the affection could be arrested by antiphlogistic treatment. At 
that time (now many years ago) I did not possess the knowledge of the power of 
mercury in inflammation of the retina, which subsequent experience has given 
me. I directed a full bleeding from the arm, free purging, low diet, repose of the 
organ, and general rest. At the end of two days the sight was worse: cupping 
and a blister were now ordered ; but there was no improvement at the end of two 
days more. I now determined on trying mercury, and ordered two grains of 
calomel every four hours. Before the remedy had affected the system, vision 
was quite lost, or at least reduced to the mere power of distinguishing light from 
darkness. Full salivation, which took place in about a week from the first appli- 
cation of this patient at the infirmary, suspended all the symptoms ; the sight 
immediately improved, and was soon completely restored." 

A soldier, unacquainted with the proper method of observing an eclipse of the 
sun, employed for that purpose a piece of opaque glass, with a transparent point 
in its centre. Notwithstanding the vivid and painful impression he experienced 
from the rays that passed through the lucid part of the glass, he continued to look 
at the sun till the eclipse was over, using his right eye. He was soon after seized 
with vertigo, and pain in the right side of the head, and found himself almost 
entirely deprived of the sight of the right eye. Some weeks afterwards, the pain 
in the head continuing, he came under the care of Barron Larrey, who observed 
that the vessels of the eye were injected, the pupil somewhat smaller than that of 
the other eye, retaining, however, its natural freedom of motion ; the vision very 
obscure or almost gone. This man recovered his sight completely after two 
bleedings, one from the temporal artery, the other from the jugular vein; blisters 
to the temple and nape of the neck; ice to the head, and moxas. — [Mackenzie 
from the Memoir es de Chirurgie.) 

In the year 1832, a young man standing in a door-way, by a lamp-iron, in a 
thunder-storm, was struck by the lightning, fell backwards, and was convulsed. 
He said afterwards that the lightning appeared to enter his eye with a scorching 
sensation. During the night vision was quite lost. The next morning there was 
no redness, nor any unusual appearance of the eye. The iris was motionless, 
however, and the patient could not see even the sun. He was treated with calo- 
mel, and his sight returned; but the retina remained extremely irritable, and 
unable to bear the light. A month afterwards, when this account was written, he 
could see distinctly enough, but he could not use his eyes without the protection 
of blue glasses. — [Lawrence.) 

In these cases the nervous apparatus that ministers to vision is not, I believe, 
in general, the only part of the nervous system that is injured. In August, 1839, 
Phoebe Judge, a delicate-looking girl, eleven years old, became my patient in the 
Middlesex Hospital. She had lost, in a great degree, the power of using her 
legs : when she attempted to stand they separated, and she sank down. She had 
not perfect control over her bladder. The desire to make water was frequent, 
and if not immediately attended to, the urine escaped in spite of her efforts to 
retain it. The same urgency, and inability to wait, occurred whenever her 
bowels were about to act. Sensibility in the legs and thighs was impaired, but 
not extinct. 

Her parents informed me that some time previously, while stooping to raise up 
a sister in a room at Hampstead, she had been struck by lightning, fell backwards, 
became blind, and remained so for ten days, She did not lose her consciousness, 



AMAUROSIS. 



221 



but complained immediately that the lightning had hurt her eyes. They presented 
no visible injury or defect, but the upper lids fell, and she was unable to raise 
them. It was soon found, however, that when pressure was made on the right 
eyelid she could open the other eye. The palsy of her limbs commenced, by 
degrees, two or three days afterwards. The power of vision returned suddenly, 
and at the same moment the power of moving her limbs was restored ; but it 
gradually went again. When she lay down her limbs were still ; but they began 
to tremble, and to be agitated as soon as she sat up. Even when lying in bed, 
she had, occasionally, a sensation and dread, as if she were falling down. She 
had been in this state nearly three weeks. 

She was put upon steel, and a tonic plan of treatment, and in ten days she 
could walk, dragging her left leg a little after her. In ten days more she was dis- 
missed quite well, and able to run from one end of a long ward to the other. 

The greater number of the cases of amaurosis depending upon a morbid con- 
dition of the retina itself, belong to the class that I have now been mentioning : 
there is congestion of the vessels of the retina; or inflammation, chronic or acute. 
In a few instances a totally opposite condition of the blood-vessels is presumed to 
exist. I say presumed to exist, because our judgment of this matter is founded, 
as before, upon the nature of the circumstances that have caused the affection, and 
upon the nature of the treatment that removes it. On these grounds some cases 
of amaurosis (few in number, speaking comparatively) may fairly be ascribed to 
a deficient supply of blood to the vessels of the retina. We know that a tem- 
porary defect of sight may be produced by a diminished circulation through the 
retina, as in approaching syncope under hemorrhage ; and we can therefore the 
more readily believe that more permanent amaurosis may be occasioned by causes 
that gradually lessen the quantity of blood circulating in the body, and debilitate 
the whole system. " It is well known (writes the late Dr. Gooch) that large 
losses of blood enfeeble vision. I saw a striking instance of this in a lady who 
flooded to death. When I entered the chamber she had no pulse, and she was 
tossing about in that restless state which is so fatal a sign in these terrific cases. 
She could still speak; asked whether I was come ? (she knew I had been sent for) 
and said, ' Am I in any danger ? — How dark the room is ! I can't see.' The 
shutters were open, the blind up, and the light from the window facing the bed 
fell strong on her face. I had the curiosity to lift the lid, and to observe the state 
of the eye. The pupil was completely dilated, and perfectly motionless, though 
the light fell full upon it. Who can doubt that here the insensibility of the retina 
depended on the deficiency of its circulation?" 

One might ask, also, who can doubt that the retina may become insensible from 
a similar state of the circulation in it, brought on by some long-continued drain 
upon the system ? Amaurosis of this kind, proceeding from too profuse and pro- 
tracted a secretion (which may be considered a sort of hemorrhage), is sometimes 
noticed in nurses. Mr. Lawrence describes the case of a young mother of slender 
make, who suckled her first child, which was strong, and took the breast very 
often ; her milk was abundant. After two or three months she began to feel very 
weak, could not lift a weight, and cried frequently, without having any moral 
reason for grief. She became totally blind, and was led to his house by a friend. 
He found her pallid, with a small feeble pulse. The pupils were of middle size, 
and the irides moved slightly. The retina was completely insensible. She could 
not discern the situation of the window, nor see a lighted candle held close to her. 
After weaning the child, and using generous diet, she got perfectly well. Some 
counter-irritation was employed in this instance, but I question whether it had 
any thing to do with the recovery. Such cases are not uncommon, and their well- 
known occurrence has probably tended to encourage the notion — too prevalent 
among both patients and practitioners — that amaurosis is always essentially a dis- 
ease of debility, and requires tonic and stimulant remedies ; bark, and high feed- 
ing, and strychnia, and electricity. "Our eyes are weak" say they, "and we 
require strengthening medicines." You must perceive from what has already 



222 



DISEASES OF THE EYE. 



been said, how necessary it is to discriminate in such cases : to look closely into 
all the circumstances under which the disease has occurred. 

When amaurosis is the result of pressure or of disease, in the course of the 
optic nerve, or in the sensorium, the complaint is generally less within the power 
of remedial measures. We cannot say, indeed, in many instances, where the 
cause of defect lies: and in obscure cases, I should always advise a trial of the 
mercurial plan. I have again and again seen slight palsy of some of the volun- 
tary muscles, evidently depending upon some morbid condition of the brain, clear 
away rapidly upon the affection of the gums by mercury ; and the lost power of 
the retina will sometimes return under similar treatment. 

There is something very peculiar in the expression of countenance, and in the 
gait, of an amaurotic person, by attending to which alone, you may almost recog- 
nize his disease. He comes into a room with an air of uncertainty in his move- 
ments ; the eyes are not directed towards the surrounding objects ; the eyelids are 
wide open; to use a strange but common and intelligible phrase, the patient seems 
gazing upon vacancy — has an unmeaning stare ; and there is a want of that har- 
mony of movement and expression which results in a great measure from the 
information obtained by the exercise of vision. This seeming stare at nothing at 
all, is not observed in patients who are blind in consequence of opacity of the 
crystaline lens or its capsule, i. e., in consequence of cataract. They, on the 
contrary, while they cannot see, still seem to look about them, as if they were 
conscious that the power of sight remained to the retina, although light was shut 
out from it. 

When the amaurosis is incomplete, the motions of the iris are sluggish, and the 
pupil is larger than ordinary. When the blindness is total, the commonest con- 
dition of the eye is that of great dilatation of the pupil, with complete immobility 
of the iris. A mere ring of iris is all that is visible, and no change takes place in 
the diameter of the pupil, under the greatest variation of the light that falls upon it. 

Sometimes, on the other hand, though the amaurosis be total, the iris is as 
active as ever; and this is a very interesting circumstance, and may help us, in 
some degree, to conjecture the actual seat of the malady. When the amaurosis 
is confined to one eye, this may happen. You examine the diseased eye, and 
you find that the pupil enlarges, or contracts, as you diminish or increase the 
light. But the other eye is open. Shut the sound eye, and try the amaurotic 
eye again, and you find the pupil fixed, although you vary the light. The motion 
you formerly noticed was sympathetic of the motion of the iris in the healthy 
eye. We express this otherwise by saying that the associated movements of the 
iris were natural and lively, but its independent movements were lost. But some- 
times the independent movement is unaffected : nay, the motions of both irides 
may be perfect, although both eyes are completely amaurotic. I may state, by 
the way, that caeteris paribus, when both eyes are affected, that is a ground for 
supposing the cause of the disease to be situate within the cranium. And I 
should come to the same conclusion if, in the case where one eye alone was 
amaurotic, I found the independent motion of the iris of that eye unimpaired. We 
know that in the healthy condition of the parts, the brightness of the light admitted 
to the retina determines the size of the pupil; but the motions of the iris do not 
depend solely or directly upon the retina. It has been ascertained, by experi- 
ments made upon animals, that the pupil may be made to contract either by 
mechanical irritation of the optic nerve within the cranium, or by irritation of the 
third nerve; a motor nerve which sends filaments to the ophthalmic ganglion, 
whence the ciliary nerves, passing to the iris, are derived. Now the optic and 
the third nerves have some link of connection within the brain ; and if the morbid 
condition upon which the amaurosis depends is situate deeper than that point of 
connection, we may understand, I think, how disease so placed may destroy the 
power of vision, and yet leave the connection between the retina and the third 
pair unaffected: and then the influence of light falling on the retina, though it fails 
to create a perception in the mind, will be reflected back upon the third pair of 



AMAUROSIS. 



223 



nerves, and so continue to govern the motions of the pupil. In conformity with 
these views, M. Andral relates cases in which amaurosis connected with disease 
in the cerebellum was attended with brisk movements of the iris. 

There are other causes of amaurosis besides those that I have already adverted 
to. It is sometimes produced by the presence of worms in the alimentary canal.* 
It has some obscure connection with teething, probably through irritation of the 
facial branches of the fifth pair. A physician of my acquaintance, residing in 
London, has a young son, who on two or three occasions has caused him great 
uneasiness, by becoming blind in one eye without any obvious cause, and with 
no visible change in the organ ; but the blindness on each occasion has gone off 
again, apparently in consequence of the extraction of some teeth which had grown 
irregularly. I am assured by Dr. Ashburner that such cases are common. Mr. 
Lawrence relates a very singular instance of dental irritation giving rise to amau- 
rosis. A man, thirty years old, was suddenly attacked with violent pain in the 
left temple near the eye, and in that side of the face generally. The pain con- 
tinued to recur from time to time, and at length he discovered that he was blind 
in the left eye. By and by the cheek swelled, and some spoonfuls of bloody 
matter were discharged by a spontaneous opening in the lower eyelid, and then 
the pain subsided ; but after some months it returned with great severity. The 
patient then went to Wilna, with the intention of having his eye extirpated, and 
consulted Professor Galenzowski, who found the left eye totally insensible to 
light, with the pupil dilated, and no other visible alteration. He ascertained, 
however, that the first molar tooth on that side was carious : it had never caused 
the patient much uneasiness ; and the toothache which he had occasionally suffered 
had not been coincident, in point of time, with the pains in the head and eye. 
Dr. Galenzowski thought fit to extract this tooth, and was greatly surprised at 
seeing a small substance protruding from the extremity of its fang. This proved 
to be a little splinter of wood about three lines in length, which had perforated 
the centre of the tooth, and had probably been introduced in using a wooden tooth- 
pick. A probe passed from the socket into the antrum, from which a few drops 
of a thin purulent fluid escaped. The pain ceased almost entirely, and on the 
same evening the eye began to be sensible to light. The vision gradually im- 
proved, and on the ninth day from that time, after thirteen months' blindness in 
that eye, he was able to see with it as perfectly as with the other. M. Galen- 
zowski has since been in England, and he showed Mr. Lawrence the tooth, and 
the splinter of wood. Doubtless he felt some pride in exhibiting these trophies 
of his exploit. 

Amaurosis is said also to occur as an hysterical affection ; and I am certain 
that I have seen this myself. An unmarried lady, of a very nervous and suscep- 
tible habit, came to town in great apprehension about her eyes, the sight of 
one of them being quite gone. I could perceive no defect in the eye itself. I 
saw her in consultation with Mr. Travers, who took an unfavourable view of the 
case, and thought the chance of recovery was very slender. I had one reason 

* [That amaurosis is frequently dependent upon irritations seated within the stomach 
and bowels, and upon derangements of the digestive organs generally, there car* be little 
doubt. We have met with many cases of this kind, and they are repeatedly referred to, 
more especially by the German writers on the disease. Children confined in ill-venti- 
lated and ill-lighted apartments, and supplied with coarse and indigestible food, are 
often affected with a certain degree of amaurotic blindness, which is readily removed by a 
proper hygienic treatment, and such remedies as are adapted to restore the regular func- 
tions of the stomach and alimentary canal. We have observed the disease, also, in children 
who have been at too early an age, confined in crowded school rooms for many hours of 
the day, while their minds were compelled to the performance of tasks beyond their powers. 
Complete blindness, we have known suddenly to occur in consequence of the presence of 
indigestible food in the stomach, and to be as quickly removed upon its expulsion. For fur- 
ther information on this subject, the reader is referred to the chapter on amaurosis by Dr. 
Taylor, in the 2d volume of Tweedie's Library, Philadelphia edition, page 515, and to the 
very able paper of Dr. Jacob on the same subject in the Cyclopaedia of Practical Medicine, 
Philadelphia edition, vol. i. page 78. — C] 



224 



DISEASES OF THE EYE. 



for hoping a better result, in the knowledge of some facts which Mr. Travers was 
not aware of till I mentioned them to him. I had been acquainted with this lady 
for some years, and during that period she had several times almost entirely lost, 
and again recovered, the use of her lower extremities. On two occasions she 
had been affected with aphonia, and unable to speak, except in a whisper, for 
months together ; and then, on a sudden, without any apparent cause, her voice 
returned. I trusted, therefore, that this suspension of the power of vision in one 
eye might be a similar freak ; and so it turned out. After a few weeks the sight 
returned, she knew not how ; and she has since lost it a second time, and a 
second time regained it. 

Certain poisons will produce temporary amaurosis ; and the suppression of 
certain natural evacuations, as of the perspiration, of the menstrual fluid, and of 
the bleeding from piles, and the repulsion of certain eruptions, have been charged, 
by authors, with producing the same complaint. 

In those cases in which amaurosis creeps on slowly and insidiously, as it is apt 
to do from various causes : and more particularly when it depends upon a low 
and chronic inflammation, engrafted upon habitual congestion of the vessels of 
the internal tunics of the eye ; its approach is marked by sundry curious affections 
of the vision. The eye feels full or stiff, and sometimes there is pain of the head 
in its neighbourhood ; the patient complains that he sees things through a fog or 
mist, or as if a thick piece of gauze were interposed between his eye and the 
object he is looking at. In the daylight, the gauze or fog seems dull and murky, 
but in the dark it often appears shining, reddish and fiery : the flame of a candle 
is seen surrounded with a halo of prismatic colours. That amaurosis of this kind 
is often really dependent upon local congestion we are taught by the Icedenlia, by 
the circumstances that aggravate it : thus straining of any kind, which augments 
for the time the fullness of the vessels about the head, will make the mist appear 
more dense : the same effect may be produced by tying the neckcloth tight ; or 
even by stooping. Boerhaave relates the case of a man who, whenever he was 
intoxicated, laboured under complete amaurosis : it came on by degrees, increas- 
ing according to the quantity of wine he drank; and after the drunkenness went 
off, his vision returned. Surely these phenomena are very illustrative of the way 
in which nervous disorders may arise, or be made worse, from mere local ple- 
thora, in almost any part of the body. 

Sometimes the perfect amaurosis is preceded by a remarkable diminution of 
the apparent size of the objects looked at. A patient told Dr. Farre that a car- 
riage, which happened to pass the window, seemed to him as small as a wheel- 
barrow, and the horses no bigger than dogs. More commonly ocular spectra 
become visible : that is, parts of the retina lose their power, or perhaps are 
eclipsed by turgid vessels : the patient sees flies in the air, muscse volitantes, 
particles of soot, blacks, as we, who live in London, call them, which always 
float before his eyes, and seem to follow their motions ; and which are especially 
plain and troublesome when he is looking upon a white surface. They multiply 
in number till the whole becomes dark. 

Do not, however, suppose that the appearance of these muscae volitantes, even 
when .they are permanent, necessarily implies the approach of amaurosis. I 
should be sorry if it were so, for I see two of them every morning, when my 
eyes are directed towards a white basin, while I am washing my face. I can find 
them at other times if I look for them; else I am not sensible of their presence. 
They bode no further evil, if they are associated with no other defect, in function 
or in appearance, of the instrument of vision. 

It is obvious that no particular rules, no rules, that is, which will fit all cases, 
can be laid down for the treatment of so multiform a complaint as amaurosis. 
When it manifestly results from disease of the brain, as when it accompanies 
hydrocephalus, or remains after a stroke of apoplexy, our attention must be di- 
rected to the disease from which it has sprung. When there is any reason to 
suppose that congestion or chronic inflammation of the internal tunics of the eye 



AMAUROSIS. . 225 

itself is concerned in the production of the amaurosis, we must adopt the measures 
that I have already described, as the most likely to remove the congestion ; and 
especially the mercurial plan. When there is ground for suspecting that the 
blindness takes its rise in vascular exhaustion, or nervous debility, we must have 
recourse to tonics ; bark, preparations of iron, nourishing diet, the cold bath. 

After all, you will find too many cases, which will baffle your best-directed 
attempts, and in which you will be required and warranted to try other expe- 
dients. When what I may call rational measures have been expended in vain, 
you may have recourse to such as are empirical and tentative. There are various 
stimulants which have occasionally been found serviceable ; but most of them, I 
believe, fail much oftener than they succeed. Electricity is one of these : it is 
applied by taking small sparks from the eyelids, and from the integuments, round 
the orbit. The object of this is to rouse the dormant energies of the impassive 
nerve : and it appears sometimes to do this for the retina, as well as for the nerves 
supplying voluntary muscles. Mr. Ware tells us that electricity is most beneficial 
in those cases in which amaurosis has succeeded a stroke of lightning. You must 
take great care not to employ this remedy when there is any inflammatory action 
at the bottom of the complaint: it should seldom be tried therefore when the 
affection is recent. 

Strychnia has, of late years, been used for the cure of amaurosis. I shall 
hereafter take an opportunity of telling you the ordinary effects of that substance 
upon the body, when given in a certain dose — what is its poisonous operation, 
and what may sometimes be hoped from it as a remedy. In amaurosis it does 
good, when it is useful at all, by stimulating the exhausted or atonic nerve into 
action. With respect to this remedy also I may say — first endeavour to ascertain 
that it is not likely to do harm ; as it will be if the blindness depend upon any 
condition akin to inflammation. Mr. Middlemore, of Birmingham, has probably 
given this remedy an ampler trial than any other person, and he speaks very 
favourably of its effects in certain cases : in others he found it to produce so 
much pain, and spasm, and distress, that he was obliged to discontinue its use. 
It is not given, in these cases, by the mouth, but applied locally, and Mr. Middle- 
more considers that it is most efficient when placed over the supra-orbitary nerve. 
He puts a narrow blister above the eyebrow ; when it has risen he cuts off the 
cuticle, and applies a piece of linen, for half an hour, to absorb the serum that 
continues to ooze forth; then he sprinkles the strychnia, finely powdered, upon 
the raw part, and covers it with linen smeared with the unguentum cetacei. He 
repeats this every twenty-four hours, cautiously increasing the- dose till the vision 
improves, or some sensible evidence of the agency of the strychnia becomes 
apparent. He commences with the sixth part of a grain. 

I must here leave the subject of diseases of the eye. 

In addition to the lessons which I pointed out before as capable of being learned 
by attending to the disorders of this small organ, I may now mention a few others, 
of no little moment, since we shall meet with their application again and again, as 
we proceed to investigate the morbid conditions of other parts. We have seen 
enough to convince us that mercury, properly administered, has the invaluable 
power of stopping adhesive inflammation; of arresting the effusion of coagulable 
lymph from the blood-vessels : that inflammation of a given part may be sensibly 
modified by the simultaneous agency of some specific poison upon the system, as 
that of syphilis ; or by the presence of constitutional tendencies to disease, such 
as are observable in gouty and rheumatic people. And we have seen that the 
functions of a nerve may be perverted, suspended, or abolished, in various ways : 
by pressure made upon it ; by a plethoric state of its blood-vessels, or by an empty 
state of them; by inflammation of its texture, chronic or acute: and even, in 
some mysterious, or hitherto unexplained manner, by mere irritation of a distant 
part; by worms, for example, in the alimentary canal; by poisonous substances 
introduced into the stomach ; and by what, in our ignorance, we denominate the 



226 DISEASES OF THE BRAIN 

freaks and caprices of hysterical disorder. All these lessons we shall find repeated, 
as the course advances. 



LECTURE XXI. 

Diseases of the Brain and Nervous System. Difficulties of the subject. Short 
Review of some points in the Physiology of the Brain and Nerves. Peculi- 
arity of the Cerebral Circulation. Pressure. 

Having considered some of the most important disorders of the eye, because 
they afforded me the means of illustrating many of the doctrines and principles, 
which I had previously endeavoured to lay before you, of general pathology, I 
go next to the diseases of that portion of the body, which, though it includes many 
distinct parts, is called, collectively, the head. I pass over the maladies to which 
the integuments of the head are liable, because they will fall more naturally and 
conveniently into the class of cutaneous disorders ; and I come at once upon one 
of the most interesting, and at the same time most difficult and obscure subjects 
of special pathology — that which embraces the diseases of the brain and nerves. 
Though it will be a slight departure from the plan I have proposed of taking dis- 
eases as they affect different parts of the body from the head downwards in suc- 
cession, I shall speak of the diseases of the spinal cord, and of the nervous system 
generally, in connection with those of the brain. To disunite them would neither 
be easy nor useful. 

The study of the maladies and disordered conditions of the brain and nervous 
system, is surrounded with peculiar difficulties : and, accordingly, our knowledge 
of these diseases is less precise than of the diseases of most other parts of the 
body. 

1. One source of difficulty lies in the circumstance, that the structure of the 
nervous system has no perceptible or understood subservience to its functions. 
We do not discover in the mechanism of this system that adaptation of means to 
an end which is so conspicuous in many other parts of the body: and conse- 
quently, though such adaptation doubtless exists, we are not able to trace the 
reason or the manner of its interruption. We find in the lungs an apparatus of 
tubes and cells fitted for the reception of air, upon the expansion of the chest by the 
contraction of certain muscles ; of which muscles also we can see and understand 
the action. If we meet with any obstruction of those tubes, or any obvious im- 
pediment to the play of those muscles, we perceive at once how and why the 
function of respiration is deranged. But no alterations that become visible, after 
death, in the brain or spinal marrow, afford us any explanation of the interruption 
of their proper functions ; which are, in three words, sensation, thought, and 
motion. An apoplectic cell has no relation, direct or inverse, that we are capable 
of appreciating, with a sentiment ; nor a distended lateral ventricle with the exer- 
cise of the will. The morbid anatomy does not in any degree elucidate the dis- 
order, simply because the natural structure throws no light upon the healthy office 
of the parts concerned. 

2. It is a further source of difficulty, that physiologists have not yet been able 
to determine, with any thing like precision or certainty, what share the several 
parts of the brain and spinal cord have in regulating, respectively, the functions 
which all physiologists acknowledge to belong to the nervous system in the ag- 
gregate. There are many and convincing reasons, for believing that the brain is 
a complex organ ; but we can seldom put our finger upon this or that portion of 
the nervous matter which composes it, and say, here resides the influence that 
governs this or that particular function. 

3. Again, the brain and cranio-spinal axis are so encased by their bony cover- 



AND NERVOUS SYSTEM. 



227 



ings, that, in the living body, we are unable to ascertain their physical conditions 
by means of any of our senses. Of many parts of the frame we ascertain the 
state by the sense of sight; and of many parts that we cannot see, we still may 
recognize the changes by the faculty of touch, or by the ear. The brain and 
spinal cord we can neither see, nor hear, nor handle. 

4. Besides these obstacles to the acquisition of information by the exercise of 
our own senses, concerning the organs affected, the very disturbance of the func- 
tions of the brain cuts us off, in many cases, from that kind of information which 
we might otherwise derive from the statements of the patient himself. 

5. There is a still greater cause of perplexity, with which we have to contend. 
The very same symptoms accompany alterations of the brain apparently of a very 
different, nay of the most opposite kind ; and on the other hand, changes of stfuc-. 
ture, which, as far as we can perceive, are absolutely identical in their nature, 
are associated, in different cases, with totally different symptoms: and more fre- 
quently than not, nervous diseases are attended with no alterations of structure, 
appreciable by our senses. 

6. And lastly, we are perpetually asking ourselves, when we find the proper 
functions of the nervous system disordered, — is this disorder the result of disease 
in the nervous matter itself? or is it merely sympathetic of disease in other parts? 
for there are few diseases of any kind which do not in some degree, modify or 
disturb the due exercise of the offices of the brain and nerves : and it is very diffi- 
cult often, and sometimes it is impossible, to determine whether, and how far, the 
disturbance is primary or secondary. 

With all its. difficulties, however, the pathology of the brain and nerves is 
always full of interest. How can it be otherwise, when we reflect that the 
nervous system is the medium through which we hold communion with the world 
around us ; the stage upon which all the phenomena of animal life are transacted: 
the instrument of the mind? 

And with all its difficulties, there is also a good deal in the pathology of the 
brain and nerves that is fairly made out and well understood ; and we are at pre-, 
sent in the right way for advancing our knowledge of this intricate and mysterious 
subject, by that careful collection of facts, and rigid induction of particulars, that 
will lead, at length, to a safe and useful generalization. 

I shall endeavour to point out to you what is known of the morbid conditions 
of the nervous system ; I shall also state the conjectures and probabilities by 
which our judgment and practice must be guided, when absolute certainty is un- 
attainable. With mere speculative questions, that have no practical bearing, I 
shall meddle as little as I can. 

Ourknowledge, I say, of the exact functions of the different parts of the nervous 
apparatus, is scanty and imperfect. Some certainties, however, we possess ; and 
some strong probabilities which almost amount to certainties. Without first ex- 
pounding my creed upon these matters, it would be impossible for me to explain, 
as it would be for you to understand, the notions I entertain respecting many of 
the diseases of the brain and nerves. 

Omitting the sympathetic nerve and its ramifications (for we know but little of 
its office, and still less of its disorders), the nervous system is made up of certain 
masses of nervous matter, called the nervous centres; and of nerves therewith 
connected. 

The nervous centres consist of the cerebrum and cerebellum, the medulla ob- 
longata and the medulla spinalis. I shall include the cerebral hemispheres, and 
the lobes of the cerebellum, under the common term, the brain. So I shall speak 
of the oblong and of the spinal-marrow, in the single phrase, the spinal cord, or 
the craniospinal axis ; their endowments appearing to differ more in relation and 
degree than in kind. 

I adopt the belief that the gray (which are much the more vascular) portions of 
these nervous centres, form the part in which their peculiar powers reside, or are 



228 



DISEASES OF THE BRAIN 



generated ; and that their white or fibrous portions are, like the white and fibrous 
nerves, mere conductors of the nervous influence. 

I incline, also, to the opinion (recollect, if you please, that I do not press these 
opinions of mine upon you as being necessarily correct) that the influence which 
originates in the gray matter, and is transmitted by the white, will at last be found 
to consist in, or to be closely connected with, some modification of electricity. 
We know that some of the effects of this influence may be very exactly imitated, 
in animals recently dead, by galvanism. 

The functions of the brain and nerves are sensation, thought, volition, and the 
power of originating motion. Other functions indeed there are ; but these four 
are all that we need, at present, concern ourselves with. 

Now, it is a part of my creed, that the faculties of sensation, of thought, and 
of the will, belong to the brain: in all probability to the cerebrum alone. The 
precise office of the cerebellum is involved in much obscurity and dispute. Some 
of the opinions that have been formed respecting it, I shall notice hereafter. 

The chief grounds for believing that the brain proper is, exclusively, the instru- 
ment of the mind, are these : — 

1. Because this portion of the nervous centres is superadded to the cranio-spinal 
axis, in the greatest bulk and most complicated form, in man: and after him, in 
those of the inferior animals which show the largest share of reason. 

2. Because, in inferior animals which evince a certain amount of mental endow- 
ment, all manifestation of intellect ceases upon the gentle and gradual removal of 
the cerebrum and cerebellum : the animals continuing to live, for a long time, not- 
withstanding this mutilation. 

Again, it forms part of my creed on these subjects that the motive power resides 
in the spinal cord. 

The muscles furnish the instruments of motion. 

Now there is a certain class of muscles which contract without our willing their 
contraction: and generally without our being conscious that they are contracting. 
Such are the heart, the muscular fibres of the alimentary canal, and of the blad- 
der. These are, therefore, called involuntary muscles. 

There is another large class of muscles which obey the bidding of the will, 
and serve the purposes of prehension, locomotion, and bodily effort. These are 
considered and called voluntary muscles. 

There is still another distinct set of muscles, of which the habitual action is 
involuntary, yet which submit also to the interposing control of the will. You 
will call to mind at once the muscles of respiration, which act while we are asleep, 
or otherwise unconscious ; and the sphincters, which regulate the entrances and 
outlets of the body. Here, I say, the habit is involuntary, but the occasional 
action is prompted and governed by volition. But sometimes the involuntary 
action rebels against the willed action, and overcomes it. The muscle contracts 
in spite of the will. 

Nay, those muscles which, ordinarily, move only in obedience to volition, do 
sometimes, under the influence of strong emotion, or of disease, contract inde- 
pendently of any effort of the will, and even in opposition to, and defiance of, the 
voluntary power. 

Under certain circumstances the limbs move with much briskness and force in 
decapitated animals, in which sensation and volition are extinct. Some physiolo- 
gists hold, indeed, that sensation and volition are properties of the spinal cord ; 
and they would object to these cases, that no one is warranted in affirming the 
movements in question to be independent of the will. The animal has no means 
of informing us whether it feels or not, any more than the human head that has 
been severed by the axe or the guillotine. 

This point, however, has been settled by certain phenomena which are observed 
to occur, in the human body, under disease. Limbs completely palsied as to 
voluntary motion, and quite dead as to sensation, do yet, under certain conditions, 



AND NERVOUS SYSTEM. 



229 



contract and move when the integuments are pinched ; the rational patient not 
feeling the pinch, and not being conscious of the movements. 

Whence does the impulse that leads to motion in these cases proceed — how is 
the motive power awakened ? 

The answer to this physiological question has a most important bearing upon 
the pathology of the nervous system. 

It is no part of my purpose to enter into any history of the steps by which this 
curious problem has been worked out. Its solution is an achievement of our own 
time ; and I may add, of our own country. I profess no more than to sketch, in 
mere outline, the leading facts that have been ascertained ; yet I must, in passing, 
pay the tribute due to one indefatigable labourer in this department of science, 
whose sagacity has enabled him to seize the clue, and in a great measure to unfold 
the mazes of the labyrinth in which this part of the physiology of the nervous 
system was so long entangled. Dim and uncertain glimmerings of the truth 
appear in the writings of bygone authors, but it was never clearly discerned, and 
plainly stated, and successfully applied to the elucidation of a large class of dis- 
orders, until the publication, in 1832 or 1833, of Dr. Marshall Hall's ingenious 
and most interesting researches into " the functions of the medulla oblongata and 
spinal cord." Similar views appear to have suggested themselves, about the 
same time, to Professor Miiller of Berlin. I must recommend you to study the 
works of these authors ; and I may also point out, as fit writings for your perusal 
(since the doctrines I am now speaking of are comparatively new), Dr. Grainger's 
Observations on the Structure and Functions of the Spinal cord ; Dr. Carpen- 
ter's two works, Principles of General and Comparative Physiology, and Prin- 
ciples of Human Physiology : and a very able paper on the Pathology of the 
Spinal Cord, by Dr. William Budd, in the 22d volume of the Medico- Chirurgi- 
cal Transactions. 

If, on the other hand, you wish to see how nearly the idea, which has been so 
happily simplified into an intelligible principle by Dr. Hall, was reached by 
earlier observers, you may consult the writings of Dr. Whytt, upon nervous 
diseases. 

What, then, respecting this intricate subject, are the main facts and doctrines 
which modern research has made clearer? 

It seems ascertained, that the movements of those muscles which acknowledge 
the empire of the will, depend essentially upon some momentary change in the 
condition of the spinal cord. This change (whatever may be its nature) is capable 
of being effected in three several ways. 

First, volition, or emotion, originating in the brain, may send down an influence, 
which travels with electrical rapidity to the spinal cord : whence, the requisite 
change having been instantly produced, the motive influence passes, with propor- 
tional speed, along the nerves which connect the cord with the muscles to be 
moved. 

Secondly, the change productive of motion may be wrought in the cord, whether 
the brain be attached to it or not, by mechanical, chemical, or electrical agencies, 
operating directly upon the cord itself. 

Thirdly, the change productive of motion may be wrought in the cord, by an 
influence carried to the cord, not from the brain, but from the extremities of nerves 
distributed upon the internal and external surfaces of the body. 

The action of this nervous circle, whereby, I say, an influence is first carried 
from the surfaces of the body, along nerves to the spinal cord- — whence again an 
influence is transmitted, or reflected, as it were, to certain' muscles along certain 
other nerves — has been called by Dr. Hall the reflex function of the spinal cord. 
The apparatus subservient to this function is named by him the excito-motory sys- 
tem; the nerves which carry the impression to the cord are incident or excitor 
nerves; those which convey the motive impulse from the cord, reflex or motor 
nerves. Dr. Carpenter's terms (which I like better, except for their similarity in 
sound) are afferent and efferent nerves. 



230 



DISEASES OF THE BRAIN 



Mr. Grainger believes that physiology indicates, and anatomy can exh.ibit,/bwr 
sets of fibres belonging to the nerves and the nervous centres. ISensiferous, and 
volition nerves, connected with the gray substance of the cerebrum, and subordi- 
nate to the exercise of feeling and of the will ; and incident and reflex nerves, 
connected with the gray matter of the cord, and belonging to the excito-motory 
system. 

Whether this be the true state of the case, or whether the efferent fibres be the 
same, while the afferent fibres are different; the latter coming to the spinal marrow 
both from the brain and from the various surfaces, just as two trains may arrive 
at Euston Square ultimately by the same rail, although the one starts at Derby 
and the other at Birmingham ; or (which is perhaps the better illustration) just as, 
in some houses, the same bell is made to ring in the servants' hall by pulling, 
indifferently, the dining-room or the drawing-room rope: — which of these two 
hypotheses is the more correct, I am not competent to determine. 

This reflex action, independent of the will, and although attended often by con- 
sciousness and sensation, yet often also exercised when there is neither, governs 
the orifices by which air and food are introduced, and excrements are voided. 
The infant breathes and sucks by it; the adult uses his will for bringing nutriment 
into his mouth ; in both, the act of deglutition, after the food has reached a certain 
point, is involuntary. The expulsion of the feces, the urine, the semen, and the 
foetus, is regulated by the same function. Nevertheless, most of these muscular 
acts are capable of being moderated and directed by volition. The reflex power, 
on the other hand, extends, both in health and in disease, to the entire system of 
the strictly voluntary muscles; during health it is manifested only in the mainte- 
nance of what is called their tone, their natural tension and firmness : in disease, 
as we shall hereafter see, it sometimes acts upon them with terrific energy. 

Some of the difficulties which I enumerated in the beginning of the lecture, as 
impeding our researches into the diseases of the nervous centres, are insurmounta- 
ble. One or two of them, however, appear to call for a more attentive considera- 
tion. 

I say we often fail to discover any deviation from the natural condition of these 
nervous centres, or of their appendages; even when the disorder of their functions 
has been broadly displayed. 

We are not to infer, from this, that no change has taken place in these parts. 
The only legitimate conclusion is, that the nervous functions are liable to be 
deranged, impaired, or suspended, by altered conditions, not traceable by our 
senses, or at least not yet discovered by us, of the organs which minister to those 
functions. 

There may be only one such undiscovered disturbing cause, variable in degree 
in different cases ; or (what is more probable) there may be several such conditions 
differing in kind. A blow or fall, which jars the brain ; a sudden mental emo- 
tion; an electric shock ; a teaspoonful of prussic acid; anyone of these causes 
may destroy life, yet leave no vestige of its action in the nervous substance upon 
which it operates. It is probable that the fatal condition is not, in each case, the 
same. 

We may even form a reasonable conjecture of the manner in which the invisible 
changes are sometimes brought about. We can conceive, for example, that undue 
pressure upon the nervous pulp on the one hand, or insufficient pressure on the 
other, may constitute conditions of the kind we are in search of; and I shall be 
able, I think, to convince you that such is sometimes the case. Again, we can 
conceive that such conditions may be furnished by the varying state of the cere- 
bral circulation. In point of fact, we know of some changes in the circulation 
through the brain which have the effect, invariably, first of modifying, and at 
length, if they are continued, of arresting, the cerebral functions. If no blood be 
sent through the arteries of the brain, death in the way of syncope ensues; if 
venous blood circulates in those vessels, it leads to death by coma. 



AND NERVOUS SYSTEM. 



231 



But whatever may be the nature of the unknown, and perhaps fugitive, physi- 
cal conditions of the nervous centres, thus capable of disturbing or abolishing their 
functions, it is useful to keep in our minds a distinct and clear conception of the 
fact that there must be some such physical conditions. By steadily retaining this 
idea of their real existence, we may hope, at length, to get some insight into their 
nature ; which we are the less likely to obtain, if we dwell only on the obvious 
and visible injuries effected in the nervous substance; associated, as they are apt 
to be, with so perplexing a diversity of symptoms. Indeed, by the help of this 
distinct conception, we are at once enabled to reconcile some of the seeming 
anomalies and inconsistencies to which I before adverted. The same symptoms, 
I repeat, have been found to accompany physical lesions of the nervous centres, 
apparently different in kind, place, and degree : and, on the contrary, physical 
lesions, apparently identical in their nature, extent, and situation, are attended by 
different and contradictory symptoms. We must not attribute the symptoms, in 
such cases, to the visible physical lesions, but to some unperceived condition of 
the nervous centres, concomitant with those lesions. The proximate cause of 
the symptoms escapes our notice. The obvious physical changes may be remoter 
causes of the symptoms — causes of this proximate cause : but they may also be 
merely cotemporaneous effects of some other remote agency. 

I have adverted to deviations from the natural and healthy circulation of the 
blood through the brain, as being capable of modifying the nervous functions. Of 
such deviation, one mode which is conceivable, and which has been assigned as 
a presumed cause of morbid phenomena, is a variation in the relative quantity of 
blood contained respectively in the arteries and veins that lie within the cranium. 
And it seems probable enough that a healthy condition of the cerebral circulation 
may imply and require a certain balancing and adjustment of the amount of blood 
carried in these two sets of vessels. But with this theory — that disturbance of 
the functions of the brain may result from an altered ratio of the arterial and venous 
blood therein — has been associated another ; namely, that although the blood .may, 
at different times, be variously distributed between the cerebral veins and arteries, 
yet that the absolute quantity of blood circulating within the cranium is always 
and necessarily the same, or nearly so. 

This notion, broached by the second Monro of Edinburgh, and upheld (as it 
then seemed) by experiments performed upon animals by Dr. Kellie, received at 
a later period the sanction and approval of Dr. Abercrombie. And, resting upon 
such authority, I have been in the habit of delivering the same theory, not, how- 
ever, without some misgiving as to its soundness, in these lectures. It has been 
completely overthrown, of late, by Dr. George Burrows. 

The doctrine was this. The brain is closely shut up in an unyielding case of 
bone. Its surface must therefore be exempt from the influence of atmospheric 
pressure. Hence, supposing its substance to be unaltered and incompressible, it 
would seem impossible to empty the blood-vessels of the brain. The cavity being 
completely full, the blood which circulates in those vessels can neither be mate- 
rially increased, unless something is displaced or compressed to make room for 
the addition; nor materially diminished, without the entrance of something to 
supply the place of the blood subtracted. 

Dr. Kellie noticed that while, in animals bled to death, the other organs of the 
body were emptied of their blood, and blanched — the brain presented its ordinary 
appearance, and even seemed to contain more blood in its superficial vessels than 
usual. Having satisfied himself upon this point, he varied his experiment. He 
first made a small opening in the scull, by means of the trephining instrument, 
taking away a little circular piece of bone, and then he bled the animals until they 
died : and in these cases he found that the brain was as completely drained of red 
blood as the rest of the body. He did that with respect to the cranium which 
housekeepers do when they tap a barrel of beer. You know that if the barrel be 
quite full, you may introduce a fawcetat its lower orifice, but no beer will run out 



232 



DISEASES OF THE BRAIN 



through it. The pressure of the atmosphere operates upon that portion only of 
the fluid which is now exposed to the air, and its effect is to keep the beer in. 
But if you bore a small hole with a gimlet through the top of the cask, and so 
admit air to the upper surface of the beer, it will then flow readily through 
the lower outlet. Dr. Kellie imitated this process of making a vent-hole, when 
he trepanned the skulls of sheep, and admitted air to the yielding membranes of 
the brain. 

He availed himself, also, in these researches, of what he considered the con- 
verse experiment. He desired to ascertain whether, under circumstances calcu- 
lated to gorge the vessels of the head, those of the brain were or were not made 
really more full than usual. With this object he examined the brains of two men 
who had been hanged. When the scalp in these cases was divided, a great quan- 
tity of blood escaped ; marking plainly enough the congestion of the vessels exterior 
to the cranium, but there was no such congestion observable within. " The sinuses 
contained blood, but in no extraordinary quantity ; the larger vessels on the sur- 
face and between the convolutions were but moderately filled; and the pia mater 
was, upon the whole, paler, and less vascular than we often find it in ordinary 
cases." Similar appearances have been noticed by myself. I paid particular atten- 
tion to the condition of the head during the examination, below-stairs, of the body 
of Bishop, the murderer of the Italian boy. When the corpse was brought hither 
after the execution, the eyes were blood-shotten, and the lips and countenance 
turgid and livid. The inner surface of the scalp, when it was turned back, and 
the exposed surface of the skull, were very red and bloody; and in one part, on 
the right side of the head, there was some blood extravasated. But when the 
bone had been sawn through, and the skull-cap removed, the large veins of the 
brain did not appear unnaturally full. 

In the year 1826 I was present in St. Bartholomew's Hospital, at the opening 
of the head of a woman who had been hanged the day before, for murder. I find 
the following statement in a note which I made at the time. " The scalp was 
bloody, but the brain was of very natural texture and appearance, and not more 
than commonly full of blood." 

Among the propositions deduced by Dr. Kellie from his observations and ex- 
periments were the following: — 

1. That in the brains of animals that have died of hemorrhage, there is no lack 
of blood, but, on the contrary, very often a state of venous congestion. 

2. That congestion of the cerebral vessels is not met with in those cases in 
which we should most expect to find it; in persons, for example, who die stran- 
gled. 

3. That the quantity of blood in the cerebral vessels is not affected by gravita- 
tion : in other words, that it remains the same, whatever may be the posture of 
the body, and the position of the head. 

Dr. Burrows, distrusting the whole theory, and unsatisfied with the experi- 
ments by which it was fortified, determined to repeat them, taking care as much 
as was possible, to exclude every conceivable source of fallacy : and he has 
shown., most convincingly, that Dr. Kellie's conclusions were erroneous. 

First, he demonstrated that hemorrhage has a most decided effect in depleting 
the eerebral blood-vessels, and in reducing the quantity of blood within, as well 
as upon the outside of the cranium. Two well-grown rabbits were killed: the 
one (A) by opening the jugular vein and carotid artery on one side of the throat ; 
the other "(B) by strangulation. Round the throat of the first, as soon as it was 
dead, a ligature was tightly drawn, to prevent any further escape of blood from 
the vessels of the head. 

"The contrast between the two brains in point of vascularity, both on the 
surface and in the interior, was most striking. In the one, scarcely the trace of 
a blood-vessel could be seen ; in the other, every vessel was turgid with blood." 

He next investigated the effect of posture upon the condition of the intercranial 
vessels. 



AND NERVOUS SYSTEM. 



233 



" Two full-grown rabbits were killed by prnssic acid ; and while their hearts 
were still pulsating, the one (C) was suspended by the ears, the other (D) by the 
hind legs. They were left suspended for twenty-four hours ; and before they 
were taken down for examination, a light ligature was placed round the throat of 
each rabbit, to prevent, as effectually as was possible, any further flow of blood 
to or from the head, after they were removed from their respective positions. 

M In the rabbit (C) the whole of the external parts of the head, the ears, the 
eyeballs, &c, were pallid and flaccid ; the muscles of the scalp and bones of the 
cranium were also remarkably exsanguine. Upon opening the cranium, the 
membranes and substance of the brain were pallid, the sinuses and other vessels 
were exsanguine — anaemic beyond my expectation. 

" In the rabbit (D), the external parts of the head, the ears, eyeballs, &c, were 
turgid, livid, and congested. The muscles and bones of the cranium were of a 
dark hue, and gorged with blood, which at some parts appeared extravasated. 
Upon opening the cranium, the membranes and vessels were dark and turgid with 
liquid blood; the superficial veins were prominent, the longitudinal and lateral 
sinuses were gorged with dark blood, and there was straining of the tissues, if 
not extravasation of blood into the membranes. The substance of the brain was 
uniformly dark, and congested to a remarkable extent." 

From these experiments, Dr. Burrows draws the logical inference, that " the 
principle of the subsidence of fluids after death operates on the parts contained 
within the cranium, as well as upon those situated in the thorax or abdomen." 

And of that absence of vascularity sometimes observed within the skulls of 
persons who have died of strangulation, he offers a very satisfactory explanation. 

In the first place, the cerebral vessels are, in some instances, highly congested. 
Something will depend upon the position of the rope ; which may press unequally 
upon the jugular veins on the opposite sides of the neck, leaving one of them 
more or less pervious. 

" But there is another still more efficient cause of the occasional absence of 
congestion of the cerebral vessels after death by hanging. It is the subsidence of 
the fluid blood after death, while the body is yet suspended, through the cervical 
vessels which are not completely obliterated by the pressure of the cord. And, 
it should be recollected, there are some channels which are scarcely, if at all, 
affected by the compression of the rope. These other channels are the vertebral 
sinuses, and special plexus of veins, so ably delineated by M. Breschet." 

Moreover, the manner in which the corpse is generally examined, proves an 
additional source of fallacy. All the great vessels of the neck are usually cut 
across, and the viscera of the thorax removed from the body, before the skull is 
opened. Then, while the head is elevated, during the operation of taking off the 
calvarium, and examining the brain, the blood, still fluid (as it almost always 
remains, after sudden death of any kind,) " gravitates from the cranium, and pours 
from the divided cervical vessels into the chest." 

By this refutation of a prevalent error, not unlikely to warp or mislead our 
practice in some cerebral disorders, Dr. Burrows has done the science of medicine 
an essential service. 

The theory which he has demolished involved probably more than one erro- 
neous assumption. Dr. Burrows thinks that the anatomical structure of the human 
cranium does not warrant the opinion that its contents are withdrawn from the 
pressure of the atmosphere. " The numerous fissures, and foramina, for the 
transmission of vessels and nerves through the bones of the cranium, appear to 
me (he says) to do away with the idea of the cranium being a perfect sphere, like 
a glass globe, to which it has been compared by some writers. If there were not 
always an equilibrium of pressure on the parts within and without the cranium, 
very serious consequences would arise at the various foramina of the skull." 

We fall back, therefore, upon another principle, whereby some of the difficulty 
and obscureness which attend certain affections of the brain and nerves may be 
explained. I mean the principle of varying pressure upon the nervous substance. 



234 



DISEASES OF THE BRAIN. 



Physiologists say that the cerebral matter is incompressible. This is another of 
the questionable assumptions implied in the foregoing theory. Upon what grounds 
the opinion may rest, I am ignorant: but whether the brain be compressible or 
not, whether, that is, it be or be not reducible by pressure into a smaller compass, 
it is clearly capable of having different degrees of pressure applied to it, and of 
being pressed out of its ordinary form. We shall see, hereafter, that by pressure 
exercised from within, by the distension of what are called the ventricles of the 
brain, the convolutions on its surface are sometimes flattened, and the natural 
furrows between them nearly effaced. Pressure there certainly is in what I shall 
have to describe to you as hypertrophy of the brain. There must be considerable 
pressure on the nervous pulp when blood is poured out within it from a ruptured 
artery in ceVebral hemorrhage. But the phenomena noticeable when a portion 
of the skull has been removed by the trephine, show very clearly that the ence- 
phalon sustains pressure from varying states of the circulation during perfect 
health. The surface of the brain, seen through the circular opening in the bone, 
is observed to pulsate ; and to pulsate with a twofold motion. With every systole 
of the heart, the surface prptudes a little ; and it again subsides with the succeed- 
ing diastole. This shows that the tension of the arteries, produced by every con- 
traction of the ventricles of the heart, exerts a degree of pressure upon the contents 
of the cranium. But the brain has an alternate movement also, corresponding with 
the movements of the thorax in breathing; rising with every act of expiration, and 
sinking with every act of inspiration. Now, during expiration, the blood escapes 
less freely from the head through the veins ; and thus again vascular fulness is 
found connected with evidence of pressure on the parts within the head. In 
further proof of this, if any were needed, I may again refer to Dr. Kellie's experi- 
ments. He removed a portion of the cranium of a dog by the trephine. The 
brain was observed to rise and fall alternately, but so as always to fill the cranium ; 
the rise being marked by a sort of protrusion through the hole that had been made. 
One of the carotid arteries was now opened, and in a minute or two afterwards 
there was an evident gradual sinking and receding 1 of the brain from the margin 
of the bone. So, likewise, when the blood was flowing from the rabbit (A) in 
Dr. Burrows' experiment, "the conjunctiva was observed to become pallid, and 
the eyeballs to shrink within the sockets." 

It is certain then that, whether the cerebral pulp yields to it or not, there is a 
constant alternation of a greater and a less compressing force, exerted upon it, 
during life. It is not improbable that this continual variation of the compressing 
force may be essential to the performance of the cerebral functions. May not the 
brain be thus incessantly charged, if indeed it be (as has been suggested by no 
less a philosopher than Sir John Herschel) " an electric pile, constantly in action," 
discharging itself by the nerves, at brief intervals, " when the tension of the elec- 
tricity developed reaches a certain point?" However this may be, it is equally 
certain that the compressing force may transgress its natural limits, in either 
direction ; may be too great or too little. The functions of the nervous centres 
may be perverted, or lost, when the pressure becomes excessive ; or, on the other 
hand, when the pressure is insufficient. 

It is plain that excess of pressure may cause fatal coma, or defect of pressure 
fatal syncope, and yet no evidence of the operation of these causes be left in the 
dead brain. And we may explain, by the help of this same theory of pressure, 
a very singular phenomenon observed in certain forms of cerebral disease ; I 
mean the occasional recurrence only of the symptoms, although the organic dis- 
ease itself be permanent. For example, we see continually persons who are 
epileptic : that is, they have fits of convulsion and stupor now and then, and 
appear perfectly well in the intervals. After the death of such patients we some- 
times find organic disease of the brain ; a piece of bone perhaps projecting from 
the cranium, or a tumour, or a cyst : and this we are apt to consider as a suffi- 
cient explanation of the preceding disease ; but we are always pressed with this 



SYMPTOMS OF CEREBRAL DISEASES. 



235 



difficulty; if the tumour or piece of bone was the cause of the paroxysms, why 
had the paroxysms any cessation ? 

It seems probable, or not improbable, that in such cases as these, and in many 
others, the permanent morbid condition is a predisposing cause only of the occa- 
sional symptoms ; rendering the diseased organ more sensible to variations in the 
circulation; to accidental circumstances which determine an undue amount of 
compressing force, or a deficient amount; and I think Dr. Abercrombie has gone 
too far when he says " we may safely assert that the brain is not compressible 
by any sucli force as can be conveyed to it from the heart through the carotid and 
vertebral arteries." 

Dr. Kellie narrates the following curious circumstance : — " Mr. G., with a 
numerous train of distressing symptoms, which too well marked the existence of 
enlargement of the heart, and the violent propulsive energy of that viscus, had 
only one characteristic of any disturbance within the head. On looking upwards 
to the whitened ceiling of a room, he saw a darkened spectrum, which vanished 
and reappeared with great regularity. It was soon discovered that the appearance 
of this umbra was synchronous with the systole of the heart, so that he used 
often, in my presence, to count his pulse with the utmost precision, by keeping 
his eye fixed on the ceiling, and numbering every appearance of the spectrum." 
In this case it is presumable that by each contraction of the left ventricle of the 
heart, plethora of the cerebral blood-vessels was produced, and therefore an excels 
of pressure upon the cerebral substance. In that which I am about to quote it 
seems, on the other hand, probable that comparative emptiness of the vessels of 
the brain, and a consequent defect of the requisite degree of pressure, occasioned 
the morbid phenomenon. 

A gentleman, thirty years old, was reduced to a state of extreme weakness and 
emaciation by some complaint of his stomach. As the debility advanced he be- 
came very deaf; and this symptom varied in the following instructive manner. 
He was very deaf while sitting erect, or standing; but when he lay horizontally, 
with his head quite low, he could hear very well. If, when standing, he stooped 
forwards, so as to produce flushing of the face, his hearing was perfect; and upon 
raising himself again into the erect posture, he continued to hear distinctly as 
long as the flushing continued : as this went off the deafness returned. (Aber- 
crombie.) An old clergyman, who is sometimes my patient, is troubled by two 
grievances : deafness and an intermitting pulse. They are both always benefited 
by quina. 

Objections, I should tell you, have been raised against this theory of pressure 
affecting the functions of the nervous centres ; but I think the objections are sus- 
ceptible of a satisfactory answer. I must content myself, however, for the pre- 
sent, with having pointed out the main grounds upon which the theory rests. 
The difficulties that attend it, and the considerations which diminish the force of 
those difficulties, will come necessarily before us on a future occasion. 



LECTURE XXII. 

Symptoms of Cerebral Diseases. — Inflammation of the Dura Mater and Arach- 
noid, from external injury ; from Disease of the Bones of the Ear, and of the 
Nose. — Inflammation of the Pia Mater. 

The functions of the brain, summarily expressed, being sensation, thought, and 
voluntary motion, we naturally look for disturbances of those functions whenever 
the organ suffers disorder or disease. And experience has made us familiar with 
various forms of disturbance to which these same cerebral functions are liable. 
Let us pass them shortly in review, 



236 



DISEASES OF THE BRAIN. 



1. The faculty of sensation may be morbidly keen, or morbidly obtuse ; or it 
may be perverted : in other words, it may deviate in degree, or in kind, from the 
healthy standard. 

The sensations referred to the several surfaces and structures of the body, and 
to the organs of sense, may (without any fault in those parts and organs) be pre- 
ternaturally acute. Tenderness ascribed to different parts, their natural sensations 
being heightened into pain ; a general state of irritability ; intolerance of light, 
and of noise ; are so many instances of this over-sensitiveness of the percipient 
organ. 

Under the head of diminished or defective sensation may be ranked, numbness 
in all its degrees, up to total loss of sensibility or anesthesia ; dullness of hearing, 
deafness ; dimness of sight, blindness ; failure, or absolute extinction of the senses 
of taste and of smell. 

Perverted sensations, sensations unnatural in kind, are very numerous. To 
mention a few: giddiness ; nausea ; ringing in the ears; ocular spectra; ill smells 
in the nostrils; false tastes on the palate; itching; and sundry uneasy feelings, 
many of which are indescribable. Various kinds of pain belong to this class ; 
spirits violently high ; causeless depression, anxiety, and dread. 

2. Innumerable degrees and varieties of disturbance of the faculty of thought 
are met with. Delirium in all its shades; dullness and confusion of intellect; 
sundry defects of memory ; incapacity of judgment; and every degree of stupor 
up to complete coma. 

3. Of the function of voluntary motion there are also various kinds and grada- 
tions of derangement : twitchings of the muscles ; tremors of the limbs ; rigidity 
from spasm; irregular and involuntary jactitation ; convulsions; muscular debility ; 
palsy. 

Now, as I stated before, there is, and there can be, no physical exploration of 
the living brain. We are limited, therefore, in studying its diseases, to the rational 
symptoms. It becomes our task to interpret the import of the multiform disturb- 
ances of function just enumerated, in every case in which more or fewer of them 
appear ; and when you are told that these symptoms are apt to present themselves 
in almost every conceivable order and combination, and, moreover, that many of 
them may be sympathetic of diseases of other parts than the brain, you will 
scarcely need to be further informed, that the language they speak is often very 
hard to construe ; that we frequently fail to reach and discover, by these outward 
signals, the inward things they denote. 

I am about to consider, in the first place, some of the inflammatory affections 
of the brain, and some which may easily be mistaken for inflammatory affections ; 
and I warn you beforehand, that, in respect to exactness of diagnosis, we are 
sadly barren of certainties in these matters. Hints, sketches, approximations, are 
nearly all that I can promise concerning not a few of the many diseased conditions 
to which the brain and its appendages are obnoxious. 

In the brain, as in other composite organs, inflammation may be general or 
partial. It may attack certain tissues only : it may be seated in the substance of 
the cerebral mass ; or in the membranes that envelop it. 

I need not tell any of you that the membranes which invest the brain are three 
in number; the fibrous dura mater, the serous arachnoid, and the pia mater, which 
is composed of blood-vessels held together by a web of areolar tissue. 

Speaking generally, inflammation of the cerebral substance alone, is perhaps 
more common than inflammation of the investing membranes alone. The central 
parts of the nervous mass may and do suffer inflammation, while the membranes 
escape. But it seems to me scarcely possible that inflammation of the pia mater 
should take place without implicating also the surface of the convolutions with 
which it has so close a relation, and so intimate a vascular connection. 

Again, with respect to the membranes themselves, the dura mater may be 
inflamed while the pia mater remains unaffected. I believe also that the arach- 
noid may suffer inflammation, and leave the subjacent pia mater untouched, 



DURA MATER AND ARACHNOID. 



237 



Whether the arachnoid ever escapes participating in the inflammation of the 
dura mater on the one side, or of the pia mater on the other, is to be doubted. 

Can we separate and distinguish these several inflammations by assigning to 
each its proper external phenomena? Seldom; scarcely ever. Doubtless each 
has its peculiar symptoms; and if inflammation were often strictly limited to the 
one membrane or the other, and if the course and events of the inflammation did 
not modify the condition of the brain itself, by pressure, or by affecting the circu- 
lation of blood through it, then we might expect greater uniformity, and might hope 
by careful and repeated observation to seize upon the desired distinctions. But 
this simplicity is not exhibited by the inflammatory affections of the parts within 
the cranium. Inflammation commencing in one membrane is apt to spread readily 
and rapidly to the rest, and to the cerebral substance; and the complication of 
diseased conditions coexisting within the skull at the same time, throws confusion 
over the whole subject. This uncertainty of exact diagnosis is however of the 
less consequence, inasmuch as when we have learned that inflammation is going on 
in any part of the encephalon, we have learned enough to direct us as to the 
general plan of treatment to be adopted. 

After all, certain symptoms do present themselves more frequently when one 
part is inflamed, and certain other symptoms more frequently when another part 
is inflamed ; and it will be proper and convenient to contemplate certain forms of 
meningeal inflammation separately. 

Let us, first, then, consider inflammation as it is confined, occasionally, to the 
dura mater — or to the dura mater and arachnoid. 

This very rarely happens as an idiopathic or spontaneous disease; but it is not 
at all uncommon as a result of external injury. And we may advantageously 
trace its ordinary phenomena and consequences, by attending to these instances 
of traumatic inflammation of the dura mater. They were excellently well de- 
scribed many years ago, by Mr. Pott. A man receives a blow on the head; the 
blow stuns him perhaps at the time, but he presently recovers himself, and 
remains, for a certain period, apparently in perfect health. But after some days 
he begins to complain ; he has pain of the head, is restless, cannot sleep, has a 
frequent and hard pfllse, a hot and dry skin, his countenance becomes flushed, 
his eyes are red and ferrety ; rigours, nausea, and vomiting supervene : and, 
towards the end, delirium, convulsions, or coma. Meanwhile the part which was 
struck becomes puffy, tumid, and somewhat tender; and if this tumid portion of 
the scalp be cut through, the pericranium beneath it is found to be separated from 
the bone; moreover, the bone itself is observed to be altered in colour, whiter and 
drier than the healthy bone ; and if a piece of this bone be removed, it is also 
seen that the dura mater on the other side of it is detached from the cranium, and 
sometimes smeared with lymph or puriform matter. This is a form of disease 
very often met with by the surgeon. I have watched, with much interest, several 
such cases under the care of my hospital colleagues. One or two of them I will 
briefly describe. 

In the year 1833, during Christmas time, the coachman of a lady living in my 
neighbourhood fell, being intoxicated, into a cellar or area, struck in his fall one 
side of his head, and tore up the scalp over a considerable space. He was car- 
ried to the hospital, where the loose flap of integuments was cleansed and replaced. 
After some days erysipelas came on, and then a much larger portion of the scalp 
sloughed away, so that the bone was laid bare to a frightful extent, and looked, at 
a little distance, as he sat up in bed, like the tonsure of a monk. Nevertheless the 
man seemed wonderfully free from suffering or distress : his pulse, indeed, was 
frequent, but it was said to be so during health. His intellect was clear, and he 
had no head symptoms ; or rather, no brain symptoms. 

In the early part of February, 1834, he had a shivering fit, which was followed 
by convulsions of the right side of the body, and subsequently by paralysis of 
the right arm and leg, and by stupor, from which he could easily be roused. 



238 



DISEASES OF THE BRAIN. 



He would put out his tongue when desired to do so ; but to every question he 
answered "yes." A portion of the left parietal bone was evidently dead : here 
the trephine was applied ; and a piece of bone being removed, the dura mater 
was exposed. It looked as if it also had* lost its vitality. Some pus lay upon it. 
No relief followed the operation. 

On the 10th of February fluctuation was detected beneath the dura mater, which 
was then slit open. About three drachms of puriform fluid escaped. The patient 
died soon afterwards, having had no active delirium throughout. 

The surface of the dura mater was found to be nearly of its natural appearance, 
except where the trepanning had been performed. At that spot it was dry and 
sloughy. Over the whole of the anterior and lateral surface of the left hemi- 
sphere there lay, upon the arachnoid, a thick coating of coagulable lymph, smeared 
with pus: this extended down the posterior part of the hemisphere also, nearly to its 
base. There was no other morbid appearance ; no fluid in the pia mater, nor in 
the ventricles. The substance of the brain was everywhere perfectly sound and 
healthy : it was divided in all directions in search of an abscess, but nothing 
unnatural could be detected. 

Another man came to the hospital to have a small incised wound of the scalp 
looked at. The injury appeared to be trivial; the cut was dressed, and the man 
made an out-patient. A few days afterwards he came again, incompletely para- 
lytic on one side of his body. I saw this man's skull trepanned ; he was perfectly 
calm and collected: that part of the dura mater which corresponded to the wound 
was found to be inflamed; and there was pus diffused over the arachnoid covering 
the cerebral convolutions on the same side. He sank quietly into a state of coma, 
and so died. Not the slightest incoherence or delirium had been manifested : there 
had been no convulsions, nor was there any other morbid appearance within the 
cranium. 

I mention these cases to show you the grounds of my own opinion, that inflam- 
mation, beginning in the fibrous membrane, may affect the arachnoid, without 
necessarily extending to the pia mater; just as inflammation may overspread the 
pleura, or the pericardium, without touching the lung or heart which those serous 
membranes respectively clothe. Here no sensible traces of inflammation were 
discovered deeper than the free surface of the arachnoid ; and there had been no 
disturbance, till towards the end, of the proper functions of the brain. I conclude 
that the disease did not pass beyond the serous membrane ; for I can scarcely con- 
ceive inflammation of the pia mater to exist without involving, in some degree, 
the surface of the brain; nor inflammation of the surface of the brain to exist 
without some manifest derangement of the cerebral functions. In the instances 
that I have been relating, the final stupor and palsy may reasonably be ascribed to 
pressure resulting from the events of the inflammation of the arachnoid : from the 
effused pus and lymph. 

Inflammation of the dura mater is very rare as a simple and idiopathic affec- 
tion. Dr. A bercrombie relates one instance of it, as the only one he had seen; 
and even that was not a pure case of inflammation of the dura mater. There was 
pus upon that membrane, which adhered to the cranium over a space as big as a 
crown-piece, and at that spot was ulcerated. But there was also found an adven- 
titious membrane beneath the arachnoid where it covers the brain. 

Speaking generally, this complaint is marked by pain of the head, by fever, and 
by rigors which intermit; and so regular sometimes are the intermissions, that the 
practitioner may be tempted to believe that he has got an aguish patient, and to 
administer bark. The intellectual faculties, especially at the outset of the disease, 
are but little affected ; which is just what we might expect. The dura mater and 
the arachnoid lying apart from the sensorium, their inflammation can have no other 
than an indirect influence upon its functions. 

Although inflammation of the dura mater is very uncommon as an idiopathic or 
primary disorder, we very frequently meet with it as a secondary affection ; and 
then there are few diseases more surely fatal or less within the reach of remedies. 



DURA MATER AND ARACHNOID. 



239 



It is as a consequence of what is called otitis, that physicians are chiefly accus- 
tomed to encounter inflammation of the dura mater. It results from disease of 
the internal ear, and of the petrous portion of the temporal bone. Sometimes 
acute inflammation arises within the tympanum, when there has been no previous 
disease : the patient has severe headache ; at length a gush of matter comes from 
the external meatus, but the pain does not, as it usually does in such cases, cease ; 
it continues, or even increases in intensity : the patient begins to shiver ; he be- 
comes dull and drowsy; slight delirium, perhaps, occurs; and by degrees he 
sinks into stupor. In some instances no pus issues externally. More commonly 
symptoms of the same kind supervene upon a chronic discharge of purulent mat- 
ter from the ear. It is scarcely possible to sketch an accurate general picture of 
this insidious but most dangerous complaint. Next to seeing and watching actual 
cases of it, the best way of becoming acquainted with its phenomena is by attend- 
ing to recorded instances. I will bring before you, therefore, some examples of 
inflammation of the dura mater, occurring in connection with disease of the interior 
of the organ of hearing. 

A youth, sixteen years old, applied to the late Dr. Powell (who has related the 
case in the fifth volume of the Transactions of the College of Physicians) on ac- 
count of an eruption, with an acrid discharge behind the right ear. He had become 
deaf five years before, after scarlet fever, but no discharge took place at that time 
from the ear. In the following year, however, he had the measles, and then an 
abscess formed in the right ear; and after giving him much pain, it burst. He had 
again suffered, three days before Dr. Powell first saw him, a sudden attack of very 
severe pain in the same ear. The pain quite deprived him of rest; but he had 
no fever, nor delirium, nor coma. He slept, indeed, a great deal, but that was the 
effect of opiates, which he took to relieve the pain. This symptom was quieted 
by the opium; but it always returned with severity if the medicine was sus- 
pended. A foetid discharge came from the ear. On the tenth day of this attack, 
after a most violent paroxysm of pain, his strength rapidly declined, and he died. 

" When the head was examined, the structure of the dura mater was healthy 
and natural, but beneath this membrane the whole superior surface of the right 
hemisphere was covered with a layer of coagulable lymph and pus. The ves- 
sels of the substance of the brain were not more numerous or loaded than usual, 
and the brain itself was healthy in every part. In the base of the skull the dura 
mater adhered to the bone, except at one part, of about half an inch diameter, 
just over the petrous portion of the temporal bone, where it was black and 
sloughy. The subjacent portion of the bone itself was carious, black, and crum- 
bling; and contained foetid pus." 

In this case, you will observe, there was no symptom to mark the extensive 
mischief within the head, except the pain : the pulse never exceeded 72 ; the 
skin was warm and moist; there was neither fever, nor delirium, nor convulsion, 
nor coma. 

A girl, aged nine, (I take this case from Dr. Abercrombie, whose volume on 
the diseases of the brain is full of practically instructive examples,) had been lia- 
ble to attacks of suppuration of the ear, which were usually preceded by severe 
pain, and some fever. She suffered one of these attacks in the left ear, in July, 
1810. Upon the discharge of matter from the ear she did not obtain ease, as she 
had done on former occasions ; but continued to be affected with pain, which 
extended over the forehead. When Dr. Abercrombie saw her, he found that, 
besides the pain, she had some vomiting, and impatience of light. Her look was 
oppressed ; the pulse 84. Blood-letting, purging, blistering, and mercury, were 
employed without relief. Two days afterwards there was slight and transient 
delirium, a degree of stupor, and slight convulsions. She lay constantly with 
both her hands pressed upon her forehead, and moaning from pain, of which there 
had not been the least alleviation. On the fifth day from the commencement of 
the discharge, she continued sensible, and died suddenly in the afternoon, without 
either squinting, blindness, or coma, the pulse having been always under 90. A 



240 



DISEASES OF THE BRAIN. 



considerable quantity of colourless fluid was found in the ventricles of the brain, 
which, in other respects, was healthy. In the left lobe of the cerebellum there 
was an abscess of considerable extent, containing purulent matter of intolerable 
foetor. The dura mater, where it covered this part of the cerebellum, was thick- 
ened and spongy, and the bone corresponding to this portion was soft, and slightly 
carious on its inner surface ; but there was no communication with the cavity of 
the ear. 

Here again the pain was the most prominent symptom, and probably resulted 
from the partial inflammation of the dura mater. It is interesting to mark these 
two points: — that the disease in the bone imparted disease to the dura mater, 
although no passage was opened from the tympanum ; and that this inflammatory 
state of the external membrane of the brain led (apparently) to deep-seated sup- 
puration in the cerebellum ; the parts lying between the abscess and the dura 
mater escaping. 

This last, and somewhat singular circumstance, might have been owing, (so at 
least I conjecture,) to the extension of the inflammation from the suppurating ear 
to some of the veins of the skull ; and the consequent formation in the cerebellum 
of one of those secondary abscesses so commonly noticed in uncircumscribed 
phlebitis. Two very remarkable instances of diffused inflammation of veins, and 
of its terrible effects, occurring in connection with purulent otorrhcea, have fallen 
under my own observation; one of them in private practice, the other in the hos- 
pital. As I am not aware that such consequences as supervened in these cases 
upon otitis, have received much attention, I will briefly describe them. 

The first of these two patients was a boy, eleven years old, whom I attended 
with Dr. Maclntyre and Mr. Arnott. He had had a discharge of offensive puru- 
lent matter from his ear since the time when, four years before, he had gone 
through scarlet fever. In August, 1833, he went, for a walk, into Kensington 
Gardens, and there lay down, and slept upon the damp grass. The next day he 
was attacked with headache, shivering, and fever. Strong rigors, followed by 
heat and perspiration, occurred very regularly for two or three days in succession ; 
suggesting the suspicion that his complaint might be ague : but then pain and swell- 
ing of some of the joints came on, and. were, at first, considered rheumatic. How- 
ever, the true and alarming nature of the case soon became apparent. Abscesses 
formed in and about the affected joints ; and one of these fluctuating swellings 
was opened, and a considerable quantity of foul, grumous, dark-coloured matter 
let out. After about a fortnight the child sunk under the continued irritation of 
the disease. The hip-joint presented a frightful specimen of disorganization; it 
was full of unhealthy sanious pus, the ligamentum teres was destroyed, the arti- 
cular cartilages were gone, and matter had burrowed extensively among the sur- 
rounding muscles. The knee and ankle joints of the same limb were in a similar 
state. It is curious that the destructive disease of the joints was limited to those 
of the right lower extremity, while the primary suppuration was in the left ear. 
Unfortunately the head was not examined ; but that the fatal disorder had pene- 
trated from the ear to the dura mater, I entertain no doubt: in all probability the 
inflammation had involved the veins or sinuses of the head. 

The second case had many points of similarity with this. 

William Marriott, aged 19, was admitted under my care into the Middlesex 
Hospital, on the 18th of October, 1834, having pain and tumefaction of the right 
shoulder, wrist, and foot, with redness of the latter. He complained also of 
headache, vertigo, drowsiness, and of an occasional feeling of stupor. His skin 
was hot and dry, his face flushed, his tongue furred, his pulse frequent (112), 
and his bowels were relaxed. A puriforrp discharge came from his right ear. 

He had been suddenly seized, a week before, with sharp pain in that ear, 
which lasted twenty-four hours, when the discharge commenced, and the pain 
was relieved. He then began also to have headache, which had never left him, 
and to be sometimes dizzy. Three days previously to his admission the rheu- 
matism (as he supposed it to be) commenced in the foot. When this part was 



DURA MATER AND ARACHNOID. 



241 



examined, the redness was found to be circumscribed, somewhat livid, and limited 
to the great toe. It had much the appearance of gout. 

He soon began to be troubled with shivering fits, which recurred regularly 
every morning about the same hour, and were followed by burning heat of the 
skin, but no sweating. An abscess formed near the toe, and was opened by Mr. 
Mayo, and some healthy-looking pus evacuated. Next a large fluctuating tumour 
near the shoulder was punctured, and three ounces of pus, mixed with blood, 
came out. After this incision the rigors ceased; but the abscesses continued 
open, and the discharge had an offensive smell. On the 14th of November it 
was discovered that matter had collected in the left hip : this also was emptied by 
puncture. On the 1st of December, a very large quantity, not less than three 
pints, of unhealthy and grumous pus, was let out from a vast abscess which had 
formed in the loins : and pus was noticed in his stools. The discharge from the 
shoulder came at last to resemble the lees of port wine. 

During all this while the patient remained feverish, with a dry parched tongue, 
and a rapid and feeble pulse. The diarrhoea continued, more or less, throughout. 
For some time before his death, which happened about the middle of the month 
of December, the left leg and thigh had been much enlarged by 03.de ma. 

1 was not able to be present at the inspection of the body ; and I have to regret 
that in the report which I received of it, the condition of the brain, of its mem- 
branes, and of its veins, was not noted. 

The right shoulder-joint was extensively diseased ; the cartilages were destroyed 
by ulceration over a considerable space. Those of the left hip were entire, but 
the synovial cavity was full of foul matter. The joint of the great toe was impli- 
cated also in the abscess which had formed there. The femoral vein, on the left 
side, was plugged up, throughout its whole extent, by a coagulum, which was 
firm and of a reddish brown colour at the upper part of the vessel, loose and 
darker towards the ham. The saphena was pervious: the iliac was free from 
disease. 

The lungs had undergone partial disorganization. Several distinct portions of 
the pulmonary tissue were nearly solid, while the tissue immediately around them 
was crepitant and healthy. From these small solidified portions, purulent matter 
could be made to ooze by gentle pressure. 

The mastoid cells of the right temporal bone were filled with pus, and there 
was a slit-like opening in the membrana tympani. The small bones of the ear 
were sound. 

I much lament that in these instances, the direct link of connection between the 
disease of the ear and the disorganization of the joints was not demonstrated : for 
seeing (they say) is believing. Yet the pain of the ear, the discharge of pus 
from the external meatus, the subsequent pain of the head, coming on with fevers 
and rigors, and followed after a short interval by destructive suppuration in seve- 
ral distant parts, and, in the last case, the actual femoral phlebitis : these circum- 
stances form a chain of presumptive evidence, amounting, in my judgment, to 
moral certainty, that the fatal mischief, in each case, found entrance through " the 
porches of the ear;" and that the dura mater underwent inflammation. The 
same evidence is scarcely less affirmative of the complication of cerebral phle- 
bitis. Perhaps the veins of the diploe, which in the cranial bones are of con- 
siderable magnitude, were involved in the inflammatory mischief; perhaps the 
large sinuses of the brain. The close vicinity of the lateral sinus to the diseased 
bone, and its formation by a duplicature of the dura mater, would seem to render 
such a complication highly probable. 

These views, which were brought forward in my first course of lectures here, 
in 1836, have been confirmed by the publication, very recently ( 1841) in the 
Medical Gazette, by Dr. Bruce of Liverpool, of two cases witnessed by himself, 
of" Phlebitis of the cerebral sinuses as a result of purulent otorrhcsa." He refers 
to several other instances of the same kind recorded by different authors. This 
combination of disease is doubtless more common than had been heretofore sup- 
16 



242 



DISEASES OF THE BRAIN. 



posed : and the important pathological considerations connected with it will pro- 
bably receive further illustration, now that the attention of the profession has been 
called to the subject by Dr. Bruce's paper. 

Dr. Griffin has published, in the Dublin Journal of Science, two examples of 
otitis attended with symptoms exactly resembling those of intermittent fever. 
One of them is as follows : — A young man, previously healthy, was attacked with 
fits of shivering, accompanied by pain in the left side of the head. At first the 
paroxysms were rather irregular, but they soon assumed the form of tertian ague; 
coming on every other day, at about the same hour ; the cold fit commencing at 
noon, and lasting about half an hour, followed by a hot stage of somewhat longer 
duration, and then a profuse sweat. In the intermissions the pain in the head was 
trilling: there was no thirst nor heat of skin, but he did not sleep. A tumour 
formed over the mastoid process of the left side, and was opened, and a quantity 
of extremely offensive brownish pus sprang out with great force. This gave 
much relief. The bone was carious over a space as big as a shilling. After 
about ten days, the pain in the head and in the mastoid process became very 
severe; the patient had violent shivering fits many times in the day, great thirst, 
heat of skin, vomiting, and delirium: his face was flushed, and his pulse hard; 
and he died within a few hours after the accession of these last symptoms. 

The most remarkable features in this case were the similarity of the fits of 
shivering to the paroxysms of ague, their regular recurrence at periods of forty- 
eight hours, and the circumstance that they seemed to be checked, for some 
time, by the treatment proper in ague; namely, the exhibition of bark. The 
occurrence of quotidian paroxysms of the same kind has been noticed in relating 
some of the previous cases. 

I have related them to show you what different symptoms may result from 
inflammation of the dura mater; and to put you upon your guard against over- 
looking the cause from which such inflammation does frequently originate. The 
suppuration of the tympanum, and consequent disease of the bone, are more 
common in scrofulous persons than in others; and they are more apt to occur as 
a sequel of scarlet fever than in any other way. I conceive that the inflammation 
of the throat, belonging to that disorder, and often constituting all its danger, 
creeps along the Eustachian tube into the interior of the ear. In strumous subjects 
the fire thus lighted smoulders on, or if it ever goes out, is readily rekindled : 
that part of the temporal bone, in which the organ of hearing is principally lodged, 
becomes carious : the membrana tympani is perforated : the little bones of the 
ear come away : more or less deafness ensues ; and from time to time, or habi- 
tually it may be, there is a discharge of pus from the external orifice. At length 
the inner surface of the bone participates in the disease; and then the inflamma- 
tion is apt to be propagated to the dura mater, in the manner of which I have 
given you some instances. It is in the first onset of the inflammation in the ear 
that remedies are most likely to be efficient in preventing this catastrophe. 
Leeches applied early and repeatedly to the mastoid process, especially when 
that part becomes tender, as it often does in such cases, and counter-irritation 
afterwards, are the best means in our possession.* If symptoms of acute inflam- 
mation within the head supervene, the complaint requires more vigorous treatment, 
which I shall describe when I have spoken of inflammation of the other mem- 
branes of the brain. After what has been said, it is unnecessary to point out to 
you that the prognosis in these cases is very unfavourable. But we are not to 
abandon them in despair. That inflammation of the dura mater may be recovered 
from, we know, by what happens in certain injuries of the head: and the follow- 
ing would seem to be an instance of recovery when the source of the mischief 

* [The frequency with which inflammation of the dura mater supervenes upon otitis, 
especially in children, should be kept constantly in mind ; for it is only by a prompt, active 
and judicious treatment, whilst the disease is confined to the internal ear, that we can 
have any hopes of saving the patient — when inflammation has extended to the dura mater 
the termination is very generally fatal. — C] 



PIA MATER. 



243 



was situated in the ear. A young lady, after the usual symptoms in the head, 
lay for three or four days in a state of perfect coma, and her condition was thought 
utterly hopeless. Her medical attendants continued to visit her as a matter of 
form ; and one day they were agreeably surprised to find her sitting up, and free 
from complaint : a copious discharge of matter had taken place from the ear, with 
immediate relief: and she continued in good health. — (Abercrombie.) We can- 
not be sure in such a case that the matter came from the brain ; but the symptoms 
made that supposition exceedingly probable. The case shows clearly one of two 
things ; either that pus may thus escape from the skull, and the patient get well ; 
or that pus shut up in the cavity of the tympanum may produce the urgent symp- 
toms that are known to result from cerebral pressure. 

Cases are recorded of analogous disease communicated from the carious sethmoid 
bone to the dura mater; the patients having had pain in the forehead and purulent 
discharge from the nose, and becoming at last forgetful and delirious, and dying 
in a state of coma. I have never met with an instance of this kind; nor of in- 
flammation spreading inwards from the socket of the eye ; but I make no doubt 
that each may occasionally happen. 

These three, then — idiopathic inflammation of the dura mater — very rare ; in- 
flammation of the dura mater by extension of disease from the aelhmoid bone, or 
from the orbit — also infrequent ; and inflammation of the dura mater by extension 
of disease from the petrous portion of the temporal bone — very common : consti- 
tute those forms of inflammation of the outermost tunic of the brain, which the 
physician may be called upon to treat. The inflammation is not always — nay, 
perhaps it is seldom, if ever — restricted to that tunic; but it begins there; and 
the essence of the disease is inflammation of the dura mater. 

Acute arachnitis — by which I mean active and uncombined inflammation of 
the arachnoid membrane — is, I apprehend, a very uncommon disorder ; although 
that term is of frequent occurrence in medical writings. I have shown you 
already that inflammation may pass from the fibrous dura mater, to the serous 
membrane reflected over it ; and thence (by what is sometimes called contiguous 
sympathy) to the opposite portion of the same membrane spread over the surface 
of the brain. So, likewise, inflammation may extend from the pia mater to the 
arachnoid. If simple arachnitis, of an acute kind, ever happens, it has not been 
my fortune to see or to recognize it ; and I can tell you nothing about it. In 
truth, the authors who use the word arachnitis do not intend thereby to express 
unmixed inflammation of the arachnoid ; but include under that term inflamma- 
tion of the pia mater also. Some apply the name meningitis to that compound 
affection ; and the only objection to this nomenclature is, that the dura mater is 
as much one of the meninges of the brain as either of the two others. 

In the few remarks which I have to make upon inflammation of the pia mater 
(or, if you will, of the pia mater and arachnoid at once), I shall chiefly follow Dr. 
Abercrombie: because his observations are comparatively recent, and carefully 
made ; because his veracity, and sobriety of judgment, and philosophical turn of 
mind, are well known ; and because his cases (as regards this particular affection) 
are quite to the point, and his descriptions clear and concise. 

But I must premise a word or two respecting the anatomical characters of the 
disease. 

When the upper part of the skull, and the dura mater, have been removed, you 
may frequently see, on the surface of the exposed brain, what seems to be a thin 
layer of a clear gelatinous substance : but this appearance is fallacious. Puncture 
here and there the transparent arachnoid, and a limpid fluid, like water, trickles 
out; and the jelly-like investment of the convolutions is gone. Now this thin 
serous liquid; thus collected in the meshes of the pia mater, may be the event of 
inflammation of that membrane: but it may also be produced, and it very often 
indeed is produced, by simple congestion and remora in the cerebral veins. Nay, 
a certain amount of serosity, in this situation, belongs to the condition of health. 



244 



DISEASES OF THE BRAIN. 



We cannot, therefore, with any certainty, infer, merely from seeing this serous 
effusion, that there has been inflammation : we judge of its import, by noting the 
co-existence, or the absence, of other traces of inflammation ; and by the charac- 
ter of the symptoms that preceded death. 

On the other hand, we may be sure that there has been inflammation of one or 
both of these tunics of the brain when we find false membranes between them ; 
layers, i. e., of coagulable lymph. In the effusion of this substance I conclude 
that the vessels of the pia mater play the main part ; both because it is always, in 
such cases, excessively vascular, while the arachnoid is seldom found to be so in 
any remarkable degree, if at all : and also, because the false membrane commonly, 
though not always, sends down layers between those duplicatures of the pia mater 
which descend into the sulci formed by the convolutions ; where, as you know, 
the arachnoid does not go. In fact, considering the arachnoid as the serous mem- 
brane of the brain, we should expect that, when inflamed, it would present the 
events or products of inflammation on its free surface; and we sometimes find 
them there ; but this is very rare ; and for my own part, I look upon those effu- 
sions which lie beneath the arachnoid, between it and the pia mater, as being 
furnished exclusively by the vessels of which the latter membrane is mainly 
composed. 

Now the inflammation of these membranes (taking them together) commences, 
and declares itself, by no fixed or uniform symptoms. The most common and 
striking phenomena is a sudden and long-continued paroxysm of general convul- 
sions. Sometimes this is the first thing noticed. Sometimes it comes on after a 
few days of discomfort, slight headache, and vomiting. The convulsions recur, 
and at length end in coma. Sometimes, again, the first attack of convulsions is 
preceded by violent pain in the head, setting in quite suddenly, and attended with 
screaming. Considering, on the one hand, the intimate connection between the 
pia mater and the gray matter of the convolutions, and, on the other, the pre- 
sumed functions of that gray matter, we might expect that inflammation of the pia 
mater would soon be attended with some manifest derangement of the mental 
faculties. Accordingly, delirium, often violent and continued, is stated by most 
authors to accompany and denote inflammation of the membranes; and especially 
of the membranes where they invest the upper surface of the cerebral hemi- 
spheres. Yet I do not find that symptom mentioned in any of the various 
examples of meningitis recorded by Dr. Abercrombie. He does give cases, 
indeed, in which there was much delirium ; but they were not cases of menin- 
gitis of any kind. He relates them as instances " of a very dangerous modifica- 
tion of the disease, which shows only increased vascularity." I venture with 
great humility to question or criticise any opinion of Dr. Abercrombie's ; but I 
entertain no doubt about the nature of the cases which he so describes ; and I hope 
to convince you by-and-by that they are not examples of inflammation at all : they 
neither show the anatomical characters of inflammation, nor yield to the remedies 
of inflammation. Excluding these cases, I do not find delirium specified as a 
symptom of uncombined meningitis. I shall abridge one or two of the well- 
marked examples of the disease. 

A girl, aged nine, woke suddenly in the middle of the night, screaming from 
violent headache, and exclaiming that some person had given her a blow on the 
head. For the next two days she complained of some, but not much pain in her 
forehead, and did not even remain constantly in bed: no alarm was felt about her. 
On the third day she was seized with violent and long-continued convulsions, and 
immediately after the convulsions she fell into a state of deep coma: she remained 
in this state, with a natural pulse, till she died, on the sixth day of the disease. 

When the dura mater had been removed, the other membranes appeared highly 
vascular, except where this appearance was concealed by a layer of yellow adven- 
titious membrane, spread out betwixt the arachnoid and the pia mater. This was 
distributed in irregular patches over various parts of the surface of the brain, but 
was most abundant on the upper part of the right hemisphere. It was as thick 



PIA MATER. 



245 



as a wafer, and in some places dipped down between the convolutions. A con- 
siderable quantity of it extended over the surface of the cerebellum also. 

A child two years old was suddenly attacked one morning with severe and long- 
continued convulsions. The convulsions recurred many times ; in the intervals 
she was dull and torpid, in a state of partial coma, with occasional starting, and a 
frequent and feeble pulse. On the fourth day she sank. 

The surface of the brain, when the dura mater was removed, was covered in 
many places, betwixt the arachnoid and pia mater, by an adventitious membrane. 
It was chiefly found above the openings between the convolutions, and in some 
places appeared to descend a little way between them. The arachnoid when 
detached seemed to be healthy ; but the pia mater was in the highest state of 
vascularity throughout; and when the brain was cut vertically, the spaces between 
the convolutions were most strikingly marked by a bright line of vivid redness, 
produced by the inflamed membrane. There was no effusion in the ventricles, 
and no other morbid appearance. 

In another example, the whole surface of the brain was covered by a continued 
stratum of yellow false membrane, lying between the arachnoid and pia mater, 
and in some parts following the course of the pia mater through the whole depth 
of the convolutions : the pia mater and arachnoid adhered together everywhere, 
very firmly, by means of it : not a trace of it could be found either on the outer 
surface of the arachnoid, or the inner surface of the pia mater : the arachnoid 
itself, when separated, presented no unusual appearance, but the pia mater was 
everywhere excessively vascular. There was no serous effusion, and the brain 
and cerebellum were perfectly healthy. 

Now in this dissection there was unequivocal evidence of acute and extensive 
inflammation of these membranes, or I should say, of the pia mater; yet the 
symptoms had been very obscure. The child in whom the disease occurred was 
convalescent from a mild attack of scarlet fever. One evening he became very 
feverish, and complained of his belly. Three days afterwards he had frequent 
vomiting, followed by stupor, and some convulsive movements of his face and 
arms, and death took place four days and a half after the feverishness began. We 
learn from this case, that general and severe inflammation of the innermost mem- 
brane may exist, and prove fatal, without giving rise to any violent symptoms 
at all. 

I must trouble you with one more history, because it affords another example 
of what I have mentioned as being rare; viz., the effusion of the products of 
inflammatory action upon the outer surface of the arachnoid, — marking therefore 
very distinctly the inflammation of that membrane. It was evidently combined, 
however, with inflammation of the pia mater also. A child, eight months old, 
died after more than three weeks' illness ; which, began with fever, restlessness, 
and quick breathing ; afterwards there were frequent convulsive affections, with 
much oppression ; and at last severe convulsions, squinting, and coma. At an 
early period of the complaint, a remarkable prominence of the anterior fontanelle 
was noticed ; in the second week this increased considerably ; and in the third 
week, it was elevated into a distinct circumscribed tumour, which was soft and 
fluctuating, and pressure upon it occasioned convulsions. It was opened by a 
small puncture, and discharged at first some purulent matter, afterwards bloody 
serum. No change took place in the symptoms, and the child died four days 
after. 

A deposit of thick flocculent matter mixed with pus was found covering the 
surface of the brain to a considerable extent, and lying upon the free surface of 
the arachnoid. There was a similar deposition also between the arachnoid and 
the pia mater, and considerable effusion into the ventricles. 

If the sketches I have been giving you afford a true outline of the phenomena 
which attend acute inflammation of the pia mater, or of the pia mater and arach- 
noid jointly, what, you may naturally ask, is the nature of those cases in which 
there is high excitement, and much fever, and great delirium, and which are 



246 



DISEASES OF THE BRAIN. 



sometimes spoken of as phrenitis, or as brain-fever? Why these are instances 
of acute inflammation of the whole contents of the cranium ; of the brain and its 
membranes ; of the encephalon in short; and, therefore, the disease has, not im- 
properly, been called encephalitis. Of this formidable malady I shall give you 
some account to-morrow. 



LECTURE XXIII. 

Acute and general Inflammation of the Encephalon. Period of Excitement. 
Modes in which the disease may commence. Period of Collapse. Treatment. 
Delirium tremens. 

Acute inflammation does sometimes appear to invade at once the whole of the 
parts that are lodged within the skull; or, beginning in one part, it extends ra- 
pidly to all the rest. As the contents of the cranium are called, collectively, the 
encephalon, so the disorder which I am about to consider has been named enceph- 
alitis. It is an uncouth appellation, but it will serve its purpose. Cullen, and 
many others, apply the term phrenitis to the same disease. You may choose 
between these names, taking care to remember what they signify. The malady 
is sometimes described as inflammation of the membranes of the brain. I be- 
lieve this to have arisen from the circumstance that the effects of the intiammation, 
which become visible after death, are often more striking and obvious on the 
surface of the brain, or in its ventricles, than in the cerebral substance itself. An 
abscess in the nervous mass can scarcely be overlooked : a softening of the cere- 
bral pulp may escape the notice of a hasty or inexpert observer: and those 
changes of colour, which sometimes denote increased vascularity of the same 
part, may very easily be passed over without attracting much attention. 

Phrenitis, or encephalitis, or acute and general inflammation of the brain and 
its membranes, as it occurs in adults, presents two periods, which are marked by 
different symptoms, and in most instances are very distinctly observable. In the 
first period what are called symptoms of excitement predominate; the functions 
of the organ are exaggerated as well as disordered : in the second period those 
symptoms appear which are comprised under the term collapse. Sometimes 
these two sets of symptoms, instead of following each other, are more or less 
mixed and confounded together. But the distinction is real, and requires to be 
attended to. 

The symptoms that characterize the period of excitement, are pain of the head, 
often intense and deeply seated, or extending over a large part of it; a sense of 
constriction across the forehead ; throbbing of the temporal arteries, flushing of 
the face ; injection of the eyes, which have a wild and brilliant look ; contraction 
of the pupils ; preternatural sensibility to external impressions, amounting fre- 
quently to impatience of light, and of sound; violent delirium; want of sleep; 
paroxysms of general convulsion ; a parched and dry skin ; a frequent and hard 
pulse ; a white tongue ; thirst ; nausea and vomiting ; constipation of the bowels. 

You are not to look for all these symptoms in every case ; nor to conclude that 
your patient has not inflammation of the brain because the phenomena I have been 
enumerating do not all present themselves, or do not take place in any regular 
order of succession. 

In fact, we find, in actual practice, that encephalitis is apt to come on, to com- 
mence I mean, as far as symptoms are concerned, in three or four different ways. 

Sometimes there is a sudden alteration of manner, and the patient, complaining 
probably of his head, becomes all at once and furiously delirious; and fever is 
lighted up. These are symptoms which cannot pass unnoticed, and which im- 



ENCEPHALITIS. 



247 



mediately direct one's attention to the head. They may, however, be fallacious, 
as we shall see by-and-by. 

In other cases the first thing remarked is nausea and vomiting : and these symp- 
toms may soon cease; or they may continue several days, and even sometimes 
throughout the whole course of the disease. Bitter fluids are brought up, yellow 
or green, and evidently containing a good deal of bile; and whatever is introduced 
into the stomach, even a small quantity of the most simple drink, is immediately 
rejected. With this state of matters there is generally much constipation, and 
the bowels refuse to act except under the stimulus of strong purgatives. 

It is important to attend to these symptoms ; for, occurring, as they usually do, 
with headache, they may easily deceive a person who is not previously aware of 
what they may portend. If the patient has not been previously subject to sick 
headaches, and if the epigastrium and abdomen be natural, not tender, nor dis- 
tended, as they are apt to be when the stomach itself is in fault, we have the more 
reason to look narrowly into the case, and to suspect that some serious mischief 
of which the nausea is a token, may be going on in the brain. I would observe, 
by the way, that where there is much vomiting of bile, persons are apt, both 
patients and their doctors, to blame the liver, to set down the disorder as bilious ; 
but you ought to be aware, that whenever vomiting is often repeated, or long con- 
tinued, bile is to be expected in the matters brought up : the action of the duode- 
num, as well as that of the stomach, is inverted ; and the bile passes in the wrong 
direction. If you have ever suffered from sea-sickness, you must know that after 
the puking has gone on for a little while, bile is constantly voided. 

Again, some cases of acute inflammation of the brain set in neither with sudden 
and great disturbance of the intellectual functions, nor with sickness and vomiting, 
but with a paroxysm of general convulsion, such as often ushers in an attack of 
meningitis. This symptom, according to Andral, is a much more certain sign of 
cerebral inflammation, than the occurrence of active delirium ; and I quite agree 
with him in so thinking. 

It is probable (but I speak conjecturally only) that this diversity of symptoms, 
marking the onset of encephalitis, may depend upon the part in which the in- 
flammation begins ; and that it is soon propagated from that part to the whole of 
the organ. I should suppose that when nausea and vomiting are the earliest symp- 
toms, the inflammation has taken its point of departure in the cerebral pulp; in 
the substance of the brain ; and that when the attack comes on with a sudden fit 
of convulsion, the inflammation has commenced in the pia mater or arachnoid. 
This is consonant with what we know of inflammation of those parts when they 
are separately affected. Again, it seems to me presumable that the cases which 
are characterized by early and fierce delirium are cases in which the inflammatory 
action has invaded the whole of the encephalon, substance and membranes, simul- 
taneously. I say I offer these as conjectures of my own: what it is of import- 
ance for you to remember is, that inflammation of the brain does commence in 
the three several ways that I have been describing. 

There are some cases, however, that cannot be brought within even this gene- 
ral rule. They begin in some irregular or obscure manner, or with some unusual 
phenomenon. Andral states that he has seen a few striking instances of inflam- 
mation of the brain, of which the first sign was a sudden loss of the power of 
speech; and Dr. Abercrombie relates a very remarkable case in which the same 
thing happened. I call it very remarkable both on account of the singular man- 
ner in which the disease first showed itself, and because it furnishes an example 
of encephalitis produced by direct exposure to intense heat of the sun — insolation ; 
an event very uncommon in our climate. It occurred in the practice of a surgeon 
at Selkirk, in Scotland : — 

" A young man, aged 16, bathed twice, on the 5th of June, 1818, in the river 
Tweed. After coming out the second time he lay down on the bank and fell 
asleep, without his hat, and with his head exposed to the direct beams of a hot 
sun. On awaking, he was speechless ; but walked home, and seemed to be 



248 



DISEASES OF THE BRAIN. 



otherwise in good health. He was bled and purged, and the next day recovered 
his speech, but lost it again at intervals several times during the three or four fol- 
lowing days. He was forgetful, and his look was dull and heavy: he made little 
complaint, but when closely questioned said he hall a dull uneasiness at the back 
of his head. In a few days more he had squinting and double vision, and a very 
obstinate state of bowels, and his pulse was 60. After further bleeding the pulse 
rose to 86; but he sank gradually into coma, and died on the 30th. 

The substance of the brain in general was found highly vascular, and a very 
considerable extent of it was in a state of softening mixed with suppuration. The 
ventricles were distended with fluid, and the membranes in many places were 
much thickened. One very curious circumstance (affording perhaps some expla- 
nation of the readiness with which the inflammation was produced) was, that the 
cranium was of very unequal thickness at its upper part; in one spot, as big as a 
sixpence, it was as thin as writing paper, and transparent. 

However, the phenomena which I mentioned at first constitute the common 
and ordinary symptoms of acute inflammation of the brain and its membranes. 
They continue for a variable period ; from twelve hours to two days, or more ; 
and then they are succeeded by others, which characterize the second stage of the 
complaint, or the period of collapse, as it is called. These result, I apprehend, 
from the events and products of the inflammatory action; the violence of which 
is over or abated. The patient ceases to complain of headache ; instead of being 
excited or wildly delirious, he mutters indistinctly, and falls into a state of stupor, 
from which it is difficult, and at length impossible, to rouse him. His vision and 
hearing are no longer painfully acute, but dull, or perverted ; strabismus and double 
vision are not uncommon; and the pupil from being contracted to the size of a 
pin's head, becomes first oscillating, then widely dilated, and ultimately motion- 
less. The patient is not shaken, at this period, with violent convulsions ; but 
twitch ings of his muscles, and startings of their tendons come on, and some of 
his limbs are agitated with tremors, or become powerless and palsied ; the coun- 
tenance is ghastly and cadaverous; cold sweats break out; the sphincters relax: 
at length the coma becomes profound, and life ceases. 

The disease, when it proves fatal, as it too often does, mostly runs a rapid 
course. It may kill in as short a time as twenty-four or even twelve hours; or 
the patient may struggle on for two or three weeks. The morbid appearances 
met with in the dead body are very various. Serous or puriform effusion into the 
ventricles, and into the meshes of the pia mater; layers of coagulable lymph 
between that membrane and the arachnoid ; softening of the cerebral substance, 
with pus infiltered into the softened parts ; or great vascularity, shown by a pink 
or purplish mottling of its cut surface, giving it a stained appearance. 

Let us next consider the treatment required for this frightful disorder. 

It is quite plain that in an organ so essential to life, and of such delicate organ- 
ization as the brain, and in which changes so irreparable in their nature as many 
of those I have just enumerated, so readily take place under acute inflammation, 
we cannot hope to be of much service unless we see and treat the case at an early 
period. On this account it becomes exceedingly important to recognize the nature 
of the disease, at its very commencement; and, therefore, I have taken pains to 
point out to you the various forms which it may assume, while it is yet within the 
reach of remedial measures. 

The principal of those measures are blood- letting, purging, and the application 
of cold to the head. All the particulars of the antiphlogistic regimen are to be 
rigidly observed; the patient should be kept as much as possible in silence, and 
darkness, with his head high, and on a firm pillow. And the antiphlogistic reme- 
dies are to be employed with decision and' energy. 

With respect to bleeding I can only repeat what I have said before : the blood 
should be drawn in a full stream, and suffered to flow till some decided impression 
is made upon the pulse ; or until syncope occurs, or is evidently at hand. After 
the patient has rallied a little, blood should be taken by cupping or leeches from 



ENCEPHALITIS. 



249 



the back of the neck, or the temples, or the mastoid processes; and these deple- 
tory measures must be repeated according to the violence or continuance of the 
symptoms which first demanded them. 

The application of cold to the head is a remedy of great importance in this dis- 
ease. The head must be first shaved, and the mere removal of the hair is some- 
times followed by a manifest abatement of some of the most urgent symptoms; 
of the pain, for example, and of the delirium. In cases such as I am now sup- 
posing, it will not be enough to apply wetted cloths to the head : the application 
must be colder than the ordinary temperature of the cold water; and it may be 
made colder by ice ; and the best way to ensure a permanent depression of the 
superficial heat is to put some pounded ice with a little water into a thin and flex- 
ible bladder, and to lay it on the patient's, head: there should not be too much ice, 
or its weight may be injurious. This is generally very grateful and pleasant to 
the feelings of the patient; and we often have the satisfaction of perceiving that, 
with the reduction of the external heat of the head, there is also an evident miti- 
gation of the violent symptoms; the agitation and delirium are calmed, and the 
patient sleeps, or recovers his senses. 

Another excellent and most powerful method of applying cold, is by pouring 
cold water in a slender stream upon the vertex of the head, until it produces some 
marked effect. Of course this, as well as all other strong measures, must be 
adopted with great caution, and its influence closely watched : I mean it is not to 
be left to the discretion, or indiscretion, of domestics and nurses. Dr. Aber- 
crombie tells us that he has seen a strong man, submitted to the operation of this 
cold douche, " thrown in a very few minutes into a state approaching to asphyxia, 
who immediately before had been in the highest state of maniacal excitement, 
with morbid increase of strength, defeating every attempt of four or five men to 
restrain him." Of the effect of this measure in a somewhat different morbid 
condition, he gives an instance, which I will quote, because it shows, in the first 
place, the striking power of the remedy ; and, secondly, the simple mode of 
applying it. A strong plethoric, child, five years old, after being for one day 
feverish, oppressed, and restless, fell rather suddenly into a state of perfect coma. 
She had been in that state about an hour when Dr. Abercrombie saw her. She 
lay stretched on her back motionless, and completely insensible ; her face flushed 
and turgid. She was raised into a sitting posture, and, a basin being held under 
her chin, a stream of cold water was directed against the crown of her head. In 
a few minutes, or rather seconds, she was completely recovered ; and the next 
day was in her usual health. 

This measure also is to be repeated, according to the circumstances of the case. 

Some persons recommend that a constant dripping of cold water upon the pa- 
tient's shaven head should be kept up. This may easily enough be managed by 
means of a sponge and funnel placed a little above the head. Andral mentions 
his attending with another physician (M. Recamier) a young man who laboured 
under all the symptoms of acute inflammation of the brain. Cold water was 
made to drop slowly upon his head, and complete recovery took place, although 
no other active treatment of any kind was adopted. 

In strongly recommending this efficient remedy to your notice, you will not 
understand me to advise that it should supersede the use of copious blood-letting: 
it is to be employed as an auxiliary to the lancet; not as a substitute for it. 

The third remedy which I named, that is to say, purging, is also of great im- 
portance and efficacy. But it must be hard purging. There is a great tendency 
to obstinate constipation: in most cases; and this must be overcome, and free and 
frequent evacuations from the bowels obtained ; five grains of calomel and fifteen 
of jalap should be followed in three or four hours by a strong black dose; and 
after that I should give, in such cases, three or four grains of calomel every four 
hours, and repeat the black dose at least every morning, until the symptoms gave 
way. If the mercury thus exhibited affect the gums 9 so much the better ; but 



250 



DISEASES OF THE BRAIN. 



we must not, in this disease, combine it with opium, to prevent its passing off by 
the bowels. 

Dr. Abercrombie uses this strong language in reference to the value of purga- 
tive medicines in acute inflammation of the brain : — " In all the forms of the dis- 
ease, active purging appears to be the remedy from which we find the most satis- 
factory results ; and although blood-letting is never to be neglected in the earlier 
stages of the disease, my own experience is that more recoveries from head affec- 
tions of the most alarming aspect take place under the use of very strong purging 
than under any other mode of treatment. In most of these cases, indeed, full and 
repeated bleeding had been previously employed, but without any apparent effect 
in arresting the symptoms." He has found the croton oil the most convenient 
medicine for this purpose. 

Dr. Abercrombie is disposed to regard mercury as being useful in affections of 
the brain, chiefly in virtue of its purgative operation: and the opinions of a phy- 
sician of his large experience, and observing mind, must and ought to have great 
weight. But I must not conceal from you my own persuasion that, in the early 
periods of acute inflammation of the encephalon (and it is of the early periods 
that I have hitherto been speaking), if the mercury comes in a short time to pro- 
duce its specific influence upon the gums, a great change for the better will often 
be perceived. Such is the result of my own observation. Recollect, however, 
that you are not to give calomel with the direct object of affecting the gums, but 
as part of the purgative plan, and you take the chance of its specific effect. You 
must not combine opium with it, for two reasons ; first, you would thereby shut 
up the bowels, and deprive yourself of the use of one of your best weapons ; 
and, secondly, you would incur the risk of augmenting and perplexing your pa- 
tient's head symptoms, and of puzzling yourself ; since you would not be able to 
determine how much of the coma that ensued was owing to the progress of the 
disease, how much to your remedy. 

When the second order of symptoms have arrived, those which are included 
under the general phrase of collapse, and which commonly result, I fancy, rather 
from the products of the inflammation than from the inflammation itself; from 
softening, that is, and from pressure exerted by effused serum, or lymph : when this 
order of symptoms make their appearance, I believe the time fordoing much good 
by active bleeding has gone by. If, however, blood-letting has not yet been 
employed, and especially if the pulse continue hard, whether blood has been 
already abstracted or not, it will be right to give the patient the chance of that 
remedy. Of the propriety of doing so, take the following illustration : — " A girl, 
aged eleven, had violent headache and vomiting, with great obstinacy of the 
bowels ; and these symptoms were followed by dilated pupils, and a degree of 
stupor bordering upon perfect coma; pulse 130. She had been ill five or six 
days ; purgatives, blistering, and mercury to salivation, had been employed with- 
out benefit. One bleeding from the arm gave an immediate tiara to this case, the 
headache was relieved, the pulse came down, the vomiting ceased, the bowels 
were freely acted upon by the medicines which they had formerly resisted, and 
in a few days she was quite well." (Abercrombie.) I must recite one other 
case — from among many which go to the same effect — to show the occasional 
influence of hard purging. "A young man who had had cough and dyspnoea, 
and been bled for those symptoms, appeared convalescent. One evening he 
became affected with headache, and some vomiting. About midnight, having got 
out of bed to go to stool, he fell down in a state of violent and general convulsion. 
The convulsion returned during the night six or seven times with such violence 
that one of the paroxysms continued without intermission for an hour. The pulse, 
during the night, varied from 60 to 120." (I should have mentioned before this 
great and rapid fluctuation of the pulse in respect to its frequency, as being a very 
common circumstance and sign, in inflammatory affections of the brain.) " At 
first it was found impossible to bleed him, on account of the violence of the con- 
vulsions ; but about seven in the morning a full bleeding was obtained, after which 



ENCEPHALITIS. 



251 



the convulsions ceased, except some slighter attacks during the day, which 
appeared to be arrested by pouring cold water over his head. The next day he 
was oppressed ; with occasional tremors of the limbs, and some vomiting, and he 
had one or two threatenings of convulsion. He took repeated doses of active 
purgatives with little effect ; and on the following morning he appeared to be 
sinking into a state of perfect coma, with a pulse at 50. Croton oil was now 
given, which operated powerfully seven or eight times. He passed a good night; 
and the day afterwards was free from complaint." 

Having this evidence of the separate efficacy of the three remedies — blood- 
letting, strong purgatives, and the local application of cold to the head — we have 
much encouragement to put them into combined operation in these very serious 
cases, especially when we have the opportunity of using them at an early period. 
Should the disorder happily yield to these measures, great care will long be 
required on your part, and great prudence on the part of the patient and his friends, 
lest the recent mischief should rekindle. A relapse is even more perilous than 
the first assault of the disease. Such prudence and care will consist chiefly in 
the avoidance and denial of all that might excite and disturb the brain ; whether 
it be a premature return to animal food; or indiscreet and fatiguing interviews 
and conversations; or the loo early resumption of the cares and concerns of busi- 
ness. 

Are we to employ blisters in this disease ? Not in the outset, during the period 
of excitement. They only add to the irritation, and make matters worse. And 
especially you should avoid putting them, as many are apt to do, upon the head 
itself, at that stage of the disease. We should not suppose, a priori, that they 
could then, and in that place, have any beneficial effect. They cannot divert the 
blood from the inflamed part; but they may attract it towards the encephalon. If 
they could be expected to do any good at all, it would be when they are placed 
upon the feet or legs. But this kind of revulsion is better accomplished by means 
of mustard poultices, or fomentations with hot water, which are often of much 
apparent service, in addition to the measures already spoken of. Experience 
confirms what reason teaches us to look for in this matter. 

When, however, the patient had sunk into a state of coma, he has sometimes, 
in my experience, emerged from that condition after a cap of blistering plaster 
has been put upon his head. It is only when the violent symptoms of excitement 
have abated that I can venture to advise you to employ blisters : they may then 
be applied to the nape of the neck, or behind the ears, or to the head itself. 

The symptoms which I enumerated as marking the period of collapse or sinking, 
are fearful symptoms ; but the conditions on which they depend are not, neces- 
sarily, hopeless conditions. These symptoms do not always proceed from fatal 
disorganization of the brain, but sometimes (there is reason to believe) from simple 
exhaustion of the nervous power. And this is a point of critical importance. 
Patients apparently moribund are occasionally saved by the judicious administra- 
tion of stimulants and restoratives; of ammonia, Hoffman's anodyne, beef-tea, 
wine, and, it may be, of well-timed opiates. This plan of treatment you must 
therefore cautiously try, when an extreme degree of collapse occurs. If the 
structure of the brain be already seriously injured, and the disease irretrievably 
mortal, no harm can be done; while in doubtful cases, and when the symptoms 
result from mere depression of the vital powers, the patient may be rescued : and 
this chance in his disease must not be thrown away. 

Do you ask whether there be any mode of discriminating these opposite 
conditions, one of which is within, and the other beyond, the range of possible 
recovery ? I believe there is. If the tendency to death by coma be strong, the 
prospect is very discouraging: if, on the other hand, the symptoms that mark 
the mode of dying by asthenia predominate, you may hope to push the patient 
through. But to succeed, you must watch him hour by hour. Pallor, a feeble 
and flying pulse, extreme debility and tremors, coldness of the extremities, a want 
of power to respond to external impressions ; these are alarming, but not abso» 



252 



DISEASES OF THE BRAIN. 



lutely desperate symptoms, especially if the mental faculties remain. Whereas 
profound stupor, partial palsy, profuse sweats, are of the worst omen ; yet even 
these do not preclude the trial, together with blistering the head, of internal stimuli ; 
and no other plan affords even a gleam of hope. 

There is just one caution that I wish to mention before I leave the subject of 
acute encephalitis; and it applies to all cases of coma and insensibility, and espe- 
cially when there is any paralysis mixed with the coma: it is, that you should 
daily ascertain that the bladder is emptied. Always make the attendants show 
you the urine that has been passed ; and lay your hand upon the hypogastric 
region, and try whether there is any undue hardness and prominence there, pro- 
duced by the distended bladder. I shall revert to this matter more particularly at 
some future time ; and I content myself with merely suggesting its importance to 
you now, in all cases of head affection. If the patient does not or cannot empty 
his bladder, of course it must be emptied for him, by means of a catheter. 

It would seem perhaps the most natural arrangement if I next proceeded to 
speak of cerebral inflammations which are chronic, or partial. These forms of 
disease are more common, in adults, than acute and general encephalitis. I shall 
be obliged also to treat, separately, of inflammation of the brain as it is modified 
by its occurrence in young children, — of what is called acute hydrocephalus. 
But before I touch upon any of these, I am desirous to bring under your notice at 
once a very singular and extremely interesting complaint, which is not, I am per- 
suaded, in its essential nature, inflammatory, but which may easily be mistaken, 
and has over and over again been mistaken, for acute inflammation of the brain 
and its membranes, with the consideration of which we have just been occupied. 
The mistake is the more serious, because the remedies that I have been recom- 
mending for encephalitis, and especially blood-letting, not only are not required, 
but are in most cases positively injurious, in the disorder of which I am now 
about to speak: and which is best known under the appellation of delirium 
tremens. Nay, this affection of the nervous system may actually be brought on, 
in a predisposed subject, by the abstraction of blood. I go apparently out of my 
way in taking notice of this complaint now, but I do so that I may have the op- 
portunity of contrasting it with encephalitis, while the phenomena of the latter 
disease are fresh in your memory. It certainly resembles it also in many respects : 
and it has been regarded as an inflammatory disorder by some excellent patho- 
logists. 

The symptoms which mark a decided attack of delirium tremens, and which 
have sometimes been found so equivocal, are very striking. You will be sum- 
moned to a man who is supposed to be mad, or to have brain fever. You find 
him with a red face, perhaps, and injected eyes, talking wildly and incessantly, 
fidgeting with his hands, affected often with tremors of the limbs, having a rapid 
pulse, and bathed in sweat. Now it is very natural that a person not on his guard 
should look upon these symptoms as indicating inflammation within the head. 
But if you look closely into the matter you will find in the state of the patient, 
and in his history, some things very peculiar. The delirium you will generally 
find to be, not a fierce or mischievous delirium, but a busy delirium : he does 
whatever you desire him to do, but he does it in a hurried manner, with a sort of 
anxiety to perform it properly. During the approach of the malady, while he is 
yet able to go about, he manifests great impatience of any interference, or advice, 
or assistance, in his ordinary duties, which he sets about in a bustling and blun- 
dering manner. His loquacity is extreme, and he refers to matters that are not 
present before him : he is not altogether inattentive to the objects and proceedings 
that are going on around him, but his. mind wanders away to other subjects. 
There is an odd mixture of the real and the ideal in his thoughts and language. 
Sometimes he is very suspicious that those who are about him intend him some 
injury; or that he is surrounded by enemies. You will find also that he does 
not sleep ; that he has not slept perhaps for several nights, but been restless and 



DELIRIUM TREMENS, 



253 



rambling : and you will generally learn that he has been habitually intemperate, 
or subject to some great source of care, or anxiety, or excitement: and in many 
cases he has recently been somehow or other debarred from his customary stimu- 
lus. In addition to these points in his history, you will frequently be told that 
having been unwell, first he has been kept upon low diet, and then, as the delirium 
came on, he has been freely bled ; and that he has been none the better, but 
coinmonty the worse, for the bleeding. When you gather such particulars as 
these from his friends (for upon his own statements you cannot place any reliance), 
and when you find the delirium to have the characters I have been attempting to 
describe, and especially when there has been obstinate watchfulness, and the 
tongue is moist, and the skin is sweating, you may be pretty certain that your 
patient is affected, not with inflammation of the brain, but with delirium tremens ; 
and that if you bleed him further you will make him worse. 

But what are you to do under such a fearful state of things? Why the great 
indication is to procure sleep; and the remedy which, in nine instances out of 
ten, you will find successful, is opium. The beneficial effects of this drug, in 
tolerably favourable cases of delirium tremens, are really surprising. I will give 
you an example or two, which will be more instructive than any abstract de- 
scription. 

In the year 1831 I was requested, by a most respectable practitioner in this 
town, to visit a patient of his whom he reported to have had phrenitis, for which 
he had been freely bled, cupped from the back of the neck and purged; and who, 
he believed, was now rapidly sinking, and not likely to survive many hours. I 
found the patient, a middle-aged man, with a red face, ferrety eyes, a frequent 
pulse, bathed in perspiration, busy with his hands, which trembled a little, and 
talking much and incoherently. He was particularly anxious that his legs should 
not be scarified, told me he was willing to do any thing I pleased, if I would not 
scarify his legs, nor let any one else scarify them. There was nothing the matter 
with his legs, nor had it entered any body's head, but his own, that they wanted 
scarifying. He had not slept for several nights. He had been intemperate, espe- 
cially of late, drinking a good deal ; and somewhat anxious about his affairs : he 
was a builder. 

His former history was not very promising. He had brought up a good deal 
of blood a few months before, and some years previously he had had jaundice ; 
latterly he had been troubled with indigestion. 

I saw him in the afternoon, and prescribed one-third of a grain of morphia : in 
the evening he was just in the same state. I then directed half a drachm of laud- 
anum to be given immediately, and twenty drops every two hours afterwards, till 
he slept. I said to the gentleman who had called me to the case, that I thought it 
very likely our patient might be well the next day; he smiled and shook his head. 
I was obliged to leave London, early the next morning, for two or three days ; on 
my return, I learned from the medical man that the patient took five doses of the 
laudanum, after which he fell asleep, and slept soundly, and for a long time, and 
then awoke (to his attendant's extreme surprise and satisfaction) sane, and well. 

I was asked by the apothecary of the Middlesex Hospital to see a publican in 
that neighbourhood. I found a large strong man between 30 and 40 years of age. 
He had been without sleep for several nights, somewhat incoherent, and (what is 
not usual in such cases) violent, threatening and striking those about him because 
they refused him access to strong drink. He was joint proprietor with another 
in a gin-shop, and for some time previously he had been a sot, and daily muddled 
"with drink. He told me he was quite well ; there was not much tremor. I 
found that the object of his partner and relations in sending for me was that I 
might sanction his removal to St. Luke's, for his strength made him altogether 
unmanageable, and his insane and extraordinary conduct was hurting the business 
of the house. I declined to take any part in consigning him to a mad house, and 
recommended morphia. After one full dose he soon slept; and the next day he 
was quite rational, and comparatively well 



254 



DELIRIUM TREMENS. 



These are the broad outlines of delirium tremens : there are many other features 
wanted to complete the portrait of the disease, which I shall endeavour to paint at 
our next meeting. 



LECTURE XXIV. 

Delirium Tremens, concluded. Chronic Inflammation of the Brain. Soften- 
ing, Suppuration, Abscess, Induration, Tumours in the Brain. 

I drew a rude outline, yesterday, of that singular and interesting malady usu- 
ally denominated delirium tremens. The disease is very common in this country ; 
for its causes are in common and powerful operation. You will meet with it in 
every walk of life : and you will be almost sure to witness several examples of it 
during the course of every year, in any of our metropolitan hospitals. It is not a 
chronic or vague complaint, likely to be treated with placebos, or by waiting upon 
nature. Active measures are pretty certain to be adopted ; and, in many cases, 
one plan of treatment, vigorously pursued, will hurry the patient to his grave ; 
another plan will restore him to health with an almost magical celerity. It cer- 
tainly bears a strong resemblance to that most formidable disease, inflammation of 
the brain and its membranes ; but the great remedy for encephalitis acts like a 
poison in pure delirium tremens ; and the drug, by the timely and careful adminis- 
tration of which we can often promise a speedy cure in delirium tremens, is one 
which we must carefully avoid, in the earlier treatment, at least, of encephalitis. 
Accuracy of diagnosis, therefore, between these different disorders, with similar 
outward signals, becomes of the very highest importance. 

Delirium — tremens. — There is delirium always ; and there is generally, but 
not always, tremor. The name is a good enough name, in my humble opinion ; 
yet it has been found fault with, because the trembling is not in all cases present; 
and some have, therefore, christened it delirium e potu, or delirium ebriositatis : 
but these terms are open to just the same objection as the other; for though the 
disorder is most commonly connected with intemperate habits, that is not always 
the case. One very curious fault has been discovered in the name : it is said that 
the delirium cannot tremble ; and, therefore, that it is better to say, delirium cum 
tremore, or tremefaciens : and you would hardly suppose it, but there has been a 
sort of contention for the honour of thus mending the nomenclature of this dis- 
ease. But they who object to delirium tremens appear to see no harm in deli- 
rium ferox ; whereas it is just as incorrect to say delirium is fierce, as to say that 
it trembles : it is the patient who is furious, even as it is the patient who trem- 
bles ; and all this dispute about a name is mere trifling. It matters not what we 
call a disease, so that the name conveys no erroneous theory as to its nature or 
treatment. No such source of error attaches itself to the term delirium tremens : 
and, therefore, if it be only to avoid the inconvenience of change, we will adhere 
to that term. 

Recollect that the strong features of the complaint are sleeplessness ; a busy, 
but not angry or violent delirium; constant chattering; trembling of the hands, 
arid an eager and fidgety employment of them. To these are added other symp- 
toms which, though they are not so calculated to strike a looker-on, are of not less 
importance, inasmuch as they help to establish the diagnosis. The tongue is 
moist and creamy; the pulse, though frequent, is soft; the skin is perspiring, 
and most commonly the patient is drenched in sweat. The sweat is usually de : 
scribed as having an offensive or a peculiar smell : I cannot say that I have 
observed it to be so. The face also is said to be pale ; but that, I know, is not 
always the case, and therefore this point cannot be relied upon as a distinguishing 



DELIRIUM TREMENS. 



255 



circumstance. In one of the instances which I related in the last lecture, the face 
was flushed, and the eyes red and ferrety. 

Let me remind you, in a few words, of the peculiar characters of the delirium. 
If you question the patient about his disease, he answers quite to the purpose ; 
describes, in an agitated manner, his feelings, puts out his tongue, and does what- 
ever you bid him : but immediately afterwards he is wandering from the scene 
around him to some other that exists only in his imagination. Generally his 
thoughts appear to be distressful and anxious ; he is giving orders that relate to 
his business to persons who are absent ; or he is devising plans to escape from 
some imaginary enemy : he fancies that rats, mice, or other reptiles, are running 
over his bed, or that strangers are in his room. He looks suspiciously behind 
the curtain, or under his pillow, and he is perpetually wanting to get out of bed ; 
but he is readily induced to lie down again. It is very seldom that he meditates 
harm, either to himself or to others ; there is rather a mixture of cowardice and 
dread with the delirium. 

All the points that I have been mentioning require to be investigated in every 
case of this nature : and an inquiry into the previous history of the patient, into 
what the French call the commemorative symptoms, is equally important. In a 
large majority of instances you will find that he has been an habitual drunkard ; 
and very frequently that from some reason or other this habitual stimulus has 
been diminished or taken away. Some accidental illness has befallen him, and 
he has been restricted to low diet, and, as a sailor would say, 44 his grog has been 
stopped." When, with symptoms such as I described just now, you hear a his 
tory of this kind, you may be satisfied that the disease is not inflammation of the 
brain, but delirium tremens. I believe that habitual intoxication of any sort may 
lead to this disorder ; but distilled spirits more surely than wine ; wine more than 
beer. I make no doubt either, that what is alleged of the habitual use of opium, 
in preparing a person to suffer in the same way upon its being withheld, is quite 
true, although I have had but few opportunities of noticing such cases. 

But the disease is not confined to drunkards, although it is so commonly con- 
nected with that pitiable vice, as to have been called mania e potu. You meet 
with it occasionally in men who have overstrained their nervous system by other 
modes of strong excitement. Long-continued mental anxiety, that state of mind 
in which gamblers and great speculators (who are indeed gamblers) are accus- 
tomed to live, may cause it; any thing by which the mind is over wrought. A 
well-informed medical man, of temperate habits, told me a few days ago that he 
was on the brink of delirium tremens in the year 1825. He had foolishly en- 
tangled himself in some of the speculations which prevailed here like an epidemic 
at that period, and his mind was on the tenter-hooks of suspense and apprehension 
for some time. He could not sleep, and he found himself everlastingly chattering. 
It comes on in the course of certain diseases ; as sometimes, for example, in apo- 
plexy : and it is a very common result of bodily injuries and accidents, and of 
surgical operations; or, I should rather say, that it often follows such diseases 
and casualties ; for it is, even then, the consequence of the treatment and regimen 
to which the patients are subjected, rather than of the surgical or medical com- 
plaint. And it is certainly more apt to occur, under these circumstances, in old 
people ; and in those who, being younger, are known to have been intemperate. 
So frequently does the delirium manifest itself upon the cessation of the accus- 
tomed spur, that the continually recurring stimulus has been regarded as the pre- 
disposing, and the privation of that stimulus the exciting cause of the affection. 
Sometimes, however, it comes on in men who are perpetually fuddled, even 
although they have not intermitted their usual indulgence in drink. We had a 
porter (an old soldier he had been) at the Middlesex Hospital, who was of great 
use to us as a subject to practise upon, and to show to the pupils. I never saw 
him so drunk as to be unable to perform his duty: but I cannot conscientiously 
say that I ever saw him sober. Every three or four months we were sure to 
have him in the wards with delirium tremens. Sometimes he fell into the hands 



256 



DELIRIUM TREMENS. 



of one physician, and sometimes of another; but in one of his attacks he slipped 
through our fingers. I am not certain that he was not nominally my patient on 
that last and fatal occasion : but assuredly he was never an example of the disease 
coming on from the adoption of more temperate habits. We often find that the 
malady shows itself immediately after an unusually severe debauch, which has 
disturbed the stomach and bowels, and left behind it a proportional degree of ex- 
haustion and languor. 

Without knowing why it should be so, my own experience would lead me to 
the belief that delirium tremens is very uncommon among women. The number 
of beds for females in the physicians' wards of the Middlesex Hospital is some- 
what greater than for males. On the men's side of the house cases of delirium 
tremens are very frequent: whereas 1 scarcely remember any on the women's. 
Yet each sex is obnoxious to its main causes. The gin-shops of this town are 
said to draw a fearful crowd of votaresses. And we might expect that the more 
sensitive character of the female constitution would render them especially liable 
to this peculiar consequence of the abuse of alcohol. My experience, however, 
is such as I tell you. On the other hand, Dr. Roots thinks he has seen quite as 
many instances of delirium tremens attacking females as males. The result of 
M. Rayer's observation is more in accordance with my own. Of 176 patients 
seen by him, seven only (not one in twenty-five) were women. A still smaller 
ratio is recorded by Bang, ten in 456: less than one in forty-five. The disorder 
appears to be more common in the summer than in the winter months. 

The peculiar nature of the complaint, and the proper method of treating it, 
were first brought into general notice in 1813 by a little work of Dr. Sutton's, of 
Greenwich. He saw a good deal of the diseases of the smugglers, and of the 
customers of the smugglers, who frequent the coast of Kent ; and he was struck 
by the different event of this disorder in the hands of different practitioners, ac- 
cording as bleeding or narcotics were adopted. It is the same disease which Dr. 
Abercrombie speaks of as " a dangerous modification of meningitis, which shows 
only increased vascularity." Dr. Bright also includes it among his cases of 
"Arachnitis." Both these eminent physicians had learned, however, that the 
complaint requires a particular method of treatment. Of late years many essays 
and papers on the same malady have appeared in this country, in France, and in 
the United States, where the disorder is common. But even now it is not so 
well understood, throughout the profession, as it ought to be. 

You may ask me, what is the essential nature of the disease: and I can only 
state in reply that it consists in nervous irritation. Some persons hold that this 
is tantamount to no answer at all ; but I do not agree with them. They seem to 
think that if you assign a state of the brain or nervous system which is not visible 
or tangible, you lose yourself in mere hypothesis. But we see a number of 
striking phenomena in this and in many other forms of disease, for which phe- 
nomena we can trace by our senses, in the organ affected, no physical cause; yet 
we are sure that they have a cause ; and we call that cause irritation: if we had 
given it some Chinese name it would have been all the same. From certain 
symptoms we infer irritation ; just as from certain phenomena we infer gravitation. 
I do not mean to put the two upon an equal footing; or to pretend to say that the 
laws of irritation are established with any thing like the certainty which belongs 
to the ascertained laws of gravity: but we pursue the investigation of these laws 
in the same way in the one case as in the other: and it is quite idle to object to 
an arbitrary term, like irritation, because it is meant to represent something which 
makes itself known to us only by its effects. 

Now I apprehend that we are borne out, by authentic facts, in believing that 
certain changes in the blood-vessels will lead to irritation, and at length to inflam- 
mation, of a part. But there are other sources of irritation ; and irritation in its 
turn will lead to changes in the blood-vessels. In the one case we bring back the 
blood-vessels to their healthy condition, and the symptoms of irritation cease. In 
the other we calm the irritation, and the previous effect of it upon the blood- 



DELIRIUM TREMENS. 



257 



vessels stops. In other words, deviations from the natural and healthy state of 
the nervous system are sometimes the cause, and sometimes the consequence, of 
disturbances in the sanguiferous system. Whether this be good philosophy, or 
whether it seem to you rational and intelligible, I do not. know ; but it is the best 
explanation that I can offer you upon this subject. 

I apprized you, in the last lecture, that the great remedy in delirium tremens is 
sleep ; and that our most powerful means of inducing sleep are to be found in 
opium. The opium must be given in full doses; and it must be fearlessly 
repeated if its desired effect does not follow. If the patients pass many nights 
without sleep, they will die. I have tried various forms of opium ; and I am quite 
satisfied with morphia. Some persons, however, have not found it so successful 
as solid opium, or as the common tincture, laudanum. You may try the one or 
the other, or the one after the other, if you please. No particular rules can be 
laid down that will suit all cases. After clearing out the bowels by a moderate 
purgative, you may give three grains of solid opium ; and if the patient show no 
inclination to sleep after two or three hours have elapsed, you may begin to give 
one grain every hour till he does sleep. Or you may prescribe corresponding 
quantities of the acetate or muriate of morphia: or of laudanum : or of the black 
drop: or of Battley's sedative liquor. His room, meanwhile, should be kept 
dark and quiet. If he sleeps for some time he will awake calmer and more 
sensible; perhaps perfectly so: and you must withhold the remedy, or continue 
it in smaller or less frequent doses, according to the circumstances of the case. 

Dupuytren found opiate enemata of great efficacy in the cases of traumatic 
delirium which came under his care. That mode of administering the narcotic 
may properly be adopted, if there be any impediment to its reception or retention 
by the stomach. 

Now sometimes this opiate treatment alone is quite enough : sometimes it is 
not. You will meet with patients who resist very large doses of the drug; but 
who presently sleep, or become composed, if you give some of their accustomed 
stimulus with it: "a hair (as the vulgar saying goes) of the dog that bit them:" if 
you put their opiate dose into a glass of gin, or a pint of porter. Nervous exhaus- 
tion goes along with and augments the nervous irritability. This I have continu- 
ally experienced with hospital patients. And I rather think that you may get 
some clue to the particular cases which require this treatment, by examining into 
the state of the digestive functions. If you learn that, notwithstanding the intem- 
perate habits of the patient, his appetite for food has continued unimpaired, and 
his digestion sound, you will, I believe, generally find that good nourishing 
diet, strong broths for example, and the opium, will suffice for the cure. But if 
the powers and natural sensations of the stomach have been injured and perverted, 
as is too often the fact, then a temporary recurrence to the habitual stimulus will 
frequently be necessary: and it is well to ascertain, in such cases, what the stimu- 
lus has been, whether spirits, or beer, or wine, and to order it accordingly. Of 
course this is not to be continued after the patient has recovered from his delirium; 
but the stimulus under these circumstances must be cautiously withdrawn. When 
the stomach retains its power of digestion, the bad habit of drinking ought to be 
broken off at once : and if, after sleep, you can get the patient to eat heartily of a 
beef-steak, or mutton-chop, I should always advise it. 

There are some things which I find it necessary to mention, for the sake of 
discommending them. I know persons who in treating these cases combine calo« 
mel with the opium. And they say that they cure their patients so ; and I make 
no doubt that they do ; neither can I doubt that the same success would have fol- 
lowed the same quantity of opium without the calomel. In pure cases of delirium 
tremens I advise you not to give calomel. I know no possible good it can 
answer: it is itself a source of great irritation to the nervous system in many per- 
sons : and if it comes to affect the mouth, you inflict upon your patient a super- 
fluous discomfort; and, I believe, in many cases, a downright injury. You will 
be told also of digitalis, as a specific remedy for the disease ; or you may read of 



258 * 



DELIRIUM TREMENS. 



it : but do not be led away from the standard remedies which reason recommends, 
and large experience has sanctioned. Knowing what we do of the power of 
opium generally, and of its efficacy in this complaint in particular, I should con- 
sider myself-guilty of a criminal trifling with human life if I made experiments 
with digitalis, upon the loose reports of some one or two persons, of whose credit 
or information I knew nothing ; and whose dicta had been transferred perhaps from 
some foreign journal to fill a vacant corner in one of our own. Of the combina- 
tion of opium and antimony, which has been much praised by good and compe- 
tent judges, I am unable to tell you any thing from my own experience. 

In hospital practice it sometimes becomes necessary to confine the patient to 
his bed by straps, t>r to muffle his limbs in a strait- waistcoat: but this is a most 
unfortunate necessity. Physical coercion, whether manual or mechanical, should 
never be resorted to in delirium tremens, when by any means it can be avoided. 
The angry feeling and mental fret which it produces, and the exhausting bodily 
struggles to escape or resist the thraldom, are always highly injurious and full of 
danger to the patient. A couple of strong and good-tempered attendants will not 
have much difficulty in persuading and managing the sick man, who is seldom 
either boisterous or obstinate : and if he be intractable by soft words, he will yield 
more patiently to their gentle restraint than to the force of manacles ; while the 
appearance of coercion need not be continued a moment after his acquiescence. 

I have drawn the line between encephalitis and delirium tremens with suffi- 
cient clearness, because I have taken well-marked forms of each. But I am sorry 
to add that there are mixed cases, which are very puzzling when they occur, and 
exceedingly difficult to treat; and which require opiates on the one hand, and 
moderate depletion on the other. When the indications are uncertain, or equivo- ■ 
cal, we must carefully weigh the different symptoms, and we must cautiously try 
the remedies. The circumstances that most distinguish the one form of the dis- 
ease from the other are to be found in the pulse; which is hard and resisting in 
the earlier stages of inflammation of the encephalon, soft and compressible in 
delirium tremens: iir the tongue; which is mostly parched and rough in the 
former, moist and creamy in the latter: in the skin ; which is hot and dry in the 
one case, covered with sweat in the other : in the countenance ; which is flushed 
in inflammation, and mostly (though not always) pale in delirium tremens : in 
the tremors ; which are not common in the primary periods of inflammation of 
the brain: in the usual absence of headache in delirium tremens: and in the 
peculiar characters, which I need not recount, of the delirium in the two cases. 
If these symptoms contradict each other, as they sometimes will, you had better 
act on the worst supposition, and presume that there is inflammation, and employ 
antiphlogistic remedies : but you must not do so with a strong hand ; you must 
use them cautiously, and watch their effects, and guide thereby your subsequent 
treatment. Take a moderate quantity of blood from the arm : observe whether 
it has the buffy<5oat: and note the condition of the patient afterwards. In mixed 
or ambiguous cases it will be proper to combine calomel with the opium. You 
will sometimes find a state resembling delirium tremens left after the subsidence 
of acute inflammation of the parts within the cranium, and requiring the treatment 
of delirium tremens. 

I do not know that there is much good to be expected from counter-irritation in 
this disease. But after the more decided symptoms were gone by, I have some- 
times thought that the recovery has been accelerated by the application of a blister 
to the nape of the neck. 

Inflammation of the brain, and delirium tremens, are distinct diseases. Hence, 
in the mixed cases, of which I just now spoke, we may expectafter death to find, 
and we often do find, unquestionable traces of inflammatory action within the 
skull. But pure delirium tremens frequently leaves behind it no morbid appear- 
ance whatever in the brain or its membranes. In other cases there is serous 
liquid collected in the interstices of the pia mater, or in the cerebral ventricles ; 
and I have on several occasions seen the arachnoid thicker and less transparent 



DELIRIUM TREMENS. 



259 



than is natural, and sprinkled over with little spots or streaks of a milk-white 
colour. Changes of this kind we believe to be owing to chronic inflammation of 
the membrane. But, even in these cases, I see no reason for thinking that the 
fatal disorder had any connection with the morbid state of the arachnoid. We 
meet continually with like appearances when there has been no delirium tremens ; 
and we have delirium tremens without any such appearances. The habitual 
abuse of ardent spirits leads to chronic inflammation in various parts and tissues 
of the body : in the blood-vessels, in the liver, in the kidneys, and in the arach- 
noid. We need not be surprised at finding that membrane thickened and partially 
opaque in the victims of delirium tremens ; since they are chiefly men who have 
run a long course of intemperance. I believe that disease to bear the same rela- 
tion, and no other, to the chronic arachnitis in such persons, as to the chronic 
hepatitis to which they are equally subject. There is but one morbid condition 
which, since my attention was first directed to it, I have found constant in per- 
sons dead of delirium tremens, and that is, a remarkably soft, pale, and flabby 
state of the muscular tissue of the heart. 

The chemist may be more likely to detect altered conditions in the brain, in 
these cases, than the anatomist. Very lately Dr. Percy has obtained alcohol from 
the brain of a person who died from excessive drinking ; and from those of various 
animals which had been killed by that poison. These facts are interesting, but 
they do not help us much in our attempts to explain the phenomena of the dis- 
order. 

Cases, such as I related in the last lecture, where violent symptoms are calmed 
at once, and the patient is rescued in a few hours from great apparent peril, make 
a strong impression upon those who witness them; and the practitioner gains 
amazing credit, and is spoken of to all their acquaintances as a wonderfully clever 
man. It is unfortunate that we are obliged to set off, against this advantage, a cor- 
responding danger, when the disease ends ill, of being blamed without our deserv- 
ing it. When these patients die (and they usually persist in their evil habits and 
die at last in one of the attacks of the disease), when they so die, they are apt to 
die much in the same way as patients who are poisoned by opium ; and if their 
friends are aware that we have been giving large and repeated doses of that drug, 
they sometimes have the charity to lay the death at our door: and you ought to 
be prepared for this ; and I will conclude what I have to say upon the subject of 
delirium tremens by relating a case, in which I have no doubt that I suffered 
(though quite unjustly) under that kind of imputation. 

Several years ago I was asked, one morning, by a general practitioner at the 
west end of the town, to see a patient with him : of whom he gave me this ac- 
count. The man was about forty years old. He had been attacked some days 
before with sore throat, common cynanche tonsillaris. The tonsils and fauces 
were so much swelled that his deglutition was greatly impeded, and for four or 
five days he had not been able to swallow any thing. The night before I saw 
him he had become delirious, and then had been largely bled, and he was worse 
in the morning. His bowels had also been very much purged. 

I found him propped up in his bed, with a coronet of leeches round his head. 
He was pale ; there was no headache, nor affection of his breathing ; his pulse 
Was not very frequent, and it was quite soft and compressible. He was sweating 
profusely. He answered the few questions I put to him readily and pertinently, 
and then went talking on in a rambling way about his business. He was a hack- 
ney-man or stable-keeper, in a large way. He said (I remember) that the boys 
were all ready to start, that there were two pair of horses going down the road, 
and that he must go and see after them ; and much more on the same subject. 
His mind was busy about the execution of imaginary orders. He had not slept 
at all for some nights. 

Upon my inquiring into his previous condition, his wife told me that without 
any turn for dissipation he had for some time been an habitual hard drinker ; that 
he had frequent dealings with the coachmen to the various families which he fur- 



260 



DELIRIUM TREMENS. 



nished with horses ; and that he was obliged to drink something with each of them ; 
so that every day he had many glasses of spirits, and a good deal of porter. She 
told me, also, that his mind had been anxious and uneasy ; that the business was 
a large and harassing one ; that he had embarked a considerable sum of money in 
it ; and that it had not turned out so prosperously as he had expected. 

Putting all these things together, there could be no doubt, either as to the cha- 
racter of the complaint, or as-to the treatment proper to be adopted. Here was 
a man who had been living a life of continued mental and physical excitement. 
Suddenly the stimulus to which he had been accustomed, was taken away ; 
he could not swallow, even such nourishment as his case required or admitted : 
then came on delirium — a symptom not belonging to the disease in his throat — 
and protracted watchfulness. He is largely bled, and profusely purged, and he 
gets worse instead of better under these remedies. At the same time his skin is 
moist and perspiring, and there is no hardness in his pulse. 

I recommended that the leeches should be removed from his head; that he 
should take immediately (for he could swallow now) two grains of opium, and 
afterwards twenty drops of laudanum every two or three hours till he fell asleep. 

Somewhat unluckily his wife's brother — a very young man — was the appren- 
tice or assistant of a surgeon in the neighbourhood of town, and he came in to see 
his relative. After hearing what I had said, he went home, and probably con- 
sulted his books, and then came back again with doubts whether the complaint 
really was delirium tremens after all. Whether in consequence of these doubts I 
eannot tell, but for some reason or other only one or two doses of the medicine were 
taken. I had offered to see the patient again in the evening, but his friends said 
they would send for me if he did not get better. They did not send. The pa- 
tient did not sleep. At night, therefore, at ten o'clock, three grains of opium 
were administered. The result of this was, that he passed a quiet but a sleepless 
night. Perhaps (but I cannot be sure of that) if the opium had been persisted 
with, the case might have terminated otherwise. About eight o'clock the next 
morning I was summoned to him in a great hurry: when I got there he was 
dying, perfectly comatose, breathing stertorously, with blue lips and contracted 
pupils. He had appeared so much better at seven, that he was, for the first time, 
left alone for a quarter of an hour; and when they went back to him he was 
changed in the manner I have described. 

The general practitioner with whom I had first seen the patient — a very sen- 
sible man- — was much concerned at this issue of the case, and observed to me that 
. doubtless our patient had been poisoned by the three grains of opium. I was 
able, however, to relieve his mind from this notion : and I have mentioned the 
case chiefly for the sake of guarding you against similar misgivings, under simi- 
lar e circumstances. The manner of dying was just such as opium will produce; 
but, then, death by coma is also frequently the termination of delirium tremens. 
' Effusion at length is apt to take place into the ventricles, or into the meshes of 
the pia mater, and stupor comes on, and the patient sinks. But in this instance I 
was certain that his death had nothing to do with the opium he had taken, for 
this reason : that so long a space of time had elapsed — nine hours — between his 
taking the opium and the coming on of the comatose symptoms. Dr. Christison, 
in his elaborate and valuable work on Toxicology, states it as the result of exten- 
sive inquiry into this subject, that when opium has been swallowed in a poisonous 
dose, it almost always begins to act as a poison within an hour; that very rarely 
indeed has its specific operation been postponed much beyond the hour, except, 
.occasionally, when the person taking it was intoxicated at the time. In one re- 
markable instance a drunken man took two ounces of laudanum, and no material 
stupor followed for five hours. I guess that I incurred the reproach of recom- 
mending a fatal plan of treatment in the particular case I have now related ; but I 
am quite satisfied that the opium was innocent of the patient's death, and I even 
think that his chance might have been much mended if the opiate, in smaller 
jdoses perhaps, had been steadily continued. 



DELIRIUM TREMENS. 



261 



We may be content to bear occasionally, these unfounded imputations when we 
consider the other side of the account, and call to mind the far greater number of 
instances in which spontaneous recoveries are credited to us as cures ; and the 
Doctor, like Belinda's Betty, is " praised for labours not his own."* 

I should next wish to put you in possession of what has been ascertained in 
respect to partial and to chronic inflammation of the brain, as these are met with 
in adults ; for I must speak of the head affections of children separately. But I 
really do not know how to bring this part of the subject before you in a practical 
manner. If I were first to describe symptoms, and then to state what organic 
changes had been discovered after death preceded by them, I should have to tell 
you of different symptoms with the same morbid conditions, and of the same 

[* The account given by the author, of the character, phenomena, causes, and treat- 
ment of delirium tremens, is, upon the whole, so very judicious, that it* would scarcely 
appear to demand any other comment, than one of general approval. But as there exists 
a very decided difference of opinion among American practitioners in regard to the proper 
management of the disease, a few words upon this point may not be improper. 

Four different plans of treatment have been recommended, and the results of their ex- 
tensive employment for a series of years, have been adduced, by their respective advocates, 
in evidence of the superior efficacy of each. One practitioner cures all or nearly all his 
cases by repeated emetics, another, by the free exhibition of alcoholic drinks, and a third, 
by opiates in free doses, continued at short intervals, until sleep is procured — while a 
fourth considers that neither excitants proper nor opiates are necessary, but simply a 
state of tranquillity in a quiet and darkened chamber — with perhaps an emetic to unload 
the stomach in the commencement of the attack, and some gentle cathartic to keep the 
bowels open — and when the stomach will retain it a light nutritious and easily digested diet. 

The opiate practice is the one, in favour of the superior efficacy of which we have the 
most imposing weight of evidence — and it is unquestionably the one that will, in the ma- 
jority of cases, when judiciously and cautiously managed, the most promptly and effectually 
remove the symptoms of the disease. That the opiate practice has been abused, we are 
perfectly aware. Uuder the supposition that opium to any extent that may be requisite to 
induce speedy sleep can be administered in delirium tremens with perfect safety, we have 
cause to fear that a state of coma has in more than one instance been induced from which 
the patient has never awoke. We have never been in the habit of administering large 
doses of opium, and have usually combined each dose with an equal quantity of camphor, 
and about half a grain of ipecacuanha. In young, robust, and plethoric subjects, we 
believe that the application of cups to the temples and nape of the neck, or even a moderate 
bleeding from the arm is an important measure in the commencement of the attack which 
should not be lost sight of. 

That there are many cases of delirium tremens in which a perfect recovery may be ef- 
fected without the administration of opium or of any stimulant is very certain. — but our 
experience has taught us, that when the disease occurs in confirmed inebriates, with a 
broken down constitution, and in whom there is almost complete destruction of the 
proper functions of the digestive organs, almost the only means by which it can be cer- 
tainly and promptly arrested is opium administered in moderate doses at short intervals. 

The treatment of* delirium tremens by alcoholic drinks, while we can have no doubt of 
its very general efficacy, — is attended with an evil of too serious a character, to permit us to 
give to it, under any circumstances, our sanction. It cannot fail, we are persuaded, to 
confirm the patient in his intemperate habits — and thus render him liable to a renewal of 
the disease after a short interval. That it is not the only successful treatment we are con- 
vinced from ample experience. In the practice of our preceptor as well as in our own, 
which has extended now beyond a quarter of a century, we have had sufficient oppor- 
tunities for testing the value of the opiate practice in this disease and have seldom been 
disappointed in its effects. We do not say that the patient will invariably recover under 
it. There are cases, in which, from the condition of the patient's system — the complica- 
tion of the temulent delirium with serious disease of the brain or other important organs, 
death is inevitable under any plan of treatment : we believe, however, that in the general 
run of cases, the success of a properly conducted opiate treatment will equal that of any 
other; while in the old, broken down drunkard, it or the stimulant practice, is the only one 
upon which any dependance can be placed. Of the emetic treatment, as recommended 
by Dr. Klapp, we cannot, it is true, speak from experience ; in the very few cases in which 
we have tried we were disappointed in its effects. 

On the subject of the proper treatment of delirium tremens, the reader may consult with 
profit Dunglison's Practice of Medicine, 2d edition, vol. ii., page 274, and the able note by 
Dr. Gerhard in Tweedie's Library, American Edition, vol. ii., page 237. — C] 



262 



DISEASES OF THE BRAIN. 



symptoms with different morbid conditions, in various individuals. I believe the 
best method, upon the whole, will be to describe the several morbid appearances 
which the brain is found to present; and then to mention the symptoms that have 
most commonly been observed to occur in association with such morbid conditions. 
I must premise, however, that the whole subject is full of uncertainty and appa- 
rent irregularity. Doubtless there is some constant and uniform connection of 
cause and effect between the altered physical states of the brain and the altered 
manifestation of its functions: but we have not yet been successful in our search 
after those settled relations; or we have but partial and imperfect glimpses of 
them. 

One very remarkable condition of the brain has been several times mentioned 
in these lectures; viz. softening — ramollissement. A great deal of attention has 
been paid to this condition of late years, both in France and in this country: and 
some points in its pathology have been fairly made out. I will bring them toge- 
ther as concisely as I can. In the first place, the softening varies greatly in 
degree, from the consistence which naturally belongs to the cerebral substance, to 
that of thin cream. Tn its minor degrees it may be easily overlooked ; and is 
more perceptible by the touch than by the eye. The cerebral matter is less co- 
herent, but it is not yet discontinuous or broken down. It may be washed away, 
however, by letting a slender stream of water fall upon it ; and the softened parts 
are thus easily distinguishable from those which retain their natural consistence. 
In the next stage of softening we recognize the complaint at once, for the softened 
parts undergo a change of form by their own weight: parts that are prominent in 
the healthy state, as the optic thalami, corpora striata, and convolutions, sink 
down, as it were, and are more or less flattened. If you make a horizontal sec- 
tion through a part thus diseased, a portion of the softened brain adheres to the 
knife, and is removed by it, and a depression is left. In a still more advanced 
degree, the natural texture of the organ in the softened part is entirely destroyed 
and confused by the change, diffluent: you may pour the softened matter out. 

The colour of the softened portions varies also considerably. Sometimes they 
are unchanged in colour: sometimes they are quite white, and present a strong 
contrast with the tint of the neighbouring parts : sometimes they are marked with 
various shades of redness, from a rosy pink to an orange, or deep red, or even a 
mahogany brown. Often there are red spots mixed irregularly with the softened 
cerebral pulp, and giving it very much the appearance of a mixture of raspberries 
and cream. In other cases we find the softened mass of a pale yellow, or straw 
colour, infiltered, as it were, with purulent matter: and sometimes it is mixed 
with serous fluid. 

Softening of the brain is usually partial. It may occupy any part ; but it is said 
to be more frequently met with in the gray than in the white matter ; and more often 
in the gray matter of the convolutions than of the more central parts of the brain. 

You will find softening of the septum lucidum, and of the fornix, occurring 
very frequently in connection with an accumulation of serous fluid in the lateral 
ventricles. 

Now it is well established that softening of the brain is a common result of two 
very different morbid conditions. It is often caused by inflammation of the soft- 
ened part : it is often caused, also, if I may say so, by its starvation ; by the dimi- 
nished supply of arterial blood, in consequence of diseased blood-vessels. 

Can we distinguish these two forms of softening from each other by their 
physical characters ? Why, sometimes, we can : and sometimes, it must be con- 
fessed, we cannot. 

The same parts that are most liable to have their consistence diminished through 
an inflammatory process, are also most liable to be softened from defect of nutrition. 
The most vascular parts of the brain, in short: the gray matter of the convolu- 
tions, and the gray matter of the thalami, and corpora striata. 

It is stated, however, that softening of the corpus callosum, septum lucidum, 
and fornix, from obliteration of the arteries, is extremely rare. 



RAMOLLISSEMENT. 



263 



If there be pus mixed with the softened brain, we know that there has been 
preceding inflammation. Again, if we find the arteries impervious, we conclude 
that the softening has not been inflammatory. Dr. Carswell states that the obli- 
terated arteries may occupy the softened cerebral substance, and often be seen 
ramifying through it; and that when this substance is removed by pouring water 
upon it, the solidified vessels retain their situation, and feel sometimes as hard as 
fine wires. But we come to the same conclusion if we find the larger vessels, the 
carotid or vertebral arteries, obstructed by ossification ; and a large portion of the 
brain unnaturally soft. 

We have no certain test of the nature of the softening in its being red. The 
redness may be the result of inflammatory congestion; but cerebral hemorrhage 
may occasion softening; and, on the other hand, softening may give rise to cere- 
bral hemorrhage. This may be said, however; that the redness is seldom con- 
siderable when the softening proceeds from obliteration of the arteries. When 
the softening extends much beyond the redness, or the effused blood; or when 
the redness occupies several small portions only of the softened pulp; we may 
presume that the blood was extravasated subsequently to, and in consequence of, 
the softening. On the other hand, when redness and vascularity can be traced 
into the brain, some way beyond the softened part, we may regard the softening 
as the consequence of inflammation. And we adopt the same belief, with still 
greater confidence, when around the softened and disorganized pulp we find the 
cerebral substance hardened, and of a uniform reddish colour. 

In attempting to make the diagnosis between these two forms of softening, we 
get some assistance by noticing the age of the patient. The ossification, which 
gives rise to the obliteration of the arteries, is almost peculiar to the advanced 
periods of life; whereas inflammatory softening may occur at any age; in child- 
ren, in adults, or in old persons. 

Some of the French pathologists have laid down this rule, as the result of their 
experience in regard to softening of the brain — that it is attended, during the earlier 
part of its progress, with a permanently contracted state of the flexor muscles of 
one or more of the limbs. " In some cases the contraction of these muscles 
amounts only to a slight degree of stiffness ; in others it reaches such an extent, 
that if the arm be the part affected, the hand is clenched, and remains pressed 
against the shoulder ; or, if the leg, the heel is carried up to the hip." Sometimes 
this tonic spasm is so strong that you cannot extend the limb ; and the attempt to 
do so gives the patient pain. After a certain time the rigidity is succeeded by 
complete relaxation ; the contracted limb has become utterly palsied. 

I believe that this is a valuable diagnostic symptom of softening, and especially 
of inflammator) r softening — when it occurs. But it is often wanting. I wish I 
could tell you something more certain and constant in respect to the symptoms of 
this interesting change; but the facts which I have myself observed, and which 
have been recorded by others, will not permit me to do so. Dr. Abercrombie 
even goes so far as to say, that judging from the cases that have fallen under his 
own notice, there is no foundation for the statement that ramollissement is dis- 
tinguished by tonic contraction of one or more limbs ; that the same thing is met 
with in connection with affections of the membranes, without any disease of the 
cerebral substance ; and with the encysted abscess of the brain ; and that it is 
frequently observed in cases of typhus fever where there is much cerebral disturb- 
ance, but which terminate favourably. I will give you the general result of his 
experience in this matter as being untinctured with any wish to reduce his facts 
into conformity with a preconceived opinion, or hasty generalization. He states 
that "the cases which terminate by ramollissement seem in general to be charac- 
terized by convulsion, more or less extensive, followed by paralysis and coma ; 
the convulsion ceasing for some time before death, and being succeeded by the 
coma." But he saw one case in which " the convulsion continued with the 
utmost violence till the very time of death." In another instance " there was no 
convulsion at all, but a sudden attack of palsy, exactly resembling the ordinary 



264 



DISEASES OF THE BRAIN. 



attack of hemiplegia from other causes." In two cases he found " ramollissement 
of very limited extent, in connection with symptoms of long standing, both cases 
being at last rapidly fatal by a sudden attack of convulsion." In other cases 
44 there was extensive destruction of the cerebral substance, without either para- 
lysis or convulsion, and even without coma." 

When you rind the softened substance infiltered with purulent matter, you may 
call the case one of suppuration of the brain. But suppuration also occurs in 
another form; viz., in the form of abscess. The pus is contained in a regular 
well-defined cavity, surrounded by cerebral matter in a healthy or in a hardened 
state. Now in suppuration occurring in the brain, there is the same puzzling 
diversity of symptoms as in cases of simple softening. Still, in the main, there 
seems an approach to the same order of symptoms ; convulsions in the earlier 
period constituting the most prominent feature of the disease ; paralysis in the 
latter. I will take one of Dr. Abercrombie's cases in illustration of the formation 
of encysted abscess in the brain. 

A girl, aged eleven, thin and delicate, after having complained for some days 
of headache, was seized on the 11th of January, with convulsions, which con- 
tinued about half an hour: paralysis of the right arm followed the attack of convul- 
sion. She was bled from the arm, and purged, and cold was applied to her head ; 
and she was much benefited by this treatment. On the 13th the headache was 
much abated, and she had recovered a considerable degree of motion of the arm. 
On the 15th the headache increased again, and the arm became more paralytic, 
and she was again bled : and on the 16th and 17th the power of moving the arm 
was greatly improved. On the 18th, after being affected with increase of head- 
ache, and some vomiting, she became convulsed, the convulsion being confined 
entirely to the head, and to the right arm ; the head was drawn towards the right 
side, with a rolling movement of the eyes ; the arm was in constant and violent 
motion. She was sensible and complained of headache. Being bled to eight 
ounces, the convulsion ceased instantly, and the headache was relieved; but the 
right arm remained in a state of complete paralysis. Her pulse, during the five 
following days, fell from 100 to 60 ; some headache continued ; she had occasional 
vomiting; and the convulsive attacks returned several times; they were entirely 
confined to the right arm, which after the 23d, was left in a state of permanent 
palsy. Hitherto no other parts of the body had been affected by the convulsion ; 
but on the 24th it attacked the right thigh and leff, and left them powerless. The 
former remedies were repeated without any effect. The thigh and leg went 
through a course precisely similar to that described in regard to the arm, and on 
the 29th were permanently incapable of motion. 

She was now, therefore, paralytic of the whole right. side; she had no return 
of convulsion, was perfectly sensible, and made little complaint. Gradually she 
became dull and oppressed, and at length fell into a state of perfect coma, and 
died on the 14th of February, a little more than a month after the commencement 
of her illness. 

In the upper part of the left hemisphere of the brain there were two distinctly 
defined abscesses, containing together from six to eight ounces of very foetid pus. 
They were lined by a firm white membrane; and a thin septum of firm white 
matter separated them from each other. The one was in the anterior part of the 
hemisphere, very near the surface; and the other immediately behind it. In the 
posterior part of the right hemisphere there was a small abscess containing about 
half an ounce of pus. There was no serous effusion in any part of the brain, and 
no other morbid appearance. 

In this very interesting case it is worth remarking how the convulsion preceded 
the paralysis, and how the palsy was more'than once diminished by antiphlogistic 
measures. 

It is reasonable to conclude— it can hardly be called a conjecture — that in such 
cases of partial disease of the brain as I have hitherto mentioned, the occurrence 
of convulsion, or of rigidity, marks the inflammatory stage ; and the supervention 



INDURATION. 



265 



of permanent paralysis denotes the period of softening or suppuration, of complete 
disorganization, that is, of the texture of the brain in that part. 

Partial inflammation of the brain, especially when it is chronic, sometimes pro- 
duces a totally different change from any that have yet been described. Instead 
of becoming softer, or being converted into pus, the inflamed part is indurated ; 
comes to resemble in consistence portions of brain that have been for a short time 
immersed in weak nitric acid. In this state it is often unusually vascular and 
injected. When the induration is greater in degree, the hardened part assumes 
the appearance of wax, or of boiled white of egg, or (as Andral says) of Gruyere 
cheese, and contains but little blood, but is, on the contrary, distinguished by its 
pearly whiteness. That these changes are the result of slow inflammatory action 
is the more probable, because they are sometimes found to exist around an old 
apoplectic clot or cell; the blood effused having acted as a cause of inflammation 
of the neighbouring part, just as any foreign substance might do. In the_progress 
of cases in which partial induration is effected, convulsive movements are common, 
but paralysis does not appear to be so frequently present. The symptoms may 
go on for months, and often remit, and are again aggravated by paroxysms. 
These cases are the more interesting, because they offer a greater probability 
of cure than those that are attended with an opposite condition of the cerebral 
mass. 

Besides these varieties of inflammation, and their consequences, the brain is 
often infested with tumours, which also give rise to a great diversity of symp- 
toms. There are fibrous tumours which grow rather around the nervous matter 
than within it, and are connected with the dura mater. They have been found 
at almost all parts of the surface of the brain ; at its base, at its sides, and towards 
its summit. Scrofulous tubercles are also not uncommon: these are embedded in 
the nervous substance, and assume a round form, for the reason I formerly men- 
tioned, viz., because the tubercular matter that is separated from the blood is not 
cast into any particular mould (as it is when it is effused into the small bronchial 
tubes), but poured forth into the homogeneous pulp, which exerts an equal degree 
of pressure upon it on all sides. These scrofulous tubercles of the brain are 
infinitely more frequent in children than in adults ; and they are more commonly 
met with in the cerebral hemispheres than in any other part of the brain, occupy- 
ing the cortical and medullary substance indifferently. They sometimes appear 
to originate in the pia mater. They differ from pulmonary tubercles in this 
respect, that they are seldom numerous in the same brain. Sometimes one only 
is found. They vary in magnitude from the size of a large pin's head to that of 
a hen's egg ; and they are sometimes even bigger than that. The substance of 
the brain immediately surrounding these tubercles may be unchanged, in which 
case it is probable that the tubercles themselves give rise to no particular symp- 
toms, the cerebral matter of the spots they occupy having been gradually absorbed 
to make room for them; but at length important alterations take place in the 
neighbouring texture; congestions of blood, or softening, or suppuration; and 
then the ordinary consequences of these changes declare themselves outwardly. 

Cancerous tumours occur also in the substance of the brain. They usually 
occupy a large portion of it before they extinguish life. Hydatids are sometimes 
found there. 

Now of the occurrence of these various local maladies of the brain it is neces- 
sary that you should be aware, for you may expect to meet with them frequently 
in practice. And it is right also that you should be aware that they do not dis- 
close their precise nature by any peculiar symptoms, or succession of symptoms. 
They all, sooner or later, disturb the functions of the organ in which they are 
situated ; and they may all disturb them exactly after the same fashion. We may 
judge, sometimes, from other circumstances, that the disease is of this or of that 
character. If we see scrofulous or cancerous disease in other parts of the body 3 
we infer that the symptoms which denote disease of the brain are caused by 



266 



DISEASES OF THE BRAIN. 



scrofulous or cancerous tumours there situated ; but from the symptoms them- 
selves, we can only learn that there is some morbid condition of the brain. 

I attended, recently, with Dr. Latham, a youth, whose symptoms led us to 
believe that he had tubercular disease of the peritoneum ; a very formidable com- 
plaint, which I shall more particularly describe hereafter. We thought it probable, 
also, although there were no physical signs of pulmonary disease, that his lungs 
contained crude tubercles. After some time, he went down to the coast; and 
was there attacked with a fit of general convulsions. Up to that period he had 
shown no symptoms whatever indicative of organic disease within the head. On 
being apprized of this seizure, we expressed in a letter to the physician then 
attending him, our opinion that it had resulted from the presence of scrofulous 
tumours in the patient's brain. The convulsions returned a few days afterwards 
with great violence, and he died. It was as we had conjectured. The perito- 
neum was found studded with innumerable miliary tubercles: there were a few 
crude tubercles, of some size, around the roots of the lungs ; and two large masses 
of the same sort in the brain. Here, you see, we were directed to a correct 
special diagnosis of. the cerebral disease, simply by the evidence which had satis- 
fied us that scrofulous tubercles existed in other parts of the body.* 

In the case of specific tumours there is really nothing to be done by way of 
cure. We must then treat the symptoms, and seek to alleviate them as they 
arise. When it appears likely, or not unlikely, that the cerebral symptoms may 
be the result of cerebral inflammation, we must give the patient the chance of 
being benefited by some of the remedies of inflammation : we must treat the case 
in this instance upon the most favourable supposition. The class of remedies 
from which most may be hoped in equivocal cases, are local bleeding, counter- 
irritation, and especially the cautious and regulated employment of mercury. I 
have stated to you before, that I have known several obscure but threatening 
symptoms of brain disease clear entirely away, when the gums were made sore 
by mercury, and kept slightly tender for some little time. It is possible, that we 
may sometimes do our patients harm by this mercurial treatment. We may, now 
and then, accelerate the arrival of death in persons whom nothing could save ; 
but we must not be deterred from giving them this chance of being rescued from 
a disorder which may be susceptible of cure, but which, if unchecked, will be 
inevitably fatal. 



LECTURE XXV. 

Hypertrophy of the Brain: Atrophy. Acute Hydrocephalus ; Premonitory 
Signs; Different Modes of Attack; Stages of the Disease; Anatomical 
Characters ; Causes. 

There is a very curious morbid condition of the brain, to which I shall advert 
before I take up the consideration of certain cerebral diseases as they occur in 
children. The condition of which I am about to speak I was totally ignorant of 
till I had been for some years in practice. In the spring of 1833 I admitted a 
young woman, 19 years old, into the Middlesex Hospital. Her countenance was 
sallow, and her lips pale. She complained of pain in her chest and limbs ; of great 
and increasing debility, and wasting; and of nightly perspirations. She had some 
cough, and a frequent pulse; and although no morbid sounds were audible in her 
lungs, I suspected that they might contain small or scattered tubercles. She had 
been in the hospital scarcely a week, when she had a violent fit of epilepsy ; and 

* [For a more full account of the present state of our knowledge in regard to tubercles 
of the brain, see the Editor's Treatise on Diseases of Children, page 572. — C] 



HYPERTROPHY. 



267 



when she was somewhat recovered, she told us, for the first time, that she was 
subject to such attacks. The convulsions recurred on the same day, and she be- 
came insensible, and remained so during the whole of the next day, and till the 
evening of the day after, when she died. During this period of insensibility she 
had many convulsive fits ; the pupils were dilated, the pulse 100, small and feeble. 
Leeches were applied to the temples, a blister to the neck, and afterwards to the 
shaven head, and other measures were used, but in vain. 

When the surface of the brain was exposed by the removal of the skull-cap, 
and of the dura mater, it was observed that the convolutions were remarkably flat- 
tened, so that the little furrows between them were nearly effaced; and the surface 
of the arachnoid membrane was perfectly dry. These are not very unusual, though 
they are unnatural appearances. I had often seen such before : and I ventured to 
say that we should find some cause of strong pressure in the central part of the 
brain ; effusion of serum into the ventricles, or a large extravasation of blood. But 
to my great surprise, and much to the discredit of my prophecy, we found nothing 
of the kind. The ventricles were even smaller than natural, and contained scarcely 
any moisture. The skull-cap was afterwards examined, and the bone was found 
to be uncommonly thick, dense, and heavy ; and its inner surface, without being 
rough, was very irregular. I regret that, in this examination, the state of the 
blood-vessels of the brain, and the consistence of the cerebral matter itself, were 
not particularly noticed. In the record made at the time by my clinical assistant, 
it is merely stated that the brain was otherwise healthy. There was no disease 
in the lungs. 

This dissection interested me much, fori had never seen nor heard of anything 
like it before. But upon looking into some modern authors,! discovered that the 
same phenomena had been noticed by two or three observers, who had very pro- 
perly (as it seems to me) considered them as the result of hypertrophy of the 
brain. There is a very good memoir upon the subject, by M. Dance, published 
in the fifth volume of Breschet's Repertoire oV Jinatomie : and Andral gives an 
account of the disease in his Pathology. It appears that Morgagni had not over- 
looked it, for he speaks of instances in which the brain seemed too big for its 
bony enclosure. When, in these cases, the skull is sawn through, the upper 
loose portion of bone starts up, as if moved by a spring, and the edges of the bone 
remain widely apart. Laennec, also, in Corvisart's Journal, states that upon 
opening the bodies of persons whom he had thought affected with hydrocephalus, 
he had been surprised at finding a very small quantity only of fluid in the ventri- 
cles, while the convolutions on the surface of the brain were strangely flattened ; 
proving that the cerebral mass had undergone strong compression, which could 
only have arisen from its preternatural volume, and undue nutrition. 

Besides the characters I have mentioned, the hypertrophied and compressed 
brain is firmer and tougher than natural ; it contains but little red blood ; and sec- 
tions of it are seen to be unusually dry and pale. 

In several of the cases of hypertrophy of the brain recorded by authors, the 
patients had suffered epileptic fits, or rather paroxysms of convulsion ; and in some 
of them the convulsions terminated in paralysis. Andral states that the intel- 
lectual faculties have been observed, in some instances, to become dull and obtuse. 
Many of the patients were subject to severe headaches. All these symptoms are 
common to various cerebral complaints. The diagnosis of this rare disorder can 
be no better than conjectural ; and its treatment we have still to seek. 

Andral remarks, what is very true, that hypertrophy of the brain, i. e., an un- 
due and disproportionate development of that organ may, and does happen, without 
giving rise to any morbid phenomena at all. But, in such instances, the brain- 
case is equally enlarged in capacity; so that no pressure upon the cerebral mass 
results from its own preternatural growth. It is only when the brain increases 
faster than the bony sphere which contains it, that the hypertrophy becomes a 
disease. In my patient there was also, in one sense, hypertrophy of the skull; 
the bone was considerably thicker, and more compact and heavy, than is usual; 



268 



DISEASES OF THE BRAIN. 



but the capacity of the cavity had not undergone a proportional augmentation : 
nay it might, for any thing I know, be diminished in consequence of the increased 
thickness of the bone ; the case may have been one of concentric hypertrophy of 
the bone, without any fault of the brain itself; but what makes this the less pro- 
bable is, that in other cases, the skull has been found of the ordinary thickness 
and density ; but loo small for its contents. 

It is of some importance for you to be aware that the brain, and its case, may 
be extravagantly developed without there being any disease, or any symptoms of 
disease. M. Scoutetten gives an instance of this which he observed in a child 
five years old. Its head was as large as that of a well grown adult person. The 
skull was from a line and a half to two lines in thickness. The dura mater 
adhered firmly to the bone, and the cerebral mass exactly filled up the cranial 
cavity. The superior and posterior part of the brain was developed beyond mea- 
sure, so that to reach the ventricles it was necessary to make an incision nearly 
three inches in depth. There was nothing unusual to be remarked in any of the 
cerebral functions of this child; it was just like other children of the same age in 
respect of intellect. It died of acute inflammation of the bowels. 

The late Dr. Sweatman met with just such another child a few years ago: and 
I refer to his description of it the rather, because cases that occur near home are 
always more interesting, and satisfactory, than those which we merely read of in 
foreign authors. Dr. Sweatman had never read of any thing of the kind : but in 
August, 1834, a little boy, two years old, was brought to him on account of the 
size of his head. It had been gradually increasing from the age of six months, 
till it had become so large as by its weight to prevent the child from continuing 
long in the upright posture. The boy was active and lively, though thin. He 
never had any fit or convulsion; but occasionally seemed uneasy, and then would 
relieve himself by laying his head upon a chair. He had never squinted nor was 
he subject to drowsiness, or startings during sleep; and his pupils contracted 
naturally. His appetite was good, and all the animal functions were properly 
performed. Dr. Sweatman got Mr. Mayo to see the child with him: they both 
set it down as a case of hydrocephalus, but agreed in thinking that in the abscence 
of symptoms it would be wrong to risk disturbing his digestive organs by active 
medicines. In the early part of 1835 the child died of inflammation of the chest, 
and Dr. Sweatman and Mr. Mayo examined the head. I here show you a cast 
of it. It measured from ear to ear, over the vertex, twelve inches ; from the 
superciliary ridges to the occipital, thirteen inches; and in circumference twenty- 
one inches. The anterior fontanelle, which was quite flat, measured across its 
opposite angles two inches and a quarter by one and a half; the posterior fonta- 
nelle was completely closed, as was the frontal suture. There was no absorption 
of bone at any part; on the contrary it was becoming thicker. The dura mater 
adhered with great firmness to the skull ; and a layer of false membrane, as big as 
a crown-piece, was found upon its upper and anterior part. Beneath the arach- 
noid at that part there was slight jelly-like effusion. In all other respects the 
organ was sound. The convolutions were perfectly distinct, and retained their 
proper rounded shape. All the ventricles were found empty, and not dilated. 
The surfaces, however, of the medullary matter, exposed by different sections, 
presented very unusual vascularity. 

The lesson we learn from cases of this kind is, that we are not to regard every 
child that has a very large head as a hydrocephalic child ; and especially that we 
are not to inflict upon such a child a course of mercury, or other active remedies, 
unless some morbid symptoms appear. The nimia mm medici may in these, 
as in many other cases, destroy health ; produce disease where none existed before.* 

Having told you what I know of hypertrophy of the brain, it is proper that I 
should say a word or two respecting the opposite condition; of atrophy of the 

* [For sortie further facts in relation to Hypertrophy of the Brain, the reader is referred to 
the Editor's Treatise on Diseases of Children, page 336.— C] 



ACUTE HYDROCEPHALUS. 



269 



cerebral mass. There are two forms of this affection: one is congenital, and 
results from imperfect development, or an arrest of development, of the brain in its 
fetal state. In the other the change appears to take place in consequence of dis- 
ease, either in the membranes of the brain, or perhaps in its arteries ; though the 
effect of disease in the arteries is usually softening, which is a species of atrophy. 
But in the atrophy to which I am now alluding, the volume of the atrophied part 
is diminished, not its consistence. And the diminution of size may extend only 
to a few convolutions : or it may be most manifest in the interior of the organ; in 
the optic thalami and corpora striata for example. There is still another alteration 
to which some have applied the term atrophy, though improperly, I think: I 
allude to those cases, which I shall speak of more particularly soon, in which the 
form and disposition of the cerebral substance is altered, the convolutions being 
unfolded, and the nervous matter spread out by a large collection of fluid in the 
interior cavities of the brain, constituting the disease called chronic hydrocephalus. 
I have not much to say upon what may be styled atrophy proper of the brain: 
that it will give rise to symptoms we cannot doubt, but that it shows itself by any 
peculiar or characteristic symptoms is what I have not discovered. 

I shall content myself, on this subject, with showing you Cruveilhier's repre- 
sentation of a strongly pronounced example of atrophy of the entire cerebrum on 
one side. The drawing from which this engraving was made, was painted from 
the body of a patient who died in the Hotel-Dieu, dropsical, in consequence of 
disease of the heart. He was forty-two years old. When you look at the engrav- 
ing you will perceive that the left side of the cerebrum is diminutive compared 
with the right. It tilled up, however, a larger space than it appears to do in the 
plate ; for the lateral ventricle on that side was distended by a quantity of serous 
fluid, which ran out when the ventricle was punctured ; and then the surface of 
that side of the brain sank down, and collapsed. Still the convolutions on that 
side, and all the dimensions, are remarkably less than on the other. The anterior 
lobe projected half an inch further on the right than on the left side. The frontal 
bone, you will observe, is much thicker ; twice as thick on the atrophied as on 
the natural side; and the frontal sinus very wide and open. The internal parts 
of the brain are all diminished in proportion. There was a large quantity of 
serous liquid filling and distending the subarachnoid areolar tissue. The nervous 
matter was whiter and harder on the atrophied side. One very curious thing is, 
that the left lobe of the cerebellum was the bigger of the two; but there was no 
such marked difference between them as between the two sides of the cerebrum. 

Now the patient, in whom this singular disproportion between the two sides of 
his brain was met with, had been incompletely hemiplegic, as long as he could 
recollect, on the right side ; and the imperfectly palsied limbs were shrunk and 
withered, and the fingers of the hand contracted. Yet he had managed to walk 
about with the help of a stick ; and there was nothing remarkable, one way or 
the other, in the state of his intellectual faculties. 

The same condition has been seen on both sides of the brain : the organ itself 
existing in miniature, as it were, and lying at the lower part of the vaulted cavity 
of the cranium : the intermediate space being filled up with water. In long- 
standing cases of this description you must not suppose that the nervous matter 
has been compressed into a smaller compass by the effused fluid ; but that the 
fluid has been poured out to fill that part of the skull which is empty of brain, 
and which must be filled with something. This condition of the cerebrum is 
accompanied by idiotcy. 

I proceed in the next place to the consideration of that disease to which the 
name of acute hydrocephalus has been given. By that term I desire to signify 
inflammation of the brain, as it frequently occurs in children, and especially in 
scrofulous children. The inflammatory character of the disorder, though not 
always very clearly expressed in its symptoms, is sufficiently attested, in many 
of the fatal cases, by the changes discovered within the cranium. 



270 



DISEASES OF THE BRAIN. 



I made some observations, in the last lecture, respecting the nomenclature of 
diseases, and said something in defence of the name delirium tremens. Now it 
must be confessed that the complaint we are about to consider was unfortunately 
named, when it was called hydrocephalus. I repeat that it matters not at all how 
we denominate a disease, provided that its title does not involve any erroneous 
notion of its nature. I think hydrocephalus a bad name, because it reminds us 
of one circumstance only of the, malady, viz., the serous effusion, which so far 
from being the cause, or the essence, is only a frequent effect of the disease ; nay, 
it is no uncommon effect of other morbid conditions also, besides inflammation. 
But hydrocephalus, or water in the head, is an appellation so established, both 
among ourselves and with the public, that I cannot venture to propose any change. 

After what I have already stated in respect to inflammation of the brain in 
adults, you will be prepared to hear that acute hydrocephalus (remember, I restrict 
that term to the same inflammatory malady as it occurs in strumous children) — I 
say you will not be surprised to learn that acute hydrocephalus furnishes a great 
variety of symptoms ; and many variations in the mode of their coming on, and 
in their combination, and succession. 

It is of the greatest importance to recognize acute hydrocephalus in its earliest 
stages ; and even to look out for indications of its approach. I shall, therefore, 
describe those changes in the state of the young patient, which have been found 
to be, in many cases, premonitory that the disease was impending. But such 
symptoms are by no means always followed by acute hydrocephalus ; nor is acute 
hydrocephalus always preceded by such symptoms. Still, when they do occur, 
they should put us upon our guard. 

The precursory symptoms to which I allude consist chiefly in a morbid state 
of the nutritive functions. The child loses his appetite ; or his appetite becomes 
capricious : he sometimes appears to dislike his food, and sometimes devours it 
voraciously : his tongue is foul, his breath offensive, his belly enlarges, and some- 
times is tender; his bowels are torpid, and the evacuations from them unnatural; 
the stools are pale and contain but little bile ; or they are dark, with vitiated bile, 
foetid, sour-smelling, slimy, or scybalous ; and the child loses his former healthy 
aspect, becomes paler, and thinner. Even already there are obscurer indications 
of derangement in the cerebral functions ; the child is heavy, languid, and de- 
jected ; his customary spirit and activity are gone ; he gets fretful and irritable, 
and is manifestly uneasy ; and sometimes he shows a little unsteadiness and tot- 
tering in his gait. 

In very young children, when the disorder is at hand or incipient, an unnatural 
wakefulness is often observable. A frequent sudden cry or scream, a clenching 
of the little fists, and a turning in of the thumb towards the palm of the hand, 
give warning also of the approaching malady. 

Now when this sort of alteration is observed in a child who has any hereditary 
title to scrofula, or bears the marks of the strumous diathesis, or is even a preco- 
cious and particularly clever child, and still more if he present any other indica- 
tion of strumous disease, there will be much reason to apprehend that mischief is 
brewing within his head. I advert to these tokens of scrofula, because the in- 
flammation, in a majority of cases, if not in all, is of a scrofulous character. But 
there is this peculiarity in it, which distinguishes it from scrofulous inflammation 
in most other parts, viz., that as it occurs in an organ of very delicate structure, 
and one which is essential to life, its progress is more rapid, and it is more neces- 
sary to treat the disease promptly. 

It has been made a question whether the derangement of the digestive organs 
that has just been described is or is not the cause of the affection of the brain ; or 
whether both the abdominal and cerebral disorder are not common and concurrent 
effects of the same cause. It is said that the stomach and bowels are more in the 
way of being acted upon by injurious influences than the brain, and that, there- 
fore, the complaint may be supposed often to originate in their derangement; and 
great good, it is alleged, is done, the disease of the brain is often prevented, by 



ACUTE HYDROCEPHALUS. 



271 



remedying the disordered condition of the stomach and bowels. On the other 
hand, it may be stated that a similar derangement of the digestive organs often 
comes on and lasts long in children, without leading to hydrocephalus ; and 
hydrocephalus often attacks a child in whom no such symptoms of abdominal 
disease have appeared. We can never be certain, therefore, that hydrocephalus 
has been prevented, in any given case, by remedies addressed to the digestive 
organs. I cannot think the question is one of much practical importance. Whether 
the disturbances of the inutritive functions cause the brain disease, or merely indi- 
cate it, they are equally valuable in directing our attention to the head. 

In these little patients any source of irritation seems to act as an exciting cause; 
surgical operations, which are sometimes necessary at that tender age — falls or 
injuries of any kind — painful dentition. 

There are, at least, three several ways in which this disease may make its 
attacks ; and with these it is proper that you should be acquainted. 

In the first place, it may come on gradually ; after such symptoms as have 
already been spoken of as being premonitory. Probably this is the way in which 
it most frequently commences. After a period, of uncertain duration, in which 
the child has complained of occasional pains in the belly and head, and signs of 
derangement of the stomach and bowels have been present, the pain in the head 
begins to be more severe and to recur more frequently. It is not mere headache, 
but generally a sharp shooting pain, recurring at intervals ; sometimes it affects 
one side of the head more than the other; the little patients wake and shriek out 
with the pain, and this in children is a very characteristic symptom. As coma 
comes on this shrieking gives place to art habitual moaning, which is scarcely- 
less characteristic. Very often in the beginning of the disease there are pain and 
stiffness at the back of the neck; sometimes there is much pain of the limbs in 
the early periods, and in some children extreme tenderness of the scalp, so that 
they cannot endure to have the head shaved. The pain of the head becomes 
complicated with vomiting, and both these symptoms are aggravated by motion. 
Very often nausea is excited by the erect posture, and the patient begs to lie 
down. The child sighs frequently, and looks grave or sad ; his eyes are pained 
by a strong light, so that he knits his brows. The pulse becomes rapid, and the 
disturbance and irregularity in the abdominal functions increase. This stage of 
the complaint may last ten days or a fortnight, the child becoming daily more 
weak, and more peevish, and looking more and more ill. 

In the second form of attack there are no premonitory symptoms ; or they occur 
for a very short while only before the disease sets in suddenly and violently, with 
acute pain in the head and high fever; or with convulsion : the face is flushed, the 
eyes are brilliant ; there is intolerance of light and of sound, and there are pain 
and tenderness of the abdomen. In short, the disease, when it commences in 
this manner, is very like an attack of continued fever. You may find these varie- 
ties described in Dr. Cheyne's excellent treatise on this disorder. " We are led 
to suspect," he says, " some deeply-seated evil from the frantic screams and com- 
plaints of the head and belly, alternating with stupor, or rather lowness, and un- 
willingness to be roused; and we are struck with the great irritability of the 
stomach, which exists in a degree beyond what we generally find it in the fevers 
of this country ; retching and vomiting being brought on by a change of posture, 
and certainly by every attempt to sit up in bed ; and the disordered state of the 
bowels, which attends this irritability of the stomach, is also remarkable : and 
when at any time the child has a little respite from the violence of these symp- 
toms, we find our suspicions confirmed by his looks ; for when the features do 
not express pain or terror, there is not unfrequently a vacancy of look, the eyes 
being set, with an expression of dejeetion which is peculiar to certain diseases of 
the brain.'' The mode of attack which has now been described, although the 
most regular in its progress, is not so common as the first, nor as the third, which 
I have yet to mention. The third way in which the disease makes its advances 
is very insidious : the head symptoms supervene upon the subsidence of some 



272 



DISEASES OF THE BRAIN. 



other malady: presently after the disappearance of an eruption from the scalp ; 
during the decline of scarlet fever, small-pox, hooping-cough, or any inflammatory 
or febrile complaint; and even after painful dentition. In these cases the early 
symptoms are often but slightly marked, or do not take place at all; the sudden 
occurrence of convulsions or paralysis affording the first evidence that the brain 
is implicated. This is the most dangerous form of hydrocephalus. It has received 
the expressive title of water-stroke. 

In whatever way the disease makes its invasion, it is apt to be attended with 
many and variable symptoms ; and different observers, with a view of facilitating 
their description of the disease, and of making it more intelligible and more easily 
remembered, have divided the symptoms into groups, and considered each group 
as characteristic of a particular stage of the malady. But they have not all done 
this in the same way. It may be of use, however, to inform you of the different 
classifications which have thus been proposed. Dr. Whytt, who was almost the 
first person in this country who wrote upon this disease (I believe Dr. Paisley of 
Glasgow, was the first: you may see his paper in the third volume of the Edin- 
burgh Medical Essays), Dr. Whytt, I say, whose description is an extremely 
good one, took the pulse — which undergoes very remarkable variations in the 
course of the disease — as the ground of his division. He makes three stages of 
it therefore; the first, in which the pulse is frequent; the second, in which it is 
slow and irregular; and the third, in which it again becomes frequent and feeble. 
These successive fluctuations in the pulse are to be noticed in very many cases. 
Dr. Golis, again, an eminent German writer on hydrocephalus, whose little work 
was translated by the late Dr. Gooch, as being the best book on the subject that 
he was acquainted with, makes four stages, according to what he believes to be 
the condition of the brain in each. First, he has the period of turgescence, which 
corresponds with tha't period in which the premonitory symptoms occur; secondly, 
the period of inflammation ; thirdly, the period of effusion; fourthly, the period 
of palsy. The two last would appear to be almost identically the same. Dr. 
Cheyne makes three stages; which he finds marked, not like Dr. Whytt, by the 
state of the circulation, but by the state of the nervous system. Thus he calls the 
first the period of increased sensibility, when every stimulus produces an impres- 
sion more than proportioned to its common effects. In the second stage, that of 
diminished sensibility, the child is not easily roused, his pupil is dilated, and his 
pulse slow ; he is lethargic, with obstinately costive bowels. The third stage 
with him is that of palsy and convulsions, in which there is squinting, rolling of 
the head, stupor, convulsions, with a rapid thready pulse. 

Cases often occur, however, that baffle all these attempts at classification. Con- 
vulsions, instead of being among the last, are not seldom among the very first 
symptoms. The pulse is sometimes remarkably slow at the outset ; sometimes 
frequent through the whole disease; and sometimes perfectly natural. 

I do not make these statements to magnify the difficulty of distinguishing the 
disease ; for the diagnosis is really not so difficult as it has sometimes been repre- 
sented ; but to show you that you must not trust to any succession of symptoms, 
still less to any one symptom, as being pathognomonic. 

The symptoms that occur during the first stage are very variable, as you may 
suppose from what I have said of the different modes in which the disease is apt 
to set in. Those that are most constant are, pain of the head, severe shooting 
pain, I say, it seems to be, for the child puts its hand there, and cries out fre- 
quently, " Oh ! my head ;" restlessness ; inability to sit up ; very disturbed sleep, 
with grinding of the teeth, and from this sleep the child often starts apparently in 
terror, and with a scream. The head is hot externally ; the little patient is an- 
noyed by light and by noise ; the pupils are contracted most commonly during 
this stage; the child is unwilling to be disturbed, and, therefore, does not reply 
readily to questions ; but the replies, when made, are correct and rational. This 
stage is marked, also, by vomiting, a total loss of appetite, a white tongue, offen- 
sive breath, costive bowels, unnatural stools, green often, or black, like tar, scanty 



ACUTE HYDROCEPHALUS. 



273 



and high-coloured urine. Dr. Golis says that the abdomen, which has been tumid 
and tender, perhaps, sinks down and becomes flat, without any increased excre- 
tion by stool ; and that this is a very characteristic symptom. The pulse in this 
stage is frequent and sharp. In short, the symptoms are such (in general) as 
indicate very plainly that inflammatory action is going on within the head. Now 
the symptoms that characterize this first stage of the complaint sometimes rapidly 
■pass into those which belong to the second. They may not be present for more 
than a few hours ; or they may last a day or two, or several days ; it is very seldom, 
I believe, that they continue longer than a week. The period answers, in the 
general character of the symptoms, to the period of excitement in encephalitis, 
which I repeat is very much the same disease, modified by its occurrence in the 
adult and otherwise healthy subject. 

So, also, the second stage of acute hydrocephalus corresponds, in its general 
features, with the period of collapse in encephalitis. The pulse becomes irregu- 
lar, extremely variable and fluctuating, and often slow: it is easily accelerated, 
however, by the smallest exertion — by taking the child out of bed, or even raising 
him into a sitting posture. With this slowness of the pulse come on a diminu- 
tion of sensibility, and general heaviness and stupor; the pupils dilate, the light 
is no longer troublesome, the vision is imperfect, often it is doubtful whether the 
child sees at all. If the eye be closely examined and watched, the degree of light 
remaining the same, the size of the pupil will frequently be seen to fluctuate or 
oscillate, till at last it is wide open and immovable. While this goes on squinting 
takes place, and double vision when the child can yet see any thing. One or both 
eyes are turned in, or more rarely outwards. Noises do not now disturb or irri- 
tate the child — who lies on his back, with the eyes half closed, in a state of drow- 
siness or stupor, which is occasionally interrupted by some cry or exclamation 
expressive of pain. Convulsions frequently occur, but not uniformly ; slight and 
partial spasmodic twitchings; or general and long-continued convulsions; para- 
lysis ; sometimes hemiplegia. The urine and stools are passed unconsciously. 
Sometimes the child, with feeble and tremulous hands, is incessantly picking his 
lips, or boring his fingers into his ears or nostrils. 

This stage may last a week or two. And what is remarkable, it is often attended 
with remissions, sometimes sudden and sometimes gradual — deceitful appearances 
of amendment, and even of convalescence. The child regains the use of its senses ; 
recognizes those about him again; appears to its anxious parents to be recovering ; 
but in a day or two it relapses into a state of deeper coma than before. And these 
fallacious symptoms of improvement may occur more than once. 

The third stage does not differ materially in the character of the symptoms 
that accompany it, from the second, except that the pulse again becomes frequent, 
nay, uncommonly rapid; beating sometimes 200 strokes in the minute, so that 
you can scarcely count it. Dr. Whytt, in one instance, reckoned more than 210 
pulsations. The child rolls its head perpetually from side to side ; moans con- 
tinually ; waves its hands in the air, or one hand, the other frequently being pal- 
sied ; sometimes there is paralysis of one side, and convulsive twitchings of the 
other. The circulation is very unequal; one part of the body will be found hot 
and dry, and another covered with a cold sweat; the cheeks are alternately pale 
and flushed; the child is raving, or insensible; the rapid pulse gets more and 
more weak ; and at length the patient expires. In many instances death takes 
place in the midst of a strong convulsion. This last period is of very uncertain 
duration ; it may be over in a few hours, or it may last a fortnight. 

For my own part, I conceive that for all practical purposes it would be quite 
enough to make two stages only of this disease. In the first the symptoms are 
those of inflammation of the parts within the cranium, or of some of those parts; 
in the second, we have the symptoms that result from the consequences and pro- 
ducts of the inflammation, from softening, and from the effusion of serum. And 
frequently these sets of symptoms are, in some respects, common to both these 
causes ; and more frequently still they are mixed up together, effusion taking 



274 



DISEASES OF THE BRAIN. 



place, yet the inflammation going on. And we may understand how the whole 
collection of symptoms may vary and fluctuate, and assume an uncertain charac- 
ter, according as the inflammatory process has ceased, or is still in progress; 
according as it exists alone, or is mingled with the further source of cerebral dis- 
turbance that is furnished by its own events ; and according as the inflammation 
may have come to an end, while its events remain behind, and declare their pre- 
sence by appropriate signs in proportion to their place and extent, and their vari- 
ous kinds and combinations. 

What are these events ? In other words, what are the morbid appearances 
presented after death in acute hydrocephalus ? 

In some cases we find traces of inflammation of the membranes of the brain ; a 
firm attachment of the skull-cap to the dura mater ; occasionally some adhesion 
of the opposite surfaces of the arachnoid membrane to each other. Very com- 
monly there is an effusion of serous fluid beneath the arachnoid, in the meshes of 
the pia mater, and especially in the depressions between the convolutions. You 
would suppose, upon looking at this collected fluid through the arachnoid, that it 
had the consistence of jelly, but it is not so ; if you divide the arachnoid by means 
of a sharp scalpel, a perfectly limpid fluid makes its escape. Not unfrequently 
there are layers of coagulable lymph interposed between the arachnoid and pia 
mater ; this is a most unequivocal evidence of foregone inflammation ; and it is 
more frequently met with in the strongly marked cases. When portions of the 
cerebral mass are removed by slicing it, a great number of red points are often 
observed, speckling its cut surface; I mention this appearance just to say, that, 
to the best of my belief, it does not warrant any conclusion in respect to the state 
of the brain before death. We find these red spots numerous in many cases, 
where there had been no cerebral affection manifested during life ; and they are 
not always to be seen when we are certain that there was inflammation.* With 
respect to the nervous matter itself it is said to be sometimes softer than natural, 
and occasionally it has been found infiltered, as it were, with serous fluid ; wet, 
and so rendered soft. Golis describes an instance of this kind, in which, he says, 
the fluid could be expressed from the cerebral substance as from a sponge.t 

But the most common and characteristic change is softening of the central 
parts of the brain, with an effusion of serous fluid into the ventricles. Generally 
the effused fluid is thin and watery; serosity rather than serum. It contains less 
animal matter, perhaps, than any other animal production. Dr. Bostock found 
that of 103 parts, 98-6 consisted of water, 1 part of salt, and *4 only of animal 
matter. It is not, therefore, in common, coagulable by heat. The quantity 
effused is uncertain ; speaking generally, it varies from two to six ounces.! 

But the effused fluid is not always clear and limpid ; sometimes it is turbid, 

* [The gray substance of the convolutions, in cases in which the sub-arachnoid tissue is 
strongly injected, is usually of a pale rose, or bright red colour. The lining membrane of 
the ventricles is occasionally injected, opaque, or covered with a pseudo-membranous 
exudation,' or with numerous white flocculi, which become very apparent when the mem- 
brane is immersed in water. It is often easily separated from the cerebral substance. The 
plexus choroides is very often injected, and thickened; sometimes, however, it is pale and 
discoloured, and lined with small hydatiform cysts; this latter appearance has, also, been 
found in the cellular texture of the pituitary gland. — C] 

j- [In some cases the substance of the brain has been found of a firmer consistence than 
natural, and to a certain extent hypertrophied. A case is related by Golis, in which, upon 
opening the skull, the whole brain expanded, so that it could not again be replaced within 
the cranium. The convolutions are sometimes flattened, apparently from pressure against 
the skull.— C] 

± [In many cases the amount of effused fluid is very trifling; in some scarcely a trace 
is to be discovered. The effusion may take place in the arachnoid or sub-arachnoid tissues, 
or in the ventricles, or in all these parts at the same time. The greatest amount is gene- 
rally met with in the lateral ventricle — occasionally the quantity is so great as to enlarge 
the posterior cornea, elevate the fornix, rupture the septum lucidum, and thus establish a 
free communication between all the ventricles. The cellular tissue of the choroid plexus 
may also be distended with serum. When the serous effusion in the brain is consider- 
able, it is often found also in the spinal canal. — C] 



ACUTE HYDROCEPHALUS. 



275 



like whey, or even puriform, with flocculent shreds floating in it. These have 
been considered as flakes of coagulable lymph ; but I question whether, in many 
cases, they are not merely fragments of the softened and broken-down materials 
in the neighbourhood ; for the septum lucidum, the fornix, and other parts form- 
ing the walls of the ventricles, are very commonly found soft, and pulpy, or en- 
tirely disorganized. The septum lucidum is perforated perhaps by a ragged 
irregular opening, the softened portion having fallen out; the fornix has lost its 
consistence, and often its figure, or falls asunder when the most gentle attempt is 
made to raise it. Dr. Abercrombie holds not only that this softness is the result 
of inflammation, which I think cannot reasonably be doubted, but that the inflam- 
mation of these central white parts constitutes the essence of the disease, in very 
many cases of acute hydrocephalus; and what bears him out in this opinion is 
the interesting fact, that this softened condition of the septum lucidum, fornix, 
and corpus callosum, may be fatal without any effusion of serum, and without 
any other morbid appearance, although with all the symptoms which are usually 
considered to indicate acute hydrocephalus. He relates two striking examples of 
this kind ; one of thern was as follows. — A woman became affected with violent 
pain in her head, shooting from temple to temple. She was extremely restless, 
tossing from one side of the bed to the other; her eyes were slightly suffused, and 
impatient of the light; pupils contracted; the pulse 60, soft and rather weak. 
She was repeatedly bled, both generally and topically, and used purgatives, cold 
applications to the head, blistering, &c. For three days she was much relieved 
by these measures ; the violent pain was removed, and she complained of pain 
only when she moved her head. She was quite sensible*, but oppressed, and 
inclined to lie without being disturbed. At the end of four days her speech be- 
came affected, of which she was aware, for she said she felt a difficulty in getting 
outlier words. Then came stupor, and at times incoherence, and double vision, 
and at last coma, and dilated pupil. She died on the eighth or ninth day of the 
disease. 

The fornix and septum lucidum were found broken down into a soft white 
pulpy mass : there was no effusion in the ventricles, and no other disease in any 
part of the brain. 

Not unfrequently scrofulous tubercles are discovered in the substance of the 
brain ; and it is probable that these would have been more frequently met with, 
if they had always been carefully looked for. They consist almost universally 
of a cheesy kind of matter, like that of large tubercles in the lungs.* 

You will find a good deal said by writers on this disease, of morbid appearances 
found in other parts besides the brain, and especially in the abdominal organs, — 
enlargement of the liver, inflammation of its peritoneal covering, a preternatural 
development of Peyer's glands, tuberculous matter in the glands of the mesentery. 
One remarkable change is very often seen, viz., intussusception of the small 
intestines. This probably takes place a short time only before death, and appears 
to be the result of spasmodic or irregular movements of the bowels, analogous to 

* [Tubercles, varying in size from that of a pin's head to that of a pea, are very generally 
found scattered irregularly over the surface of the pia matter, following it between the con- 
volutions ; occasionally, however, they occur in distinct patches'of an inch or more in extent. 
They are commonly hard, semi-transparent, and of a grayish or yellowish colour. They 
are met with, also, imbedded in the gray matter of the brain, and are here often surrounded 
by a halo of redness, usually connected with an enlarged vessel, ramifying from the pia 
mater. More rarely, tubercles are detected in the medullary portion of the brain, where 
they are often overlooked in consequence of their pale, semi-transparent, yellowish tint. 
The plexus choroides is, also, often covered with tubercles. They are very commonly 
met with, likewise, on the serous membranes of the thorax and abdomen, in the lungs, and 
occasionally in the substance of the liver. In twenty-seven out of thirty-three cases of 
hydrocephalus, Barthez and Rilliet found tubercles or granulations, associated with inflam- 
mation of the pia mater: in four cases the meningitis was unattended by any trace of 
tubercular deposition in the encephalon ; and in two cases, the granulations or meningeal 
tubercles were unattended with any traces of inflammation. In all the thirty-three cases 
the symptoms were nearly identical. — C] 



276 



DISEASES OF THE BRAIN. 



those which are observed in the voluntary muscles. The intussuscepted portions 
are easily pulled out, and show no marks of inflammation. 

There have been endless discussions respecting the true pathology of acute 
hydrocephalus, and it may be proper that I should offer you a few remarks upon 
this point, before I proceed to the treatment of the disease. 

I need not, I conceive, take any further pains to convince you that the disease 
is essentially inflammatory. We are inevitably led to that conclusion by the 
symptoms, which nearly resemble those that occur when undoubted inflammation 
has arisen from injuries of the head: by the appearances on dissection, which are 
always such as inflammation may have produced, as softening and effusion of 
serum; and frequently such as nothing but inflammation could have produced, as 
suppuration, and the formation of adventitious membranes: and lastly, by the 
unequivocal relief given by blood-letting, and other evacuations, the blood drawn 
being sometimes also sizy. 

Many persons, as I have already hinted, lay great stress, when discussing the 
pathology of acute hydrocephalus, upon the previous unhealthy state of the nutri- 
tive apparatus. They hold that the primary disease — the fons et origo rnali — 
lies in the stomach, or bowels, or liver; and that the brain affection is secondary, 
and caused by sympathy with these distant parts: and this opinion they fortify 
by referring to the frequency of organic disease, met with after death, in the 
abdominal viscera. In accordance with these views of its origin, they propose to 
cure, or to prevent, hydrocephalus, by redressing the faulty condition of the 
digestive organs. 

Now this, in my jtedgment, is not only an erroneous, but an unsafe doctrine : 
for it tends to divert our attention from the head, and to suggest a feeble and inade- 
quate plan of treatment. The grand predisposing cause of acute hydrocephalus 
is certainly the scrofulous diathesis, and this is why we see the complaint run so 
often in families : so that one child having died of that disorder affords much 
ground for apprehending that others, belonging to the same family, will become 
victims to it. The constitutional tendency is hereditary, and children born with 
it are liable and likely to have strumous disease set up in various organs at once, 
or perhaps in succession ; not, however, a succession of cause and effect, but of 
common relation to one pervading disposition. We need not be surprised that 
scrofulous inflammation should affect the brain and abdomen at the same time. 
When we find obvious organic disease of the brain, scrofulous tubercles for 
instance, which must have been antecedent to the hydrocephalus, it would be 
just as absurd to look to the abdomen for the cause of the hydrocephalus, as it 
would be to seek in the brain for an explanation of the cause of jaundice or of 
dysentery, when the liver or the colon was known to be diseased. 

I do not mean to assert that the morbid conditions of the brain and of the abdo- 
men are perfectly independent each of the other. The vomiting that is so constant 
a feature of acute hydrocephalus, the constipation that is so common a conse- 
quence of head affections, affords familiar evidence of the influence which cerebral 
disorders may exercise upon the abdominal functions. Conversely, any disease 
in other parts of the body may react injuriously upon the brain, and may some- 
times be regarded as an exciting cause of disease in that organ. 

The period of life is also a strong predisposing circumstance ; acute hydroce- 
phalus being very much more frequent during infancy and childhood than at any 
subsequent time. It is said that fifty children are attacked by it in the first five 
months of life, for one child that has it afterwards. But it may occur at any age 
up to the twelfth or fourteenth year. After that period it is comparatively rare. 

Whatever tends to deepen and aggravate the scrofulous diathesis — improper or 
insufficient nutriment, exposure to cold, inadequate clothing, impure air — may 
be regarded as a predisposing cause of acute hydrocephalus. And whatever tends 
to call scrofulous disease into action, may be reckoned among the possible exciting 
causes of acute hydrocephalus. Any general irritation may bring it cn. It some- 
times supervenes upon the drying up or repression of eruptions, as tinea capitis, 



ACUTE HYDROCEPHALUS. 



277 



or sores behind the ears. Such eruptions, therefore, occurring in strumous 
children, we must not attempt to cure suddenly; and free purging should be 
employed when they begin to disappear. The irritation produced by difficult 
and painful dentition is a very frequent exciting cause; and this is a source of 
danger which, in many cases, may be obviated by timely and judicious manage- 
ment. Violent heating exercise has sometimes, apparently, kindled the cerebral 
inflammation. Among the exciting causes we may place all physical injuries 
which jar and stun the brain; blows on the head, falls from a height, although 
the head may not be the part struck ; and all moral agencies which shock or 
Strongly disturb the nervous system ; severe bodily pain, violent fits of anger, 
sudden fright. Golis goes even so far as to say that great terror and distress of 
mind in the mother during the latter months of pregnancy may lead to the occur- 
rence of acute hydrocephalus in the child ; and he brings forward this curious fact 
In support of his opinion: — A large proportion of the children that were born in 
Vienna soon after the bombardment of that place by the French, in 1809, were 
seized with convulsions within a month after their birth, and died of inflammation 
within the cranium; effusion of coagulable lymph between the membranes, and 
of serum in the ventricles, being discovered on dissection. 



LECTURE XXVI. 

Jicute Hydrocephalus, continued. Prognosis and Mortality of the Disease. 
Treatment; Blood-letting ; Purgatives ; Cold; Mercury; Blisters. Pro- 
phylaxis. Spurious Hydrocephalus. Chronic Hydrocephalus, or Dropsy of 
the Brain., Shape of the Head and Face. Anatomical Conditions. Symp- 
toms. 

The disease, of which I described the symptoms in the last lecture, acute 
hydrocephalus, is a very dangerous disease: and, when once it is fairly established, 
many more die of it than recover. Our chance of saving the patient's life, by 
appropriate treatment, is always greater in proportion as the complaint, or the 
tendency to the complaint, is detected early ; and for that reason the precursory 
symptoms possess so high an importance. 

When our treatment commences while the symptoms are as yet rather those of 
the precursory state, than of the confirmed disease, it is impossible to say how 
many of those cases which, under such treatment, terminate favourably, would 
otherwise have ripened into well-marked hydrocephalus; and we must be content 
to have it said, without its being possible for us to refute the assertion, that not all 
of the disorders which we treat as acute hydrocephalus are really instances of that 
complaint. We must act upon the worst supposition, and not wait until the nature 
of the symptoms demonstrates that the malady is present, while it demonstrates 
also, at the same time, that it is well nigh hopeless. These are cases which 
peculiarly demand decision on the part of the medical man ; and we are bound to 
act, in some instances, upon very slight indications; as when, for example, we 
perceive what we think threatenings of acute hydrocephalus in a scrofulous child, 
or in a child belonging to a family in which others have already been cut off by 
that disorder. 

It has been supposed, by some, that the case is hopeless after effusion has taken 
place, but we cannot be sure of that; nay more, there are no symptoms by which 
we can ever te\\ for certain that effusion has taken place. 

I remember to have heard it gravely maintained, in the debating societies which 
I sometimes attended when a student, that there are no such things as absorbents, 
and no absorption, in the brain ; and therefore that perfect recovery from serous 
effusion in that organ is impossible. But this notion is refuted by plain and well- 



278 



DISEASES OF THE BRAIN. 



known facts. We shall see hereafter, that blood poured forth within the nervous 
pulp is capable of being removed by absorption. How an opinion so palpably 
erroneous could ever have found credit, except with that class of men who can or 
will believe nothing which they cannot see, I am at a loss to guess. 

The prognosis, always doubtful or bad, is a little better when the disease is 
violent, and occurs in tolerably healthy subjects, than when it creeps on slowly 
and insidiously, and in weakly, scrofulous patients. In the former case there is 
more room for the adoption of active measures ; and the disease is more likely to 
be amenable to remedies, and less likely to be obstinate ; it is also less likely to 
depend upon a permanent cause, such as the existence of a scrofulous tumour in 
the brain. 

The probable issue of the disease is often judged of by the state of the pulse. 
The quick pulse belonging to the early stages of the disease will become slow; 
but it may become slow in two very different ways : it may diminish in frequency 
in a gradual and moderate manner, and then we may hope that the alteration pro- 
ceeds from the progressive declension of the fever ; or it may drop suddenly, 
which would be a reason for our fearing that the second stage of the disease was 
about to establish itself. We must take care, under the former circumstances, 
not prematurely to assert that the disorder is on the decline, and the patient safe. 
On the other hand, if the pulse has been .morbidly slow, a gradual and slight in- 
crease in its frequency must be considered as a favourable omen ; while its rapid 
and great acceleration would show that the disease was passing into its worst and 
final stage. 

I have already cautioned you against being misled by that deceitful truce, and 
apparent improvement, which is apt to take place in the course of the disease. If 
the signs of amendment continue, or make progress, during two or three entire 
days, we may venture to admit a little more hope. But the patient can never be 
considered secure while any approach to what are thought symptoms of effusion 
remains; while the pupil continues dilated, for example; or even so long as it 
does not contract briskly under a strong light. 

The prognosis is especially bad when acute hydrocephalus supervenes upon 
other disease ; or when it is engrafted (as it sometimes is) upon the chronic form 
of the disorder. It is very seldom that the acute form subsides into the chronic. 
. To show you that we are warranted in the expectation of sometimes carrying 
our patient through this most perilous malady, I will mention a few statistical 
facts that have been recorded in respect to its mortality. Dr. Odier, of Geneva, 
states that, upon an average, eighteen cases of acute hydrocephalus occur every 
year in that place ; and of these six get well ; i. e., the recoveries are to the deaths 
as one to two. Dr. Golis, to whose work I referred in the last lecture, and who 
had the charge of a large institution for children in Vienna, gives an account of 
thirty-seven cases, out of which five recovered. He had seen upon the whole, 
forty-one instances of recovery from acute hydrocephalus. Dr. Mills, who has 
also written on the disease, has narrated twenty-eight cases, all of which died but 
seven; and Mr. Bricheteau lost four out of eleven. Adding these together, and 
taking the average, we have seventy-six instances of the disease, and nineteen 
recoveries; exactly one in four. The cases in which recovery took place were 
*mostly those in which antiphlogistic measures were adopted early. 

The treatment of acute hydrocephalus is difficult to conduct; and scarcely less 
difficult to describe and teach. The disease being essentially an inflammation, 
requires, in its earlier periods at least, the remedies of inflammation. But we 
must ever bear in mind that our patients are children ; and, for the most part, 
weakly and scrofulous children. Their time of life, and the presence of the stru- 
mous diathesis, both forbid that strenuous appliance of antiphlogistic remedies 
which might be proper and necessary in adults of strong and healthy frame. We 
take our weapons, however, in either case, from the same armoury. 

The only event of the inflammatory process compatible with the safety of the 
patient is resolution. To this end, therefore, must our efforts be earnestly directed. 



ACUTE HYDROCEPHALUS. 



279 



If the child be feverish, the pulse sharp, the head hot, the cheek flushed, the 
pain severe, and if, moreover, the case be seen early, there need be no doubt 
about the propriety of abstracting blood. It is a matter of obvious importance 
to ascertain how far we may safely and beneficially carry this measure, in the 
diseases of infants. Dr. John Clarke, a physician of large experience (the elder 
brother of the present Sir Charles Clarke), found that very young children would 
very well bear the loss of blood, even to fainting, once or twice : but that their 
vital powers were apt to sink if the bleeding, to that extent, was oftener repeated. 
It is better, in my opinion, to apply leeches to the temples, or to the mastoid pro- 
cesses, of these little patients, than to cut one of their veins. Recollect that, upon 
very young children, leeches produce an effect tantamount to that of venesection. 
Their bites bleed more freely than in grown persons, on account of the greater 
activity of the capillary circulation in children. No general rule can be prescribed 
in respect to the number of leeches to be used ; three will take as much blood in 
one case as half a dozen in another; but assuming that one leech will, on an 
average, cause the discharge of one ounce of blood, we may apply three of them 
to a strong infant of six months, when the symptoms are violent. Of course the 
further efflux of blood must be stopped if syncope occurs. In older children the 
quantity of blood requisite to be taken will be somewhat larger : six ounces 
drawn from a vein is a full bleeding, I should say, for a child five or six years old. 
I mention these quantities as mere approximations, as guides to what you may 
expect to find practically needful : the true measure and test of salutary blood- 
letting being in this, as well as in other inflammations, the effect it has at the time. 
The first bleeding, in what manner soever the blood is taken, should be a suffi- 
cient one ; should produce some decided and manifest impression. By attending 
to this rule you will break the force of the eaily disease more surely, and more 
safely too, than by drawing blood in frequent driblets ; a mode of using the remedy 
calculated to subdue the patient rather than to overcome his malady. You must 
afterwards go on with the leeches to the head, or you must withhold them, ac- 
cording to the exigency of the particular case ; according to the state of the pulse, 
the continuance or the cessation of the pain, the increase or diminution of the* 
fever, the previous, strength and condition of the child, and so forth. And let me 
once more admonish you that, as you have to deal, in general, with scrofulous 
children, any superfluous removal of blood, the abstraction of more than is required 
for extinguishing the inflammation within the head, will be likely to prove inju- 
rious to the general system ; and even dangerously to depress the vital power. 
After the full formation of the comatose state, a further prosecution of the bleed- 
ing has sometimes been rapidly followed by death. 

The next in rank and importance to bleeding come purgatives. They are to 
be exhibited with the threefold view of correcting depraved secretions, of clearing 
the alimentary canal of its irritating contents, and above all, of deriving, as the 
phrase is, from the head ; producing a discharge of the watery parts of the blood, 
and taking off the stress from the cerebral arteries. The best forms of purgative 
medicine to be used for these purposes with children, consist of calomel and jalap, 
or calomel and scammony ; and if these do not act freely, senna and salts must be 
given in aid of them. I have already made you acquainted with Dr. Abercrom- 
bie's high estimate of the efficacy of purgatives in inflammation of the brain, 
whether in the child or in the adult. Dr. Whytt, again, states that he never saw 
even temporary relief of the symptoms produced by any other means than those 
which increased the evacuations. Purgatives are to be administered, therefore, 
at an early period. But sometimes the stomach is so irritable that it rejects them. 
A previous bleeding will often correct this; and it is no small part of the benefit 
derived from the abstraction of blood, that it prepares the way for the more 
effectual operation of aperients and of mercury. A large clyster will often be of 
service, both in settling the stomach, and in procuring stools, when there is much 
vomiting, and a continual rejection of medicine given by the mouth. Dr. Cheyne 
mentions a form of medicine by which he sometimes succeeded in quieting the 



280 



DISEASES OF THE BRAIN. 



irritable stomach, and procuring evacuations ; he would give a drachm or two of 
magnesia, saturated with lemon juice, every two or three hours. You may some- 
times get calomel and scammony, however, to remain on the stomach, when 
almost every other medicine is rejected. The purgative plan should be steadily 
persisted in for several days. 

To show you how torpid the bowels are apt to be in this disease, and how diffi- 
cult it sometimes is to procure evacuations from them, I may mention the follow- 
ing circumstances which I heard Dr. Alison relate as having occurred in the 
practice of his uncle, the late Dr. Gregory, of Edinburgh. He had one patient 
who look 140 grains of calomel in the course of five days ; yet his bowels were 
not relieved, till he had also taken two doses of jalap, the first of 30, and the 
second of 35 grains. In another case, a child of twenty-eight months took in nine 
days 350 grains of calomel (nearly 40 grains a day); and in six of these days 136 
grains of jalap (more than 20 grains a day) : the effects were a gentle purging 
from the jalap, none from the previous calomel, and but slight salivation. The 
child recovered after having been nearly in a comatose state. Of course large 
doses of this kind are never to be given, until the inefficacy of smaller ones has 
been ascertained. 

Cold applied to the head : — I have before given you examples of its power. It 
is especially useful in the early periods of the disease, when there is much heat, 
and when evacuations have been obtained. I am doubtful about the propriety of 
keeping ice in contact with the surface of the head in very young children. It 
will in many cases be sufficient to lay a linen rag wet with cold water (or spirit 
and water, to promote evaporation), upon the child's head, taking care to renew 
it frequently, not merely as often as it gets dry, but as often as it gets hot ; or 
water may be poured from a pitcher upon the head, a basin being held under the 
chin. Dr. Darwall states that he has known cases, which seemed utterly hope- 
less, retrieved by letting water fall in a small succession of drops upon the scalp, 
and continuing it until the head no longer recovered its high temperature upon 
intermitting the dropping. I need scarcely say that under all circumstances it is 
expedient to keep the head somewhat elevated. The influence of this mode of 
applying cold to the head is increased, and perhaps rendered safer, by immersing 
the lower extremities of the patient at the same time in warm water. 

Different opinions have been held in respect to the value of mercury in this 
disease. Knowing how powerful an influence it has in controlling inflammatory 
action, and that the inflammation in acute hydrocephalus often leaves behind it 
traces showing that it was of the adhesive kind, I should not omit giving mercury; 
but (as I stated when upon the subject of encephalitis) I should not give it with 
the direct object of affecting the gums, of producing ptyalism. I believe the evi- 
dence respecting the efficacy of mercury carried to salivation in acute hydroce- 
phalus is this : — that some few very desperate cases have got well, the improvement 
commencing at the time when the mercurial influence on the system was becoming 
apparent; and that in other cases, the occurrence of salivation has been followed 
by no alleviation of the symptoms, but the disease has run on, unchecked, to its 
fatal termination. In truth it is a very difficult matter to salivate a child; there is 
a great reluctance in the system, at the earlier periods of life, to take on the specific 
mercurial action; and the disinclination seems peculiarly strong during the presence 
of this disease; and the younger the child, the more difficult is it to affect the 
gums. Perhaps this may be considered fortunate ; for when salivation does take 
place in these little patients, it sometimes proceeds to an alarming extent. Dr. 
John Clarke, who employed calomel largely in a variety of diseases, never saw 
more than three instances in which salivation was produced in children under 
three years of age. 

If you are desirous of taking the chance of the specific influence of mercury 
doing good, you had better give calomel as a part of the purgative plan, and rub 
in some of the mercurial ointment ; you had better do this than lock up the child's 
bowels by combining opium with the calomel; not to mention the injurious effects 



ACUTE HYDROCEPHALUS. 



281 



of opium upon young children in general, and in the early period of head affec- 
tions in particular. The calomel should be given steadily, in equal doses, at 
equal intervals. Green evacuations from the bowels, resembling wet tea-leaves 
or chopped spinach, usually follow its continued administration; and this appear- 
ance (like the rising of the gums in adults) is generally regarded as a proof that 
the influence of the mineral is felt by the system, and that it is doing all the good 
of which it is capable. 

Upon the whole, I believe it will be found that they who have had the most 
ample experience of this perilous disease, have ended with the conviction, that 
moderate local depletion, and the regulated exhibition of mercury in small quanti- 
ties, afford, generally, a better chance of success than the large bleedings, and 
the full and frequent doses of calomel, which have sometimes been recommended. 

Of blisters I may repeat the substance of what I stated when we were consider- 
ing encephalitis. I should abstain from them at the commencement of the disease. 
Even when applied at a distance from the head, they are apt to prove a source of 
hurtful irritation in these young and susceptible subjects. But in the second stage 
of the malady, I believe blisters are often of good service. They may be applied 
to the nape of the neck, or to the head : and several may be applied in succession ; 
or the ulcerated surface may be kept open by the help of irritating ointment, such 
as the unguentum cantharidis, or the ceratum sabinae. 

These are the main remedies to which we trust in the treatment of acute hydro- 
cephalus: bleeding, purgatives, cold, in the outset; mercury and blisters, of more 
equivocal efficacy than the former, in the more advanced stages of the disease. 
When there is much irritability towards the decline of the disorder, or in its latest 
period, opiates may cautiously be tried; they sometimes have appeared to be 
extremely beneficial: two or three grains of Dover's powder furnish a very eligible 
form of opiate in such cases. 

I do not feel called upon to say any thing, in addition to what I stated in a 
former lecture, about other remedies that have been proposed in acute hydroce- 
phalus ; digitalis, colchicum, squills, antimony. These may be useful, when 
they act as diuretics : but they have no specific virtue. I have told you the 
remedies which I believe to be the best; and which will save the patient, when 
judiciously used, if the case be within the compass of our cure: and you will do 
well to learn how to manage these powerful means. I am confident you will find 
that more to your purpose than trying now this and now the other remedy, because 
it is new, or because some persons tell you they have been wonderfully success- 
ful with it.* 

Let me say a word in reference to the prevention of, this disease: concerning 
which your advice will be sure to be asked again and again. In families, in which 
acute hydrocephalus has occurred, or which show decided marks of the scrofu- 
lous diathesis, the earliest attention should be paid to any deviation from the 
healthy condition of any of the functions. Weaned children in such families 
should be kept upon a nourishing but light and unstimulating diet; consisting of 
well-dressed vegetables, farinaceous substances, and a moderate proportion of 
animal food. Particular care should be taken to keep the bowels regular ; not 
that weakening purges should be given, but the bowels should be fairly relieved 

* [When the disease has reached the paralytic stage, its fatal termination is usually sup- 
posed to be inevitable; but Dr. Christie, of Scotland, and Dr. Woniger, of Hamburg, have 
each recently reported a case, in which a cure was effected after paralysis had occurred, 
by the administration of iodine. Dr. Christie employed a solution, containing sixteen 
grains of iodide of potassium, and four grains of iodine to one ounce of water, given in the 
dose of a teaspoonfnl every four hours, at the same time that a weak ointment of the binio- 
dide of mercury was rubbed upon the child's scalp. Dr. Woniger gave a solution of one 
drachm of iodide of potassium, dissolved in half an ounce of water, in the dose, at first, of 
forty, and subsequently of fifty drops every two hours. In the case of Dr. Christie, the first 
indication of improvement occurred in thirty-six hours after the employment of the iodine 
was commenced wifh, but in Dr. Woniger's case, not until after the end of seventy-tWQ 
hours. In both the recovery is said to have been complete and permanent.— C] 



282 



DISEASES OF THE BRAIN. 



at least once every day. Any disturbance of the digestive organs should be 
immediately corrected; by antacids, laxatives, change of diet, and sometimes by 
mercurials, as the hydrargyrum cum creta. Such children should also, if possible, 
be brought up in the country, and be freely exposed to mild and dry air; and in 
winter great care should be taken to have them sufficiently clothed. During the 
hazardous period of dentition, the state of the teeth and gums must be sedulously 
attended to. There is good reason for believing that a seton or an issue in the 
neck or arm has been very serviceable in warding off and preventing attacks of 
the disease. Dr. Cheyne mentions some striking instances of the good effect of 
establishing an artificial irritation at some distance from the brain, when there has 
been a disposition to disease in that organ. 

There is another caution, too, which you will often find reason for suggesting : 
and that is, not to press or encourage the development of the mental faculties in 
children who are quick and intelligent beyond their years. Parents are apt to be 
proud of the early acquirements of their little ones : they are not aware that such 
precocity of the mind implies danger to the health of the body ; and they provide 
them with instructors, and to a certain extent abridge their hours of exercise and 
amusement, that they may do justice to their cleverness. But it is our duty to 
admonish them of the risks they are thus running: to advise them to think only, 
for the present, of corroborating the corporeal strength of the child; and to avoid 
over-cultivation of his intellect until this dangerous period of his existence is got 
over. 

There is still one point remaining, and one of the utmost importance, in rela- 
tion to the acute hydrocephalus of children. I told you in the last lecture that, 
in general, the diagnosis was not very difficult. But there is a form of disorder 
very apt to be mistaken and treated for acute hydrocephalus, by those who are 
not forewarned; and one which may be rendered fatal, if the remedies of acute 
hydrocephalus be directed against it. Encephalitis, whether it occur in the child 
or in the adult, has its spurious double. As, in morals, every virtue has its cor- 
responding vice, which apes its actions and assumes its garb, so is it also with 
many opposite bodily disorders: and it is of great moment that we should be 
capable of discerning the essential difference of character that lurk*s beneath 
external similarity of feature. It is a most curious, but unquestionable fact, that 
anaemia of the brain, a diminution of its natural supply of red blood, and ex- 
haustion of the nervous power, will produce symptoms very much resembling 
those which result from the diametrically opposite condition. To excess of pres- 
sure on the one hand, and to defect of pressure or support on the other, there are 
many phenomena in common. If you pay no regard to the state of the general 
circulation, as indicated by the temperature and by the pulse, you will find the 
actual symptoms of syncope, and of apoplectic fullness, to be identically the same. 
When a human being bleeds to death — as many do from wounds, from uterine 
hemorrhage and so on — what do we see ? Why the patients may have nervous 
delirium, become convulsed, and then insensible, with a wide and fixed pupil. 
The outward visible signs of concussion and of compression of the brain are very 
much alike. The vulgar always confound them, and are clamorous that a vein 
should be opened : a measure which would be proper and useful in the one case, 
but murderous in the other. It is the same with the functions of other parts: 
we have palpitation of the heart when that organ is insufficiently supplied with 
blood; palpitation when it is over-loaded; dyspnoea, or hurried breathing, when 
the lungs are congested,; hurried breathing when blood does not arrive in them 
plentifully enough. You must see that the importance of distinguishing between 
the causes of these analogous phenomena is immense. Several authors in modern 
times have noticed the condition of the brain to which I now wish you to attend, 
and which may be called spurious hydrocephalus. Dr. Marshall Hall, Dr. Aber- 
crombie, and the late Dr. Gooch — each of these three physicians appears to have 
discriminated for himself the spurious from the genuine disease; but their several 
accounts of it were made publ.ic in the order of time in which I have here mentioned 



SPURIOUS HYDROCEPHALUS. 



283 



their names. Dr. Gooch's Essay is entitled — "Of some Symptoms in Children 
erroneously attributed to Congestion of the Brain." His description of the dis- 
order in question is very graphic. It is chiefly indicated, he says, by heaviness of 
head and drowsiness. The age of the little patients whom he had seen so affected 
was from a few months to two or three years ; they were generally small of their age 
and of delicate health, or had been exposed to debilitating causes. The physician finds 
the child lying on its nurse's lap, unable or unwilling to raise its head ; half asleep ; 
one moment opening its eyes, and the next closing them again, with a remarkable 
expression of languor. The tongue is slightly white, the skin is not hot, at times 
the nurse remarks that it is colder than natural ; in some instances there is now 
and then a slight and transient flush. In all the cases that Dr. Gooch saw, Uie 
bowels had been already disturbed by purgatives ; the symptoms had invariably 
been attributed to congestion of the brain; and the remedies employed had been 
leeches and cold lotions to the head, and purgatives — especially calomel. Under 
this treatment the patients had gradually got worse, the languor had increased, the 
pulse become quicker and weaker, and at the end of a certain number of days the 
children had died. In two instances he had known coma to come on during the 
last few hours ; stertorous breathing, and dilated and motionless pupils. 

Dr. Hall describes a very similar set of symptoms : the face pale, the cheeks 
cool or cold, the eyelids half closed, the eyes unattracted by any object put befoie 
them, the pupils unmoved on the approach of light, the breathing irregular and 
suspirious, the voice husky. These symptoms are sometimes preceded by irri-' 
tability, and a feeble attempt at reaction; in which case the diagnosis requires 
extreme care and circumspection. He attributes the disorder, which he calls the 
*< hydrocepha/ozV/ disease," principally to exhaustion. In early infancy the 
exhaustion has its origin chiefly in diarrhoea, or catharsis ; in the latter periods of 
infancy, in the loss of blood, with or without a relaxed condition of the bowels. 
The diarrhoea is often produced by improper food, and frequently succeeds wean- 
ing: or it results from the ill-timed administration of purgative medicine. The 
exhaustion from loss of blood generally follows the application of leeches, for 
some previous complaint— or for this very complaint itself, when incipient, and 
misunderstood. 

I will take one of Dr. Gooch's cases in illustration, and give it you in his own 
words. " I was going out of town (he says) one afternoon, when a gentleman 
drove up to my door in a coach, and entreated me to go and see his child, which 
he said had something the matter with its head, and that the medical attendant of 
the family was in the house, and was just going to apply leeches. I went with 
him immediately, and when I entered the nursery I found a child ten months old, 
lying in its nurse's lap, exactly in the state which I have already described; the 
same unwillingness to hold its head up, the same drowsiness, languor, absence 
of heat and all symptoms of fever. The child was not small of its age, and had 
not been weak; but it had been weaned about two months, since which it had 
never thriven. The leeches had not been put on. I took the medical gentleman 
into another room, related the foregoing case (i. e., a case in which a child had 
been leeched out of its life), and several similar to it, which had been treated in 
the same way, and had died in the same way. Then I related to him a similar 
case which I had seen in the neighbouring square, which had been treated with 
ammonia and decoction of bark, and good diet, and which had recovered ; not 
slowly, so as to make it doubtful whether the treatment was the cause of the 
recovery, but so speedily that at a third visit I took my leave. He consented to 
postpone the leeches, and to pursue the plan which I recommended. We directed 
the gruel diet to be left off, and no other to be given than ass's milk, of which the 
child was to take at least a pint and a half, and at most a quart, in the twenty-four 
hours. Its medicine was ten minims of the aromatic spirit of ammonia in a small 
draught every four hours. When we met the next day the appearance of the 
child proved that our measures had been right; the nurse was walking about the 
nursery with it upright in her arms. It looked happy and laughing. The same 



284 



DISEASES OF THE BRAIN. 



plan was continued another day ; the next day it was so well that I took my leave, 
merely directing the ammonia to be given at longer intervals, and thus gradually 
withdrawn ; the ass's milk to be continued, which kept the bowels sufficiently 
open without aperient medicine." This case contains both a picture of the mor- 
bid state, and a summary account of the treatment it requires. Instead of the sal 
volatile, you may occasionally substitute with advantage from five to ten drops of 
brandy mixed with arrow-root. You are to restrain diarrhoea if it exists ; give the 
child plain nourishing diet — there is none so good for it as that furnished from a 
mother's breast; caution the nurse or mother against raising it into the upright 
position; keep its extremities warm with flannel; and if the season permit, let a 
current of mild fresh air blow freely over it. 

Bear in mind, then, the distinctive characters of this spurious hydrocephalus — 
the pale, cool cheek; the half shut, regardless eye; the insensible pupil; the 
interrupted sighing respiration:- and when the mere symptoms are more ambigu- 
ous, your judgment concerning the true nature of the case will be much aided 
by tracing the manner in which they came on, and the causes to which they seem 
to be attributable. In very young children — in respect to whom the question is 
most likely to arise — you may often determine between congestion and exhaustion, 
between fullness and emptiness, between too much and too little pressure, by a very 
simple and easy test, which is not adverted to, so far as I remember, by any of the 
three writers whom I have mentioned. I mean, by taking notice of the state of 
the unclosed fontanelle. If the symptoms proceed from plethora, or inflammation, 
or an approach to inflammation, you will find the surface of the fontanelle convex 
and prominent, and you may safely employ, and expect benefit from, depletion. 
If, on the other hand, the symptoms originate in emptiness and want of support, 
the surface of the fontanelle will be concave and depressed ; and in that case 
leeches, or other evacuants, will do harm, and you must prescribe better diet, 
ammonia, and so forth. 

All that has hitherto been said has reference to acute hydrocephalus, which is 
an inflammation. I have next to speak of chronic hydrocephalus, which is a 
dropsy. From some cause, not well understood, a watery fluid collects within 
the skull, most commonly in the ventricles of the brain ; and this occurring at the 
earlier periods of life, before the whole of the brain-case has become solid, the 
containing parts yield to the increasing pressure, and the size of the head is aug- 
mented in various degrees; at the same time the cerebral functions are more or 
less deranged. This dropsy of the cranial cavity often commences before the 
period of intra-uterine life is completed, and the head of the foetus becomes so 
large, that it cannot pass with safety into the world. Accordingly, many of these 
infants perish at the moment when their separate existence commences ; — nascen- 
tes moriuntur. The pressure of the maternal pelvis is fatal to them ; or the 
diseased head bursts ; or it is crushed by the accoucheur, to preserve the life of 
the mother. The skull is emptied of its contents, and the shell, if I may so call 
it, collapsing, passes through the natural outlets. 

In many cases, however, the dropsical skull is expelled entire and unhurt, and 
the infant lives for a shorter or longer period. Sometimes the fluid does not 
begin to accumulate till after birth : in a few days, however, or after some weeks, 
or some months even, the head is perceived to enlarge with a rapidity quite dis- 
proportionate to the growth of the other parts of the body ; and enlarging, it be- 
comes misshapen also. The intervention of the membranous partitions called 
fontanelles and open sutures, between the ununited bones, allows the centrifugal 
pressure of the gradually accumulating water to modify the shape of the head. 
These membranous interspaces are unnaturally wide, and more numerous than in 
healthy children. Nevertheless the process of ossification goes on, but the bones 
are extremely thin. We see little islands of bone in seas (as it were) of mem- 
brane. By degrees, if the child survives, the proportion of membrane to bone 
becomes less and less, and at length the whole brain-case is hard, and firmly 



CHRONIC HYDROCEPHALUS. 



285 



closed up, its surface exhibiting an unusual number of joinings ; there are many 
ossa triquetra. 

In the mean time the direction and relations of the loose and yielding bones are 
altered. The os frontis is tilted forwards, so that the forehead, instead of slant- 
ing a little back, rises perpendicularly, or even juts out at its upper part, and 
overhangs the brow. The parietal bones bulge above towards the sides ; the 
occiput is pushed back ; and the head becomes long, broad and deep, but flat- 
tened on the top. This, at least, is the most ordinary result. In some instances, 
however, the skull rises up in a conical form, like a sugar-loaf. Not unfrequently 
the whole head is irregularly deformed, the two sides being unsymmetrical. 
Some of these rarer varieties of form are fixed and connate ; others are owing, 
probably, to the kind of external pressure to which the head has been subjectsd. 

While the skull may be rapidly enlarging, the bones of the/ace grow no faster 
than usual, perhaps not even so fast; and the disproportion that results gives an 
odd and peculiar physiognomy to the unhappy beings who are the subjects of 
this calamity. They have not the usual round or oval face of childhood. The 
forehead is broad, and the outline of the features tapers towards the chin. The 
visage is triangular. This great disproportion of size between the head and the 
face is diagnostic of the disease, and would serve to distinguish the skull of a 
hydrocephalic child from that of a giant. Heartless parents sometimes make a 
wretched profit of the deformity. A penny show of that kind existed very re- 
cently in the immediate vicinity of this College. 

When, after death, we explore the physical causes of these singular deviations 
from the natural figure and bulk of the cranium, we find that they proceed from 
the pressure of accumulated water: the complaint is manifestly a dropsy. But 
the situation of the water, and the condition of the brain itself, are subject to some 
curious varieties. 

In a certain number of cases the brain is incompletely formed ; deficient in 
some of its parts, or even altogether wanting. That portion of the cranial cavity 
which should contain the nervous pulp is filled up by a thin pellucid fluid. From 
some unknown cause, operating during the period of intra-uterine life, the pro- 
gressive formation of the brain has been arrested. Marks of imperfect develop- 
ment are often visible in other parts of the same infants ; they have a hare-lip, a 
bifid spine, or a fissured palate. It is in cases of this kind generally that the 
skull, unnaturally small perhaps, is pinched up into a conical peak, and has con- 
siderable thickness. They are obviously hopeless cases. To the physiologist 
they are subjects of much interest; for the practical physician they have none. 

But in the majority of instances, w T hen the infants survive their birth, the liquid 
is contained in the central cavities or ventricles of the brain, which are expanded 
into one. The convolutions are unfolded, and the cerebral matter is spread out 
into a hollow sphere; the irregularities of the surface have disappeared ; the whole 
of the brain is smoothly extended in a thin layer, immediately beneath the bones 
and the membranes that connect them, and surrounds the inclosed liquid like a 
bag. Less frequently a different state of matters is seen. The liquid, instead of 
being included within the cerebral substance, lies in contact with the dura mater; 
while the brain, perfect in all its essential parts, is at the bottom of the cavity. 
The difference, however, is more apparent than real; the two conditions are sub- 
stantially the same, only that, in the one case, the solid parts that lie around the 
ventricles gradually expand as the fluid slowly collects, much as an air-balloon 
dilates in proportion as gas is introduced within it ; while in the other case the 
seams, or commissures (as they are technically called), that unite the hemispheres 
of the brain, give way, or are deficient, so that the ventricles, and the general sac 
of the arachnoid form together one huge cavity; the hemispheres are turned 
aside, or folded back ; the surfaces that naturally have a central aspect look up- 
wards, and seem to constitute the summit of the cerebrum. This was the state 
of the parts within the immense skull from which the largest of the casts before 



286 



DISEASES OF THE BRAIN. 



you was taken. It belonged to a man named Cardinal, who died in Guy's Hos- 
pital, in 1825, and of whom Dr. Bright has given a very interesting account. 

Now some of the consequences of this distension of the brain and skull with 
watery fluid are simply mechanical. The child is top-heavy. His large un- 
wieldy head is too much for the muscles of his neck to sustain without fatigue ; 
or even, when they are unassisted, to sustain at all. He walks gently and care- 
fully, like a person balancing a heavy load upon his head ; or he holds and partly 
carries his head with his hands, as a milkmaid steadies and supports her pail; or 
he reclines the weight of his burden upon the chair, or table, as he sits. 

But far more important effects of the disease are those which relate to the three 
great functions of the brain. The child is soon found to be deaf or blind ; or 
palsied in one or more of its limbs; or idiotic; or all these. In other words, 
the special senses, the power of voluntary motion, and the mental faculties, are 
apt to be defective or perverted. Instances, however, do occur, in which these 
functions are, for some time, but little deranged. The greater number of those 
who are afflicted with dropsy of the brain either recover or die during their in- 
fancy. Still, a few survive, bearing their complaint to the adult period, and even 
to old age ; and in some of these individuals who, with excessively large heads, 
have yet numbered many years of existence, the intellect and the senses, if not 
entire and perfect, have been sufficiently effective to answer the common wants 
and purposes of social life : the moral emotions strong, the feelings lively and 
correct, the memory tolerably retentive, the reasoning powers respectable. Dr. 
David Monro relates the case of a hydrocephalic girl, six years old, whose head 
measured two feet four inches in circumference. She is described by him as being 
" as lively and sensible as most of her age," and as "having a strong memory." 
Dr. Bright's patient, Cardinal, was nearly thirty years of age when he died. He 
was born in 1795. At the time of his birth, his head was only a little larger than 
natural; but it had a pulpy feel ; as if it were almost destitute of bony matter. A 
fortnight afterwards, it began to increase rapidly ; and when he was five years 
old, it was but little less, according to his mother's account, than when he died. 
He could not walk alone till he was nearly six, and then only on level ground. If 
he attempted to run, or to stoop, he fell down. He was sent to school when he 
was about six, and soon learned to read well and to write tolerably ; but writing 
he soon gave up, because, as he was near-sighted, it obliged him to stoop, which 
he could not conveniently do. When a candle was held behind his head, or when 
his head happened to be between a spectator and the sun, the cranium appeared 
semi-transparent ; and this was more or less the case till he was fourteen years 
old. About the age of twenty-three, epileptic fits began to occur; and after that 
his health, which previously had been very good, failed somewhat. The ossifi- 
cation of the skull was not complete till two years before his death, the anterior 
fontanelle being the last part that closed. It has been mentioned that he was 
near-sighted ; but he was very quick of hearing, his taste was perfect, and his di- 
gestion good. Dr. Bright states that his mental faculties were very fair, and his 
memory tolerable ; but it was not retentive of dates. It was said that he was 
never known to dream. There was something childish and irritable in his 
manner, and he was easily provoked. He died, at last, of fever and diarrhoea. 
There were seven or eight pints of fluid within the cranium, in contact with the 
dura mater. On the base or floor of the skull lay the brain, with its hemispheres 
opened outwards, like the leaves of a book. 

How comes it that the cerebral functions are thus sometimes fulfilled, or go on 
so well, when the machinery through which the mental powers are manifested — 
the instrument whereon and whereby the immaterial principle mysteriously ope- 
rates — is so palpably and greatly deranged ? How comes it that life, and espe- 
cially the life of the mind, subsists at all ? These questions open very interesting 
considerations. It would appear, from such cases as I have been referring to, 
that the curious arrangement and collocation of the several parts of the brain are 
rather a matter of convenient package than of necessary relation. The pulp 



CHRONIC HYDROCEPHALUS. 



287 



which furnishes the medium of sense and thought, and volition, is there, but it is 
disposed in an unusual shape. In neither of the two varieties of the malady that 
have been described as being compatible with prolonged existence, is there any- 
necessary diminution of the cerebral mass. The brain itself, which forms a bag 
in the one case, and is split in halves in the other, has been found to weigh quite 
as much as a healthy brain at the same period of life. There has been no loss, 
therefore, of substance ; the pressure has been gradual, and it has not been made 
to act injuriously by counter-pressure ; no effectual resistance has been afforded by 
the rigidity of the brain-case ; and thus the unopposed distending force neither 
causes absorption of the cerebral pulp on the one hand, nor, on the other, induces 
coma, or convulsions, or idiocy, by its compression. 

Most commonly, however, the mental and voluntary functions are maimed or 
perverted ; and these serious calamities make parents look at a large head in a 
young child with anxious solicitude. But you are aware, after what I stated on 
this subject in the last lecture, that the head may be extravagantly large without 
dropsy of the brain and without disease. 

We have just seen that, while the brain itself is gradually unfolded, or its 
hemispheres are parted and turned aside, by the liquid accumulating within the 
cranium, the functions of the organ may suffer but little, so long as the yielding 
brain-case permits the expansion or separation of the nervous substance, without 
inordinate pressure. But as soon as undue pressure begins to be exercised, then 
morbid symptoms arise, or the defects that have previously shown themselves are 
aggravated. Hence that period of life becomes a perilous period, at which the 
skull, by the closure of its fontanelles and sutures, loses its capability of further 
expansion. In some rare cases, the closed sutures re-open under the augmenting 
pressure, and a respite is thus obtained. Dr. Baillie has recorded an instance in 
which this happened in a boy seven years old. A similar case is mentioned in 
Dr. Yeat's work on hydrocephalus. The patient was a boy nine years of age. 
The sutures of his skull separated again after having been united ; and it was re- 
marked that the teeth in the jagged edges, whereby the bones interlock with each 
other, were much fewer than is usual. If this be always so when the sutures give 
way, it will serve to facilitate our understanding how such a separation can take 
place. The skull may, however, go on expanding, although the sutures are per- 
manently closed ; there still being left intervals between the several points of ossi- 
fication, which intervals are covered by membrane only. The beautiful preparation 
on the table, showing this remarkable state of the cranium, I have borrowed for 
your inspection from Dr. Sweatman's museum. 

Indeed, although I have spoken of this complaint as being especially a disease 
of childhood, it doea§occasionally commence long after the skull has become a 
complete case of bone. Enlargement of the head, in these cases, is impossible; 
but this circumstance, and the symptoms it is apt mechanically to produce, form 
the only differences between the disorder as it affects the child and the adult. In 
both cases disturbance of the cerebral functions arises, and at length convulsions 
or coma closes the scene. In both, a dropsical state of the ventricles of the brain 
constitutes, often, the only morbid change presented after death. A young and 
distinguished lawyer of my acquaintance had one or two attacks of rather sudden 
loss of consciousness while engaged in the Court of Chancery; by degrees he 
became dull, stupid, forgetful, and, at length, insensible. In this condition he 
died. A large quantity of serous liquid was found distending the ventricles of his 
brain. No other alteration could be detected. I 

Dr. Baillie describes a case of chronic hydrocephalus that occurred in a man 
fifty years old. Six ounces of fluid were contained in the lateral ventricles. He 
had been paralytic on the right side of the body; and for eleven months before 
his death had lost the recollection of his own language, with the exception of four 
or five words, which he employed, with different intonations, to express his vari- 
ous wants. 

The celebrated Dean of St. Patrick's afforded another instance of the same 



288 



DISEASES OF THE BRAIN. 



disease, attended with a similar -interruption of the power of discoursing. The 
case, as related in Sir Walter Scott's Life of Dr. Swift, is curious, and contains 
an early suggestion of a piece of practice which, in our own time, has met with 
more favour. " A few days afterwards he sunk into a state of total insensibility, 
slept much, and could not, without great difficulty, be prevailed on to walk across 
the room. This was the effect of another bodily disease: his brain being loaded 
with water. Mr. Stevens, an ingenious clergyman of his chapter, pronounced 
this to be the case during his illness, and upon opening his head it appeared that 
he was not mistaken ; but though he often entreated the Dean's friends and phy- 
sicians that his skull might be trepanned, and the water discharged, no regard was 
paid to his opinion or advice." 

He remained from October 1742, to October 1745, in a state of silence, with 
few and slight exceptions ; and died in the 78th year of his age. 

Golis also mentions three instances in which this disease began in advanced 
life ; two of the patients were above seventy years old ; the third, who was a phy- 
sician at Vienna, likewise died in the decline of life, having suffered under the 
disorder for ten years. 

Now, what can we do in these wretched cases ? Seldom much good, I am 
afraid. Yet something we must try, for parents will flatter themselves with hopes 
of a cure : and to say the truth, there have been, under judicious management, a 
sufficient number of recoveries to forbid our despairing in any case, and to make 
it incumbent upon us to employ carefully all those measures which have occasion- 
ally brought the disease to a favourable termination. Golis even affirms, that of 
the cases which began after birth, and which he saw and treated early, he was 
fortunate enough to save the majority. 



LECTURE XXVII. 

Treatment of Chronic Hydrocephalus ; Internal Remedies: Mechanical Expedi- 
ents ; Bandages, Tapping. Symptoms of Spinal Disease. Inflammatory 
conditions of the Spinal Marrow. 

The cure of chronic hydrocephalus may be attempted by internal remedies, or 
by external mechanical expedients, or by both. 

The internal remedies by which most good appears to have been effected, and 
from which, therefore, most is to be hoped, are diuretics, ^irgatives, and above 
all, mercury, which is believed by many to have a special and powerful influence 
in promoting absorption. Conjointly with these, the abstraction of small quanti- 
ties of blood from the head, by means of leeches, has been found beneficial. 

Golis advises that calomel should be given in half-grain doses, twice a day ; or 
if that quantity should purge too much, in doses containing only one-fourth of a 
grain. At the same time he would rub a scruple or two of mercurial ointment, 
mixed with ointment of juniper berries, upon the scalp, every night. He recom- 
mends that the head should be kept constantly covered also by a woolen cap. 
Infants require, he says, no other nutriment than good breast milk ; while older 
patients should take a moderate quantity of meat. In mild weather they should 
be as much as possible in the open air. Under this plan of treatment he affirms 
that he has known the circumference of the head decrease by half an inch or an 
inch, in a period of six weeks or three months ; and that perseverance in this 
method has frequently, in his experience, been followed by perfect recovery, both 
of the mental and of the bodily powers. If no improvement should be perceptible 
in two months, he advises that diuretics should be given, with the former reme- 
dies: the acetate of potash, or squills, or both : that an issue should be made in 
the neck, or in each arm, and be kept discharging for several months. And he 



CHRONIC HYDROCEPHALUS. 



289 



thinks that when convalescence has once begun, it may often be much accelerated 
by minute doses of quina ; the fourth of a grain, for example, thrice daily. 

In a disease so unpromising as chronic hydrocephalus, we are warranted in 
trying any plan that has been found, or supposed, to be useful. An apothecary 
of considerable experience — now dead — once took the pains to write out and send 
me the particulars of two cases in which he had seen a peculiar mode of adminis- 
tering mercury successful. I will give you them nearly in his own words. 

In the year 1817, he had under his care a lad, named Scott, labouring under 
chronic hydrocephalus. He had been ill two or three years, was nearly blind, 
had very little use of his lower extremities, and could not walk across the room 
without support. He suffered violent pains in his head, and was unable to bear 
the least pressure on his scalp. His bowels were constipated, and his pulse 
" oppressed." Cupping and blistering, the blue pill, drastic purgatives, and ordi- 
nary diuretics, tried in combination and succession, gave him temporary relief ; 
but no permanent benefit was obtained. Dr. Gower then suggested a plan which 
he had himself found successful in such cases, and which had first been used by 
Dr. Carmichael Smith, who had recorded ten cases of recovery under its adop- 
tion. Dr. Gower's plan was to rub down ten grains of crude mercury with about 
a scruple of manna, and five grains of fresh squills : this was to be one dose: and 
it was to be repeated every eight hours. 

My informant rubbed the quicksilver down with conserve of roses, and then 
added the fresh squills, making the whole into the consistence proper for pills 
with liquorice powder. The patient took this dose three times a day, for nearly 
three weeks, without any ptyalism being produced. Its effects were great pros- 
tration of strength, and loss of flesh, with gradual relief of all the boy's sufferings. 
It operated profusely by the kidneys. The medicine was continued twice a day, 
and at length once, for another fortnight; when all the symptoms of the disease 
had disappeared. The boy was greatly emaciated. He was then ordered an 
ounce and a half of Griffith's mixture thrice daily; and soon regained his health 
and strength, and got quite well. He remained well eight years afterwards. 

The success obtained in this case led to the pursuance of a similar course in 
that of the son of a well-known fishmonger in Old Bond Street. He was about 
twelve years old, and afflicted in nearly the same manner as Scott, except that the 
pain in his head was more acute, and caused violent screaming: relief had been 
repeatedly given for a time, by cupping. The physician in attendance was un- 
willing to try the plan, when it was proposed to him, but said that he would give 
what was equivalent — small doses of blue pill, with squills in powder. The 
result was salivation in a few days, without any amendment. In about three 
weeks, the local effects of the mercury having subsided, and the patient then suf- 
fering extreme pain in the head, loss of sight, and want of power over the lower 
extremities, my informant was desired to adopt any measures he thought fitting. 
The medicine was given as in the former case, and with the same happy conse- 
quence. It acted, as before, without producing ptyalism, but with a great reduc- 
tion of strength and flesh. Health was restored by steel, after the symptoms of 
hydrocephalus had disappeared. This cure also was permanent. 

I think you will give me credit for not being over fond of recommending what 
maybe called conundrums, instead of well-tried and approved means of cure; 
but I say that in such a complaint as chronic hydrocephalus, we have generally 
the opportunity of testing the virtues of many reputed remedies, one after another ; 
and we are not to despise or neglect any measures that have been found beneficial, 
merely because they are out of the way, or because we cannot see in what manner 
they can excel the more common formulae. 

You will observe that these were cases in which the disease came on some 
time after the sutures of the skull had closed.* 

* [Dr. Harmay relates a case of chronic hydrocephalus, in the Edinburgh Med. and 
Surg. Journal, in which he attributes the recovery of the patient mainly to the application 
to the scalp of a liniment, composed of powdered ipecacuanha and olive oil, each two 



290 



DISEASES OF THE BRAIN. 



The mechanical remedies of chronic hydrocephalus are two : and they have a 
totally opposite mode of action. By the one, the brain is compressed ; by the 
other, it is lightened of its pressure: yet both of them have proved successful. 
What does this show? what, but a confirmation of the doctrine that there are 
different states of the encephalon, very dissimilar in their essential character, yet 
having some symptoms in common; and those the most likely of all to catch our 
attention. Such common symptoms resemble an algebraical symbol, which 
derives its value from the pins or minus sign prefixed. Surely it is of vital 
importance to study, and if we can, to settle, the differences whereby these 
inverse conditions, requiring contrary remedies, may be discriminated. 

Bandaging the head is one of these two expedients ; puncturing it the other. 
Neither of them is practically applicable after the bones of the skull have united. 

Bandages appear to have been suggested by the notion that the increase of the 
fluid within the head, and probably some of the symptoms too, might depend, 
more or less, upon the want of firmness and proper resistance in the outer con- 
taining parts ; in the feeble and half solid skull. A certain amount of support and 
pressure is requisite for the due exercise of the cerebral functions. Beyond this 
amount all increase of pressure is hurtful. The middle point of safety it may be 
hard to hit. It is certain that the easy yielding of the bony walls of the head, by 
reason of the membranous interspaces that exist in the early periods of life, proves 
oftentimes the safety of these patients. If the skull did not expand as the water 
gathered, morbid symptoms would ensue. Great nicety must therefore be requi- 
site in the use of this remedy. While the head is palpably enlarging, compres- 
sion by means of plasters or bandages would probably be mischievous. When 
the disease is stationary, and the unconnected bones of the skull are loose and 
fluctuating, and the child is pale and languid, much benefit may be expected from 
moderate and well-regulated support. The late Sir Gilbert Blane was the first, I 
believe, to suggest this mode of treatment; but its safety and efficacy have been 
more recently demonstrated by Mr. Barnard, who has related several examples of 
complete success from the employment of bandages. In these cases the children 
were pale, bloated and feeble, with flabby muscles: the bones of their heads 
were movable and floating, and the functions of the brain more or less impaired. 
Mr. Barnard applies strips of adhesive plaster, about three-quarters of an inch 
wide, completely round the heads from before backwards : covering the forehead 
from the eyebrows to the hair of the head, as low down on the sides as the ear 
will permit, and lapping over each other behind. Then, cross-strips are carried 
from one side of the head to the other over the crown; and lastly, one long slip, 
reaching from the forehead, within half an inch of the root of the nose, over the 
vertex to the nape of the neck. In his first trial of this plan, but never afterwards, 
Mr. Barnard laid pieces of linen, wetted with cold water, over the plasters. The 
only internal medicine given was castor oil, to regulate the bowels. The effects, 
in all this gentleman's cases, were these: a gradual diminution of the size of the 
head; mitigation, and ultimate disappearance, of all head symptoms, such as stra- 
bismus, rolling of the eyes, starting of the muscles, and convulsions: and at the 
same time, increased tone of the muscular system, with an improved appearance 
of the skin and of the secretions from the bowels. These are striking results. 
They show that, in certain conditions of chronic hydrocephalus, a part of the 
danger arises from a lack of due support and confinement of the brain; and they 
prove that compression alone may be equal to the cure. To such cases, Dr. 
Arnott's air-press would seem, from the facility with which its equable compress- 
ing force may be regulated, to be especially adapted. 

drachms, and half an ounce of suet. Dr. Haiinay remarks, that the application of this 
liniment, three or four times a day, is followed in about thirty-six hours, by a papular and 
vesicular eruption; and he is of the opinion, that as chronic hydrocephalus often succeeds 
to the suppression of eruptions on the scalp, the use of this counter-irritant will prove in 
many cases extremely useful — its effects are much more manageable than those of the 
tartar emetic ointment which, in' this disease, has been found advantageous. — C] 



CHRONIC HYDROCEPHALUS. 



291 



But in children who are not of this pale and feeble habit, and in whom ossifi- 
cation of the skull goes on, the period when the walls cease to yield is the period 
of danger. The water continuing to accumulate, inordinate pressure begins to 
take place. Under these circumstances, the application of bandages or plasters 
must, if nothing else be done, be insufficient or unsafe. The brain-case being no 
longer capable of expansion, there remains to be attempted a reduction of the 
quantity of the liquid which it contains. 

Now, any considerable diminution of the accumulated fluid, through the agency 
of mere absorption, is scarcely to be expected; even although we endeavour to 
aid that process by applying leeches and cold to the head, and by purgatives, or 
diuretics, or diaphoretics. Some mode, more certain and effectual, of emptying 
the distended cavity, has therefore been earnestly sought after ; and the second 
mechanical expedient of which I have spoken offers a very sure method of attain- 
ing this object. He must have been a bold physician who first proposed to decant 
the water from the brain, by means of a perforation, made with a trocar, through 
the membrane of the fontanelle, through the membranes of the brain, and through 
even the expanded cerebral substance itself. But the success of the project has 
amply vindicated his happy audacity. It is not a very new suggestion, but it nas 
received particular attention in this country of late years : and though tapping the 
brain in chronic hydrocephalus has been denounced as useless and cruel by some 
high continental authorities, by Golis and Richter especially, it furnishes one of 
the best of the few chances of safety to the patient. Of course I mean ultimate 
safety, for the operation itself is attended with the present risk of accelerating the 
patient's death. Other means, however, failing, we are justified in advising that 
hazard. We have to consider that by performing the operation we incur the 
danger of abbreviating the existence of a being, whose life, without it, could 
scarcely be long continued, or capable of enjoyment: but then we afford some 
chance of a perfect cure. A speedy death, or an uncertain life of mental and 
bodily imbecility, or complete restoration : these are the three events to be looked 
at. Of the three, the second is, in my judgment, incomparably the worst; and 
if the case were my own, if I had to decide the painful question in reference to 
one of my own children, I would accept the alternative of probable speedy death 
on the one hand ; possible complete recovery on the other. 

To say the truth, the immediate danger is not so very great as you might sup- 
pose; provided that the operation be skilfully and cautiously performed, and only 
a moderate quantity of water drawn off at a time. That even a very rough ope- 
ration is not necessarily fatal we learn from a singular case related by Mr. Great- 
wood. A child, fifteen months old, afflicted with chronic hydrocephalus, fell 
down, and struck the back part of its head against a nail, which penetrated the 
skull. Above three pints of water gradually flowed out at the orifice thus made, 
and the child was cured. 

I will mention a few instances in which tapping the brain has been performed; 
for I know no better mode of showing you the manner in which the operation 
should be done, the cautions to be attended to in doing it, and what kind of suc- 
cess it has had. 

There is an account of the performance of this operation by Lecat, in the Phi- 
losophical Transactions for the year 1751. This date is subsequent to the 
period when the Rev. Mr. Stevens suggested the propriety of trepanning Dean 
Swift's cranium. In 1778, Dr. Remmet, of Plymouth, punctured the head of a 
hydrocephalic child on five several occasions, with a lancet, and took away, in 
all, no less than eighty ounces of fluid ; five pints, as pints were measured in 
that day. The child died seventeen days after the last tapping. A very inte- 
resting case of the same kind is related by Dr. Vose, of Liverpool. His patient 
was an infant seven months old. Its head was more than twice the ordinary size. 
Three operations were performed ; the first with a couching needle. Upwards 
of three ounces were on that occasion evacuated ; and it was estimated that about 
the same quantity dribbled away afterwards. The child thereupon became very 



292 



DISEASES OF THE BRAIN. 



weak, but was presently revived by some cordial medicine. About six weeks 
afterwards, the liquid having collected again, an opening was made with a bis- 
toury, and eight ounces were removed ; and nine days after that, twelve ounces 
more, without any bad consequences. The head diminished in size, the patient 
got apparently well, and the case was published as a successful one. Unfortu- 
nately, however, the complaint afterwards returned, and the child died of it. 

Mr. Lizars, of Edinburgh, operated upon a little patient of his twenty times in 
the course of three months ; using a small trocar. Dilatation of the pupils, and 
squinting, which had previously existed, ceased immediately upon the escape of 
the water. The child recovered. Another very striking and instructive instance 
is recorded by Mr. Russell, of Edinburgh. The patient was an infant three 
months old, with an enormous head ; twenty-three inches in circumference, and 
fifteen inches and a half from one ear to the other. The child was affected with 
strabismus, and a perpetual rolling of the eyes. The usual routine measures, 
compression among the rest, had been employed without any success. By four 
operations performed at intervals of about ten days, the size of the head was con- 
siderably reduced : but, the fluid continuing to collect, calomel was given in 
small and frequent doses, and the gums became sore, and the child got well. At 
eight months old the dimensions of the head were less, by four inches in circum- 
terence, and by two inches and a half across the vertex, than they had been before 
the first tapping; and the sutures had entirely closed. 

But Dr. Conquest, of Finsbury Square, has, more than any other person, 
given authority to these operations. In a paper published in the Medical Gazette 
in March, 1838, he tells us that he had then tapped the heads of nineteen chil- 
dren for this complaint, and in ten of the nineteen cases the children survived. 
He introduces a small trocar through the coronal suture below the anterior fonta- 
nelle, and cautiously makes pressure upon the head afterwards by means of strips 
of adhesive plaster; and he closes the wound in the integuments carefully after 
each time of puncturing. The greatest quantity of liquid withdrawn by him, at 
any one time, has been twenty ounces and a half; and the greatest number of 
operations on any one child has been five, performed at intervals of from two to 
six weeks. The largest total quantity of water removed was fifty-seven or fifty- 
eight ounces by five successive tappings. 

This expedient, therefore, though doubtless hazardous, is really a valuable one. 
The rules relating to its performance may be briefly summed up. The operation 
should scarcely be had recourse to until other means have failed. The trocar 
should be small, and it should be introduced ; rpendicularly to the surface, at the 
edge of the anterior fontanelle ; so as to be as much as possible out of the way of 
the longitudinal sinus, and of the great veins that empty themselves therein- The 
fluid should be allowed to issue very slowly ; and a part of it only should be 
evacuated at once. The instant that the pulse becomes weak, or the dilated pupil 
contracts, or the expression of the child's countenance manifestly alters, the 
canula should be withdrawn, and the aperture in the skull closed. Gentle com- 
pression should be carefully made to compensate, in some degree at least, the 
pressure that has been removed with the fluid. Should the infant become pale 
and faint, it must be placed in the horizontal posture ; and a few drops of sal 
volatile, or of brandy, mixed with water, may be given. Sometimes slight inflam- 
matory action comes on in the course of a day or two after the tapping. When 
this happens, we must apply cold lotions, and leeches, and use the other remedies 
which I mentioned before, as proper to subdue such inflammation. 

I once got a surgeon to perform the operation upon the infant of a poor woman, 
after I had tried in vain all the other measures that I have spoken of. To our 
horror, when the trocar was withdrawn from the canula, instead of clear serosity, 
a fine stream of purple blood spouted forth. The opening was at a considerable 
distance from the longitudinal sinus ; but the trocar was not so delicate as it might 
have been, and I presume that one of the larger superficial veins had been pierced. 
I do not think, either, that the instrument was introduced in a sufficiently per- 



CHRONIC HYDROCEPHALUS. 



293 



pendicular direction. Of course the risk of hitting a vein is increased when the 
trocar is carried obliquely inwards : and a larger portion of the cerebral mass is 
also wounded. We naturally thought it was all over with the child, which pre- 
sently became deadly pale and faint. A verdict of infanticide by misadventure 
stared us in the face. But under the use of stimulants the infant revived again ; 
no hemorrhage went on internally, as we apprehended it would ; but the child, 
after a day or two, seemed very much the better for the loss of blood. This 
amendment, however, did not last; and the mother, who had been terrified by the 
immediate consequences of the operation, feared to come near me, lest I should 
wish to have it repeated ; and at length our patient died. I was very desirous to 
examine the interior of the head ; but this was not permitted. 

On one subsequent occasion I have witnessed the operation. The subject of 
it was an infant about eight months old. Four months after its birth, its head was 
observed to grow inordinately large. At the time of the operation the fontanelles 
were exceedingly tense ; the child screamed frequently, occasionally vomited, and 
was slightly convulsed ; the features were pinched, and the eyeballs distorted 
downwards ; but the pupils were not dilated. Four ounces of transparent liquid 
were let out by puncturing the anterior fontanelle. A few hours afterwards the 
child was tranquil, and much improved in aspect ; the distortion of the eyeballs 
had disappeared. Three ounces more were taken away the next day. For two 
days thereafter all the symptoms appeared to be mitigated ; but the skull was 
flaccid ; yielding, like a broken egg, to the gentlest pressure. On the evening of 
the fourth day after the first tapping, the respiration became hurried, the child 
grew dull, and, before midnight, expired. In this case it appeared to me that the 
chance of success was baulked by the want of external support subsequently to 
the tapping. 

You will not expect me to draw any comparison between the merits of com- 
pression and of paracentesis, as substantive remedies. They are opposite mea- 
sures, and adapted to different and opposite conditions of the brain. The one 
repairs defect of pressure ; the other relieves its excess. To hold the balance 
even requires much care, a steady and gentle hand, an accurate judgment, and 
incessant vigilance. Either expedient may suffice, alone. Both may be (and 
have been) profitably employed in the same case, in succession, according to its 
varying circumstances. If the walls of the head be tight and firm, the trocar 
should precede the bandage ; if lax and movable, compression should be cau- 
tiously tried, and followed, if need be, by the puncture.* 

I have now done with the inflammatory affections of the brain: in conjunction 
with which I have also considered some other morbid conditions, that are either 
connected with inflammation of the contents of the cranium, or resemble it in 
some of their phenomena. Thus, T have spoken of delirium tremens, which is 
apt to be mistaken for inflammation of the brain : of softening from disease of the 
cerebral arteries, which is liable to be confounded with inflammatory softening: 
of tumours of different kinds, which tend to produce inflammation, or symptoms 
like those belonging to inflammation: and of chronic hydrocephalus, which some- 
times is the sequel, sometimes the precursor, of acute hydrocephalus ; and has 
other points of analogy with that disease, the encephalitis of children.t 

* [Dr. Whitney relates, in the Edinburgh Med. and Surg. Journal, an instance of the 
successful puncture of the brain in a case of chronic hydrocephalus. By the first opera- 
tion, nine ounces of fluid were drawn off, and in three weeks subsequently, by a second 
operation, five ounces more. Neither operation was succeeded by any bad symptom, and 
the recovery of the child appears to have been complete. Two cases are related by Pro- 
fessor Wutzer, and Dr. Butcher, in the Austrian Medical Journal, in which the puncture 
of the brain was unsuccessfully employed. In the first, a child seven months old, death 
occurred in six days after the first operation; in the second case, of a child sixteen months 
old, the operation was repeated, after an interval of four weeks, and seven weeks after the 
second puncture, the child died in convulsions. — C] 

f [Meningitis encephalica. — Under this name, Dr. Brockman has recently described a 



294 



DISEASES OF THE BRAIN 



Before I take up the subject of apoplexy, and of cerebral hemorrhage, I wish to 
direct your attention to the inflammatory conditions of the spinal cord. 

The whole pathology of this portion of the nervous system is extremely inte- 
resting ; but it has not yet been so thoroughly made out as to enable any one to 
give a very systematic or satisfactory account of it. In addition to those numerous 
difficulties with which I showed you in a former lecture that the entire subject of 
the diseases of the nervous apparatus is beset, there is this further obstacle to our 
studying diligently the structural changes of the spinal marrow — that much labour 
and expense of time are required for exposing the interior of the vertebral canal ; 
which is, therefore, too often neglected in examining the dead body. 

There are certain points in the anatomy and physiology of the spinal cord 

peculiar form of cerebral disease incidental to childhood, in which the membranes of the 
medulla oblongata and pons varolii are chiefly affected. 

Dr. B. has met with fourteen cases of this affection. It was, at first, observed by him as 
a sequel of scarlatina, but subsequently, he has seen it to occur most frequently as an idio- 
pathic affection. 

It is sometimes associated with general disease of the brain; at others, it is uncompli- 
cated. Notwithstanding, in its earlier stages, it is unattended bv any serious symptoms, it 
is an affection fully as dangerous as cerebral meningitis. The first stage, or that of simple 
hyperemia, generally continues for one or two days. The child is dull and heavy, and the 
occiput is often hot; the bowels, however, are regular; there is no vomiting, no intole- 
rance of light, nor any disturbance of sleep. The general dullness of the patient, and vague 
complaints of some uneasy sensation in the head, increase as the inflammatory stage sets 
in ; the heat of the occiput is augmented ; the head becomes retracted, as in the ordinary 
cases of acute hydrocephalus; and convulsive twitchings of the limbs occur, similar to 
the effects of light .electric shocks, which recur every few minutes while the patient is 
awake, but cease during sleep. The general febrile symptoms continue during the third 
stage; the pulse, however, diminishes in frequency and fullness, but does not become either 
irregular or intermittent. The general disquietude of the child subsides, by degrees, into 
a comatose condition, in which the head becomes still more retracted, but unattended with 
strabismus, or any morbid condition of the pupil ; the peculiar air of stupidity that character- 
izes hydrocephalic patients is wanting. Two pathognomonic symptoms, however, indicate 
the occurrence of the stage of effusion. One of these is deafness ; the other difficult arti- 
culation, and difficulty in moving the tongue — both of which occur at the same time, pro- 
bably from paralysis of the motor nerves of the tongue. The deafness and affection of the 
tongue usually occur suddenly; sometimes they are first observed upon the child awaking 
from a quiet sleep. They are, according to Dr. Brockman, the earliest and most certain 
indications of the occurrence of effusion. This stage continues, sometimes, for three, and 
sometimes for fourteen, days. Its termination is in fatal paralysis, the occurrence of which 
is often preceded by various singular nervous phenomena — as sudden pauses in the respi- 
ration, or equally sudden syncope. In some cases, however, the paralysis does not follow, 
but the anomalous symptoms subside, and the patients gradually recover; until, indeed, 
the paralytic stage is fully established, the recovery of the patient is still possible. 

In the uncomplicated cases of the disease, upon examination after death, the cerebrum 
in general, presents an extremely pallid and anaemic condition, in striking contrast with the 
cerebellum, the vessels of which are turgid with blood, while its substance, also, is often 
in a state of marked hyperemia. The hypersemia increases in intensity towards the 
central portions of the encephalon ; and the membranes covering the pons varolii and 
medulla oblongata are found in a most decided state of inflammation; the portion of in- 
flamed membrane is perfectly isolated, and not more, usually, than a square inch in extent 
— the membrane of the cerebellum being entirely free from any indications of inflamma- 
tion. There is ordinarily an effusion of a serous fluid into the sub-arachnoidal tissue; 
sometimes to the extent of several ounces; occasionally a gelatinous matter is effused, 
and, in some cases, the effusion is of a purulent character. 

This form of the disease is most frequently observed in children from three to ten years 
of age, and who had previously enjoyed good health. 

The treatment recommended by Dr. Brockman, in its first two stages, is depletion, by 
leeches to the posterior part of the head, cold applications to the scalp, and the free admi- 
nistration of calomel, which latter may be continued during the stage of effusion. Here, 
however, it becomes necessary to support the strength of the patient; for this purpose 
ammonia is directed by Dr. B., but he remarks that, in some cases, the administration of 
wine maybe required. According to his experience, powerful counter-irritants, as a large 
blister, or the actual cautery, prove, also, sometimes beneficial.— C] 



AND SPINAL CORD. 



295 



which it is necessary that you should bear in mind, if you would have any clear 
notions even of what has been learned in respect to its pathology. 

1. In the first place the spinal cord (including the medulla oblongata) is the 
seat and centre of that remarkable property, the reflex function; by which so 
many of the automatic movements of the body are regulated, 

2. In order that we may feel, or be conscious of, what occurs in any part of the 
trunk or limbs, and in order that our will to move any such part should be obeyed, 
it is necessary that there should be a continuity of nervous matter between the 
part in question and the brain. If the cord be cut across at any point, or so 
crushed as to be thoroughly disorganized at that point, a complete abolition of 
sensation and of voluntary motion ensues in all those parts of the body that 
receive their sentient and motor nerves from that portion of the cord which lies 
beyond the place of the injury, reckoning from the brain. What is true in this 
respect of the mechanical division of the cord, is equally true of such disease as 
pervades and spoils the nervous matter composing it. 

Now it follows from this, that the effects of disorganizing forms of disease— as 
well as the effects of injury — must vary greatly according to the part of the cord 
they occupy, 

Thus any injury or disease affecting the whole thickness of that portion of the 
spinal marrow which is contained within the upper cervical vertebrae, is inevitably 
fatal at once ; producing suffocation by paralyzing those muscles through the play 
of which the motions of respiration are performed. You know that the intercos- 
tal muscles and the diaphragm have at all times the main share in carrying on the 
mechanical actions of respiration ; and probably they execute the whole action in 
every case of ordinary breathing. Now the intercostal muscles are furnished 
with motor nerves from the spinal cord, all along the dorsal vertebrae ; and the 
diaphragm is principally supplied by the phrenic nerves, which are chiefly 
derived from the third and fourth cervical nerves. These muscles obey the will ; 
but they act also independently of the will. The pneumogastric and trifacial 
nerves, with respect to them, are excito-motory nerves, and call into play a reflex 
power which is transmitted from the medulla oblongata. Hence any profound 
injury of the spinal cord, above the origin of the phrenic nerves, stops both the 
voluntary and the involuntary movements of the respiratory muscles, and the 
individual perishes by apncea in as strict a sense as though the access of air to the 
lungs had been suddenly prevented by a ligature drawn tightly round his wind- 
pipe. 

Again, when a segment of the cord, however small, is disorganized in its cer- 
vical part, between the origin of the phrenic and the origin of the upper intercostal 
nerves, the breathing is not instantly suspended ; but is performed entirely by 
means of the diaphragm, the intercostal muscles having no share in it. The ribs 
cease to rise and fall ; and the abdomen is alternately protruded, and sinks back 
again. In each case I suppose the disease of the cord to be such as suffices to 
paralyze the parts supplied with nerves from it, beyond the seat of the disease. 
If disease of this kind occur below 7 the giving out of the intercostal nerves, the 
breathing is not affected ; we have paraplegia only, palsy and loss of feeling in 
the lower extremities, and, perhaps, in the hips, or even higher. Now a person 
in this condition may live a long time. When the disease is situated between the 
origin of the intercostal nerves and the origin of the phrenic, he may live a few 
days, but he seldom lives a week, and never survives a month : and when the 
disease is higher still, in the very upper part of the cord, above the origin of the 
cervical nerves, he perishes oqtright. The kind and degree of disease, therefore, 
being the same, the character of the symptoms, and the amount of danger, differ 
remarkably according to the seat of the disease. 

3. Although sense and voluntary motion cease upon the disruption of the com- 
munication with the brain, the excito-motory functions of the separated portion of 
the cord are not necessarily suspended. On the contrary, they seem to acquire 
increased activity. The automatic power is apt to run riot, as it were, when the 



296 



DISEASES OF THE 



controlling influence of the sensorium is withdrawn. All of you have probably 
seen the limbs of a recently decapitated frog thrown into violent action by the 
stimulus of galvanism. I have witnessed the same thing in the human body after 
death by hanging. What is still more curious, you may have unequivocal mani- 
festations of similar phenomena in the living body. I have lately been informed, 
by Dr. William Budd, of a case in which a man was afflicted with paraplegia, in 
consequence of disease of the vertebral column. He was totally deprived of the 
power of moving his lower extremities. Sensation in them was almost, yet not 
entirely extinct. A sharp pinch, or the prick of a pin, he could feel ; but slight 
friction he was quite unconscious of: yet (as he himself said) his limbs were not; 
for when the inner edge of the foot was brushed or tickled by the hand of another 
person, the corresponding leg, over which he had no voluntary control, would 
start up, and be briskly convulsed. The same thing took place, in both limbs, 
whenever he passed his urine or feces ; so that he was obliged to have an appa- 
ratus of straps and ligatures to keep the legs down on such occasions. I have 
seen something like this myself.* 

4. Distinct and different filaments of the spinal cord connect themselves with, 
or help to form, different nerves which emerge from the cranio-spinal axis. A 
knowledge of this fact enables us to understand how it happens (as it sometimes 
does happen,) that the upper extremities are bereft of sensibility, or of voluntary 
motion, or of both, by disease of the cord, while the same functions remain perfect 
in the lower and more distant limbs. Here the disease must have spared those 
strands or filaments of the cord which pass down to connect themselves with the 
nerves given off at the lower part of the spine ; while it has affected those strands 
or filaments only which belong to certain nerves from the upper part. 

5. Under the sagacious researches of Dr. Marshall Hall, the physiology, and 
with it the whole pathology, of the spinal cord is undergoing, at this very time, a 
complete reformation. I know of no modern discovery so fruitful of important 
practical consequences, or so likely to improve our remedial management of ner- 
vous disorders, as the singularly interesting truths which he is even now engaged 
in demonstrating and enforcing. I do not profess to teach you this new physi- 
ology. I touch only, as I pass along, upon some of its cardinal points, to which 
I may have occasion to refer in future. We are considering how the signs of 
spinal disease may vary according to the particular location of that disease; and I 
would have you remark, here, that inasmuch as all the acts of ingestion and ex- 
pulsion, all the inlets and outlets of the body, are governed by the spinal marrow, 
with its corresponding apparatus of incident and motor nerves — it is to be ex- 
pected that disease in the upper part of the true spinal system should affect the 
orifices which answer to that part, and which are principally inlets — the larynx, 
the gullet, the cardia: while disease in its lower portion will be likely to disturb 
the natural functions of the lower orifices — the rectum and anus, the bladder and 
urethra, the os uteri — which are chiefly outlets. 

6. You must bear in mind also the grand discovery of Sir Charles Bell, that 
the two roots by which each spinal nerve arises have distinct and different func- 
tions ; the anterior roots being composed of motor fibrils, the posterior of sensi- 
ferous. 

It is not so clear, although that opinion is, I believe, a prevalent one, that the 
anterior columns of the spinal cord are subservient to the purposes of motion, and 
the posterior to the faculty of sensation. This has been inferred, too hastily per- 
haps, from the ascertained endowments of the anterior and posterior roots of the 
nerves : and cases are cited which appear to favour such a notion : but then other 
cases go completely to contradict it. Thus Mr. Stanley has recently published 
an account of a patient who died in St. Bartholomew's Hospital. For some time 
before his death he had been completely unable to move his lower limbs, through- 

* This very interesting case has since been published, in detail, with several others 
resembling it, in the 22d volume of the Medico- Chirurgical Transactions. 



SPINAL CORD. 



297 



out their entire extent ; while there was no discoverable impairment of sensation 
in any part of either limb. The spinal cord was the only organ found diseased : 
and the disease was strictly limited to its posterior half or columns. This por- 
tion of the cord, in its whole length, from the pons to its lower end, was of a 
dark-brown colour, and extremely soft and tenacious. The anterior half, in its 
entire length, exhibited its natural whiteness and firm consistence. The roots of 
the spinal nerves were unaltered. 

It was remarkable, and illustrative of the difficulty of these subjects, that with 
the change of structure which the cervical portion of the cord had undergone in 
this instance, there was no defect either of motion or of sensation in the upper 
limbs. 

7. We must not forget that the brain, and the spinal cord, which are distinct 
from but yet continuous with each other, sympathize largely and mutually under 
disease. This circumstance throws an additional obscurity over the study of 
their morbid conditions. It is one, however, which we cannot avoid, but which 
we must estimate and allow for, in our observation of diseases, as we best may. 

8. There are a few remarks made by Dr. Abercrombie in relation to some of 
the anatomical dispositions of the cord and its investing membranes, which may 
help us to comprehend better some of their morbid contingencies. Thus, with 
respect to the dura mater of the cord, it is practically of importance to recollect 
" that it adheres very slightly to the canal of the vertebrae by a very loose cellular 
texture ; and that it adheres very intimately to the margin of the foramen mag- 
num. In this manner a cavity is produced betwixt the membrane and the inner 
surface of the spinal canal (external, i. e., to the membrane), which cavity may 
be the seat of effusion, and which has no communication with the cavity of the 
cranium. On the other hand, the space between the dura mater and the pia 
mater (or membrane immediately covering the cord), communicates freely with 
the cavity of the cranium ; so that fluid may pass easily from one to the other, 
according to the position of the body." 

I shall pursue the same order, in speaking of the inflammatory affections of 
the spinal cord, as I followed in respect to the analogous conditions of the ence- 
phalon. And, first, let us inquire what has been noticed of inflammation of the 
membranes of the cord. They may undergo inflammation, independently of the 
substance of the cord, and independently of the brain : but this is not very com- 
mon. Usually, when we have meningitis of the cord, we have the same disease 
also within the cranium ; usually, also, with meningitis of the cord, we have 
more or less inflammation of the nervous matter composing it. The commonest 
symptoms of inflammation of the meninges of the cord (for I do not pretend to 
speak of the several membranes separately), appear to be pains, often intense, ex- 
tending along the spine, and stretching into the limbs, and aggravated usually by 
motion, and simulating therefore rheumatic pains : rigidity or tetanic contraction, ' 
and sometimes violent spasms, of the muscles of the back and neck, amounting in 
some instances to perfect opisthotonos : a similar affection of other muscles, also, 
as those of the upper or lower extremities: a sense of constriction in various 
parts, in the neck, back, and abdomen, as if those parts were girt by a tight 
string: feelings of suffocation: retention of urine: obstinate constipation: and 
with these symptoms, rigors often. 

You are not to expect all the symptoms which I have been enumerating in 
every case; they will vary according to the seat and extent of the inflammation. 
We need not wonder at the spasmodic symptoms, when we recollect that the 
nerves which issue from the body of the cord receive a covering from its pia 
mater. The pain felt along the course of the spine itself is said to be aggravated 
by percussion of the spine, but not by simple pressure ; and this seems very 
likely. 

I know of no way in which I can so well hope to awaken an interest in you 
about these diseases 5 or to offer you instruction respecting them, as by instances. 



298 



DISEASES OF THE 



The following I take, abridging it somewhat, from Dr. Abercrombie. A man, 
twenty-six years old, had for several years been subject to suppuration of the left 
ear, suffering occasional attacks of pain on that side of the head, which were fol- 
lowed by a more copious discharge from the ear. In the first week of April he 
became ill, with pain of the forehead and occiput, disturbed sleep, and loss of ap- 
petite, but no fever. At the end of the week he complained of pain extending 
along the neck. This pain gradually passed downwards in the course of the 
spine, and deserted the head ; and, at last, after many days, it fixed itself with 
intense severity at the lower part of the spine, shooting thence around the body 
towards the crest of the ilia. He became affected, also, with great uneasiness 
over the whole of the abdomen, and had much pain and difficulty in passing his 
urine. About the end of the second week in April his sufferings had become 
extreme. He could not lie in bed for five minutes at a time, but was generally 
walking about the house in a state of great agitation, grasping the lower part of 
his back with both his hands, and gnashing his teeth with the intensity of the pain. 
He had no interval of ease, and was sometimes incoherent and unmanageable. 
On the 16th, he went to take a warm bath, walking down three stairs, and into 
an adjoining street, with little assistance. His speech afterwards became some- 
what affected : there were convulsive twitches of his face, and difficulty of swal- 
lowing. Some transient squinting also was observed. The pulse was now very 
frequent. On the 18th, while sitting in a chair, he suddenly threw his head back- 
wards with great violence, fell immediately into a state of coma, in which he 
remained for two hours, and then died. During the whole disease there had been 
no paralysis, except the slight affection of his speech ; no difficulty of breathing ; 
no vomiting; and no convulsion except the twitching of his face the day before 
his death. The pulse was small and irregular. The bowels were easily kept 
open, but the pain in his back was much increased by going to stool. Two days 
before his death he had several attacks of shivering; and much purulent matter 
was discharged from his left ear during his illness. 

Upon a very careful examination of his body, every part of the brain was found 
to be in the most healthy state. Some gelatinous deposit was found under the 
medulla oblongata; and purulent matter flowed, in considerable quantity, out of 
the spinal canal. The spine being entirely laid open, the cord was seen covered 
with a coating of purulent matter, which lay betwixt it and its membranes. The 
matter was most abundant at three places ; at the upper part, near the foramen 
magnum — about the middle of the dorsal region — and at the top of the sacrum: 
but it was also distributed over the other parts with much uniformity. The sub- 
stance of the cord was soft, and separated in some places into filaments. All the 
other viscera were healthy. 

You may find several interesting examples of this form of disease in Olli- 
vier's Treatise on the Spinal Marrow. The prominent symptom was generally 
pain, referred to some part of the spine, and increased by motion; and what is 
curious, sometimes little complained of except upon motion. In general, also, it 
extended along some of the limbs, and was accompanied by muscular rigidity or 
tetanic spasms. Palsy occurred in one case; but this seemed to have been owing 
to softening of the cord itself. Constantly there was increased sensibility ; a 
circumstance which Ollivier thinks calculated to distinguish inflammation of the 
membranes from inflammation of the substance of the cord; the latter being 
usually attended' with diminished sensibility. In the case that I have quoted from 
Dr. Abercrombie, the intense pain underwent no remission or abatement. In one 
of Ollivier's examples, there was at the commencement of the disease, a striking 
intermittence of the pain; it came on with intense severity at ten at night, and 
lasted till three in the morning. 

The causes of spinal meningitis are not always to be discovered. It sometimes 
extends from within the cranium. It may be excited by external violence to the 
spine, of which a good specimen has been recorded by Sir Charles Bell. — A 
wagoner sitting on the shafts, of his cart, was thrown off by a sudden jerk, and 



SPINAL CORD. 



299 



pitched upon the back of his neck and shoulders. He was taken to the Middlesex 
Hospital, where he lay for a week, without complaining of any thing except stiff- 
ness of the back part of the neck. He could move all his limbs with freedom. 
On the eighth day after his admission he was seized with general convulsions and 
locked jaw. He then became affected with a singular convulsive motion of the 
jaw, which continued in violent and incessant movement for about five minutes. 
This was followed by maniacal delirium. He then sank into a state resembling 
typhus fever ; and after four days was found to be palsied and insensible in his 
lower extremities. The day before his death he recovered sensation in his legs. 

On dissection, a great quantity of purulent matter was found within the spinal 
canal. It appeared to have formed about the last cervical and the first dorsal 
vertebra, and to have dropped down, by its own gravity, to the lower part of the 
canal; where it produced palsy and anaesthesia of the inferior limbs by the pres- 
sure it occasioned. 

Inflammation of the substance of the spinal cord leads to the same changes in 
its texture which have been already spoken of as being often the results, in the 
brain, of inflammation of the cerebral matter. Softening — induration-r-suppura- 
tion. I need not, therefore, again describe the physical characters of these altera- 
tions. 

The symptoms which flow from inflammation of the nervous pulp of which the 
spinal marrow is composed, are by no means uniform ; nor can we expect that 
they should be so, when we recollect what has been already stated of the different 
effects that must ensue according as different parts of the cord happen to be impli- 
cated. The phenomena will vary likewise, according as the inflammation is acute 
or chronic. If we recollect how many parts of the body depend for their power 
of motion, and for their sensibility, upon the integrity of the spinal cord, we shall 
not be surprised at the diversity and multiplicity of the symptoms produced by- 
disease of the cord. Tracking inflammation and its events from the upper portion 
of the spinal marrow downwards, we should expect to find, and we actually do 
find, some such an arrangement of symptoms as the following. Convulsive 
affections of the head and face, inarticulate speech, loss of voice, trismus, difficult 
deglutition, spasmodic breathing, irregular action of the heart, constriction of the 
chest, vomiting, pain of the belly, sensation of a cord tied round the abdomen, 
dysuria, retention of urine, incontinence of urine, constipation, tenesmus, involun- 
tary stools : and with respect to the voluntary muscles corresponding to these 
parts of the spinal marrow, convulsions, or palsy; or palsy succeeding to con- 
vulsions. 

I must again have recourse to examples, to put you, more fully than any 
attempted abstract picture could put you, in possession of such forms of inflam- 
mation of the cord as you may expect to meet with in practice. 

A man, fifty-six years old, was exposed to severe cold, while traveling on the 
outside of a coach. After this he was attacked with pain in the right arm and leg, 
most severe about the shoulder, but affecting the whole side, and he had also con- 
siderable headache. He soon perceived some loss of power in the affected limbs ; 
and the progress of this was very curious. It began at the upper part of the arm, 
and extended downwards so gradually, that he was able to write distinctly, after 
he had lost the power of raising the arm, or bending the elbow. Then the leg 
became affected in the same gradual manner, and after ten or twelve days from the 
commencement of the disease, the whole leg and arm had become completely 
paralytic. Some pain continued in the parts, and it was occasionally severe, 
especially in the leg. Repeated blood-letting, and purgatives, and blistering, 
were employed. His mind remained quite entire. His pulse was 84, and rather 
weak; after some time the left arm became paralytic, rather suddenly ; but it was 
not so completely motionless as the limb on the right side ; the left leg was no! 
at all affected. Slight delirium occurred, but passed off again At the end of two 
months after the exposure to the cold, he again became delirious, and his pulse 



300 



DISEASES OF THE 



got feebler and rapid : he then fell into a state of stupor, muttering incoherently, 
but answering questions distinctly when he was roused. He lost his speech a few 
hours before death. For the last eight or ten days there had been considerable 
sloughing of the sacrum. 

The brain was found to be healthy throughout. Much bloody fluid was dis- 
charged from the spinal canal into the cavity of the cranium before the spine was 
laid open. On displaying the spinal cavity itself, the cord was found in a state 
of complete softening, from the second to the last cervical vertebra. The portions 
above and below that part were quite healthy. (Abercrombie.) 

- Comparing this case with the one I detailed of meningitis, we find that pain 
was present in both, but more severely so in the case of inflammation of the mem- 
branes : we find also, that stiffness and spasm of the muscles marked the menin- 
gitis ; palsy, the inflammation of the substance of the spinal cord. In neither of 
them were the intellectual functions disturbed till towards the last. I believe that 
the characters now pointed out belong to these forms of disease respectively. 

I shall take, from the same store-house, one more case, in which both the 
membranes and the cord were simultaneously inflamed; and which, therefore, 
was analogous to encephalitis. And I quote it the rather because it possesses one 
or two points of peculiar interest. A young man, of unhealthy constitution, 
eighteen years old, had suffered for some time from ulcers in various parts of the 
body, accompanied by exfoliations of bone from the leg, thigh, and sacrum. For 
several months before his fatal attack he had a sore on his head, as big as a shil- 
ling, with caries of the bone beneath it. At length he began to complain of pain 
in the loins, without fever. On the 2d of October this pain had increased ; it 
was chiefly seated among the lower dorsal vertebrae, and extended downwards in 
the course of the ureter, with a frequent desire to pass urine. Then the pain 
descended lower, into the sacrum, and the symptoms referable to the bladder 
ceased. But soon afterwards pain in the belly came on, and numbness of the 
inner sides of the thighs, and retention of urine ; and in two days after this there 
were perfect palsy of both thighs and legs, without loss of feeling, retention of 
urine, and involuntary stools. He had still some pain in the lower part of the 
dorsal region. He died at length, on the 14th of October, having continued quite 
sensible till about six hours before. There had not been the smallest approach 
to a renewal of power of the lower extremities, but their sensibility remained. 
There was palsy but no anxsthesia. 

All was quite sound in the brain, except some old thickening of the dura mater 
in the neighbourhood of the diseased bone. In opening the spinal canal, some 
purulent matter flowed out, during the sawing, from about the middle of the dorsal 
region ; and one of the vertebras at that place was found carious. There was an 
extensive deposit of flocculent matter, having a purulent appearance, upon the 
outside of the membranes of the cord. Bloody sanious fluid was discharged from 
beneath its dura mater, and its pia mater was highly vascular. The substance of 
the cord was found most extensively disorganized along nearly the whole extent 
of the dorsal portion. The anterior columns of this part were completely broken 
down into a soft diffluent pulp ; on the posterior part the cord was more entire. 
"When the whole cord was taken out, and suspended, it hung together by the 
posterior columns of the dorsal portion, while the anterior part of it fell off entirely, 
in a soft half-fluid state. The parts above and below the diseased portion were 
quite firm and healthy. 

The complete palsy in this instance, going along with the destruction of the 
anterior columns ; and the persistence of the sensibility, the posterior columns 
being comparatively entire ; invest the case with a remarkable degree of interest. 
We might infer from it that the anterior half of the cord is the channel through 
which the power to move the limbs is transmitted, while their sensations are car- 
ried along its posterior half; but we are checked from so concluding, by such 
cases as the one recorded by Mr. Stanley. These apparent inconsistencies may 
puzzle, but they ought not to discourage you. That time, and our advancing 



SPINAL CORD. 



301 



science, will at length explain and reconcile them, I cannot doubt. Meanwhile 
they teach a lesson which many practitioners much need — viz., that it is unphilo- 
sophical and unsafe to draw general conclusions from single cases of disease. 

At the time when these cases were noted, the peculiar reflex properties of the 
spinal cord were not understood. Henceforward we shall study its diseases from 
a new point of view, and with a clearer vision. 

Much may be learned in regard to the effects of inflammation, or any other 
cause of disorganization, confined to a limited portion of the cord, by observing 
what takes place in those injuries in which the bones of the vertebral column are 
broken, or displaced. Of course I do not dwell upon these accidents, for they 
belong to surgery ; but I have seen a good many of them, and watched them with 
deep interest. The symptoms are much more uniform than when inflammation 
occurs within the vertebral canal, independently of external injury; simply be- 
cause the injury to the cord is more definite and local. But such cases are very 
valuable objects of study to the physician. I remember several that occurred 
when I was a dresser in St. Bartholomew's Hospital ; and I will state very briefly 
the particulars of one, as an exemplar. In the year 1820, a man was brought 
there who had been thrown out of a tilt cart, in consequence of a dray running 
foul of it. He had pitched upon his head, which showed, however, no trace of 
injury. When picked up, he was found to be powerless, both in the upper and 
lower extremities. His stools passed from him without his being aware of it, and 
it was necessary to use the catheter to empty his bladder. He breathed entirely 
by the diaphragm — that is, his thorax was motionless, and his abdomen rose and 
fell with every alternate act of inspiration and expiration. These symptoms are 
perfectly distinctive of injury to the cord between the origins of the phrenic and 
intercostal nerves. He suffered pain about the middle part of the neck behind. 
He went on exceedingly well for four or five days, and then the nurse very fool- 
ishly acceded to his request to be turned on his side, which caused his death in a 
very few minutes. This is not the only instance that I have known, in which 
life has been suddenly extinguished by similar imprudence. The lesson may be 
useful. There was another patient in the same hospital, who had fractured the 
cervical portion of the spinal column. Among other remedial measures, the sur- 
geon had directed that his head should be shaved. The barber had performed 
half his task, and was turning, with his hands, the unfortunate man's head into a 
more convenient position for completing it, when he suddenly expired. The 
twist was fatal to him. 

On the examination of the body of the patient whose case I was mentioning, a 
very remarkable state of the spinal column was found. The fifth and sixth cer- 
vical vertebras were dislocated from each other without any fracture : a thing 
which has sometimes been pronounced impossible. The articular processes were 
fairly separated; and the vertebras were also forced asunder by the detachment of 
one of them from the intervertebral substance. The nervous matter of the cord 
opposite the point of dislocation was quite soft. 

There is one very common and distressing consequence of such disease of the 
spinal marrow as produces paraplegia, not particularly noted in any of the cases 
which I have related, but always to be looked for. The muscles, by means of 
which the bladder empties itself, are liable to participate in the palsy; and then 
the bladder empties itself no longer. The urine accumulates in it, and distends it, 
and even the ureter becomes distended ; and in this way not only the present but 
the prospective danger is increased. For the foundation of future disease in the 
kidneys is often thus laid, even when such distension of the bladder by its retained 
contents occurs independently of any disease of the spine; as it may do from 
stricture ; from enlargement of the prostate ; or even from the voluntary retention 
of the urine beyond a certain period, through feelings of delicacy. You are to 
look out, I say, for this distension of the bladder, and relieve or prevent it by the 
introduction of a catheter through the urethra. You must not be deceived by 
being told that the patient passes plenty of water ; that it even runs from him: 



302 



DISEASES OF THE BRAIN. 



Incontinence of urine is, in fact, in these cases, though it may sound paradoxical, 
a sign of retention of urine. The urine dribbles away because the bladder admits 
of no further distension; it overflows and runs out at the natural orifice, but the 
bladder remains constantly full and stretched. You must make an examination, 
therefore, of the hypogastric region with your hand. If you find that part of the 
belly hard and resisting, and giving out a dull sound on percussion, you may be 
sure, in these cases (where there is paralysis of the lower extremities, and the 
water dribbles away), that the bladder is full, and has lost the power of expelling 
its contents. Sometimes you may recognize the fluctuation of the urine in the 
distended bladder, and ascertain the globular shape of that organ. It will rise 
even beyond the umbilicus. But what I chiefly wished to point out to you is the 
circumstance that the bladder becomes diseased, and the urine altered in quality, 
under this state of palsy. The urine becomes thick, ropy, and alkaline, .and 
exhales a very offensive ammoniacal smell ; and the inner surface of the bladder 
is found, after death, to be thickened, red, and covered with adhesive mucus — in 
a state of chronic inflammation, in short. 



LECTURE XXVIII. 

Inflammatory and Structural Diseases of the Spinal Cord, continued. Treat- 
ment. 

Apoplexy. Its General Symptoms and Diagnosis. Different forms of the 
attack. Predisposition to Apoplexy — Natural, and Accidental. Precursory 
Symptoms. 

Allow me to repeat that the structural diseases of the spinal cord will most 
clearly reveal themselves, by their symptoms, to him who most distinctly perceives, 
and most accurately bears in mind, the physiology of that part of the nervous sys- 
tem. But to the best informed, and the most sagacious, they are too frequently 
obscure and perplexing. 

Disease occupying a portion only of the cord, but affecting the whole thickness 
of that portion, from centre to circumference, will be likely to disturb, or suspend, 
the functions of sensation and voluntary motion in all the parts supplied with 
motor or sentient nerves from that portion of the cord, and from the portion beyond 
it. So that a great variety of symptoms depend, when the amount of disease is 
the same, upon the place of the disease. A total interruption of the conducting 
function of the cord, in the neck, above the origin of the phrenic nerves, extin- 
guishes life by stopping the actions of respiration. A similar interruption in the 
cervical part of the cord, above the origin of the intercostals, but below the origin 
of the phrenic nerves, destroys life as certainly, but not so rapidly, nor in exactly 
the same manner. We find the lungs loaded with frothy serous fluid in such 
cases; we find the bladder inflamed; and, often, sloughing of the integuments and 
muscles of the nates and hips. A similar interruption below the dorsal vertebra? 
is not necessarily fatal, even when it is attended with permanent paralysis: but it 
usually is so, sooner or later. 

It is commonly believed that disease affecting the anterior columns only of thfc 
cord, will be likely to disturb, or to suspend, the power of voluntary motion in 
the corresponding parts; to produce spasm or palsy : and that disease affecting 
the posterior columns alone will be likely to alter or abolish the faculty of sensa- 
tion in the corresponding parts : to cause pain, tingling, numbness or complete 
anesthesia. But I have mentioned certain facts which contravene this opinion. 
Suspend your judgment respecting it. Neither the minute anatomy nor the 
physiology belonging to the question is yet conclusively settled. 

There seems no reason to doubt that disease affecting the lateral half only of 



APOPLEXY. 



303 



the cord will be likely to derange both the sensibility and the power of movement* 
in the corresponding parts on the same side of the body alone. 

If you impress upon your recollection the facts thus summarily stated, you will 
find in them, I think, a key to many of the phenomena which accompany, and 
denote, more or less plainly, disease of the spinal marrow. 

Inflammation of the membranes of the spine is most apt to declare itself by 
'pain, increased on motion, of the spine and of the limbs; and by rigidity and 
spasm of the muscles of the neck and back. Inflammation of the cord itself, 
which readily passes into, or rather produces, softening of its substance, is most 
commonly marked, first, with convulsive movements of some parts of the body ; 
secondly, by palsy of those parts, with or without anaesthesia. The same may 
be said of suppuration when it occurs as an event of inflammation; and the pus 
may be collected into an abscess in the nervous matter of the cord, or it may be 
diffused and mixed with softening. 

Now I need not dwell upon the treatment proper to be adopted in inflammation 
of the spinal cord and its membranes. Mutatis mutandis, it is the treatment 
already recommended in inflammation of the brain and its membranes. When 
the inflammation is acute, we must take blood freely ; from the arm, or by cup- 
ping-glasses along the sides of the spine. Blood enough may be taken by cupping 
along this tract to produce the effect of general bleeding as well as of local. Per- 
fect rest in the horizontal posture must be strictly enjoined. Mercury will 
generally be proper. 

In more chronic forms of inflammation within the spinal canal, we still have a 
capital remedy in cupping: and counter-irritation in various ways, but more 
especially by means of issues made on one or both sides of the spinous ridge, is 
also, in many cases, of most essential and unquestionable service. 

Great care must be taken, when there is palsy of the bladder, not only (as I 
admonished you in the last lecture) that the urine be regularly drawn off, but also 
that the patient be kept dry and clean: for if great attention be not paid to this 
point, sores will form where the urine remains in contact with the skin, to the 
great increase of his suffering, and of his danger. Indeed, take what pains we 
may, there is generally a strong disposition to the formation of sloughs upon the 
sacrum and hips in cases of paraplegia. They result from the perpetual pressure 
made upon those projecting points ; from the feeble state of the circulation in the 
palsied parts; and (often) from the irritation of the urine and feces, which are 
passed without the patient's consciousness. 

When the patient is kept clean and dry, and the surfaces on which the weight 
of his body has been supported begin to be red and angry, you may protect them 
by a plaster: or by rubbing them with brandy you may sometimes prevent the 
skin from breaking: or, what is best of all, you may put your patient upon one 
of Dr. Arnott's hydrostatic beds ; and then the pressure will be equally distri- 
buted over all that portion of the body which comes in contact with the water- 
proof material of the bed. 

To bring this outline of the diseased states of the spinal cord up to that point 
in which we left those of the encephalon, I may state that, like the brain, the 
spinal marrow may become hardened by chronic inflammation ; and, like the 
brain, it may be encroached upon by tumours ; fibrous, scrofulous, or malignant. 
With respect to these, all that I can now say likely to be of any practical benefit 
to you, is that the symptoms they occasion are those of slowly increasing paraly- 
sis, without fever or what is called reaction ; and that the locality, and extent, and 
effects of the paralysis, will vary according to the part of the cord in which these 
changes occur, and the depth to which they affect it. 

I proceed, in the next place, to a perfectly distinct class of diseases of the brain 
and spinal cord ; to the apoplectic affections : and especially to cerebral hemor- 
rhage, and spinal hemorrhage. 

When a person falls down suddenly, and lies without sense or motion, except 



304 



DISEASES OF THE BRAIN. 



that his pulse goes on beating, and his breathing continues, he is said to have been 
attacked with apoplexy. He appears to be in a deep sleep ; but this is not all, 
for you cannot awaken him by the same means which would rouse a healthy 
man. He is not in a state of syncope, for his pulse beats, perhaps with unna- 
tural force ; and often his face, instead of being pale, is flushed and turgid ; and 
his respiration goes on, though it may be laboured and stertorous. What I now 
denominate apoplexy, is the very same state which has so frequently been men- * 
tioned already in these lectures : it is coma occurring suddenly, or coming on (at 
least) with rapidity. What is coma ? it is that condition in which the functions 
of animal life are suspended, with the exception of the mixed function of respira- 
tion ; while the functions of organic life, and especially of the circulation, con- 
tinue in action. There is neither thought, nor the power of voluntary motion, 
nor sensation : but the pulmonary branches of the par vagum continue to excite, 
through the medulla oblongata, the involuntary movements of the thorax. When 
this upper part of the cranio-spinal axis becomes involved in the disease, and its 
reflex power ceases, the breathing ceases also, and the patient is presently dead. 

It is a common question — how would you distinguish apoplexy from the effects 
of a narcotic poison ? If you were summoned to a person in the state I have been 
describing, how could you tell whether he was affected with apoplexy, or labour- 
ing under the influence of a large dose of opium, or merely dead-drunk? Why, 
so far as the condition of the cerebral functions is concerned, you cannot discri- 
minate the one from the other. In each case there is profound coma ; but the 
cause of the coma is different in each, and you must seek to ascertain that cause 
in the history and other circumstances of the patient: you inquire whether he is 
known to have been drinking, you try if you can perceive the odour of spirits, or 
. of wine, in his breath; or you endeavour to make out whether he has been low- 
spirited, or in known difficulties ; in short, whether it is likely that he may have 
swallowed poison. But from the actual condition of his sensorial functions, you 
cannot solve the question. 

Yet let me say, thus in the outset of our remarks upon apoplexy, that it is often 
of great importance that the diagnosis should be determined. A man was found 
lying in Smithfield in a state of total insensibility, and motionless, except that he 
still breathed. He was carried into St. Bartholomew's Hospital. The house- 
surgeon thought he smelt the smell of gin in his mouth ; and thereupon very pro- 
perly made use of the stomach-pump. By means of it he discharged a large 
quantity of ardent spirit; and in the course of a few minutes the man revived, 
shook his ears, and walked away. If the gin had been suffered to remain in his 
stomach, and if the remedies of apoplexy had been vigorously put in force, the 
absorption of the poison would have been thereby accelerated ; and the debauch 
would probably have had a fatal termination. The same remarks apply still more 
urgently to the case in which opium, or any other strong narcotic poison, is lying 
in the stomach. Even when there is no great danger, either in the person's state, 
or in the remedies, used for it, it is not a very pleasant or creditable thing to make 
a false point of this kind. If we do err, however, we had better err on the safe 
side. The father of the late Professor James Gregory, of Edinburgh, (who used 
to relate the case in his lectures,) was once called out very late in the evening to 
visit an old gentleman of that place. He found him in a completely comatose 
condition ; his wife crying, and his household all plunged in grief and distress. 
They told him that the patient, whom he now saw in a fit, had come home, and 
upon the servant's opening the door to him, had fallen into the passage, on his 
back, in a state of insensibility. Dr. Gregory learned, however, that he had been 
at the- "Club," and he knew well enough that this club was composed of choice 
spirits, fond of their cups ; although the gentleman's wife did not know as much. 
Therefore he ventured to express his " hopes" to the wife that her husband was 
drunk : a charitable view of the case, at which she was extremely affronted and 
indignant. He persisted, however, in his opinion, and not long afterwards the 
patient began to recover his senses. It turned out that he had partaken more 



APOPLEXY. 



305 



liberally than the rest of the club, and was the first to be intoxicated. Two of 
his companions carried him home quite incapable of motion ; but not liking to 
introduce him themselves to his wife in that predicament, they placed him with 
his back against the door, rang the bell, and decamped. Of course when the ser- 
vant came to open the door, his master tumbled senseless on the floor. I need 
not point out to you the ridicule which the physician would have brought upon 
himself, and the damage he might have inflicted upon his patient, had he busily 
applied, in this case, the ordinary remedies of apoplexy. 

The state of coma, such as I have described as being characteristic of apoplexy, 
may terminate in one of three ways. It may cease, more or less rapidly, and 
leave the patient in perfect health. What is the exact condition of the encephalon 
during the continuance of the coma, in such cases, no one can positively tell. But 
the occurrence of temporary coma, under the influence of a narcotic poison, and 
the perfect disappearance of the coma as the effects of the drug pass off, teach us 
that the functions of the brain may be almost totally suspended for a time by causes 
which do not injure its texture. It is possible that, when there is no poison at 
work, the coma may depend upon that presumed disturbance of the balance of 
the arterial and venous circulation within the cranium, which I mentioned in a 
former lecture. It may be that the force and rapidity of the circulation in the 
cerebral vessels undergo some great alteration. It is still more probable (to my 
mind) that a temporary stress upon the cerebral blood-vessels (produced by a de- 
termination of blood towards the head, through the arteries, or by a detention of 
blood in the obstructed veins) may really exercise pressure enough to cause tran- 
sient coma. But these are mere conjectures. 

In the second place, the apoplectic coma may terminate, more or less quickly, 
in death. And on examining the brain, we may find a large quantity of extrava- 
sated blood; or a considerable effusion of serous fluid in its ventricles, or beneath 
the arachnoid ; or we may detect no deviation whatever from the healthy structure 
and natural appearance of the organ. The congestive pressure (if it indeed existed) 
has left no prints of its action. 

Fatal coma, without obvious disease in the brain to account for it, results, not 
unfrequently, from an inbred poison, of which the agency was not recognized 
until a recent period: the poison of unpurified blood. When speaking of the 
general pathology of dropsy, I mentioned a peculiar renal disease — first detected 
and described by our distinguished countryman, Dr. Richard Bright — which unfits 
the kidney for what is probably its most important office : that of removing urea 
from the system. When this excrement, thus retained, accumulates in the blood 
beyond a certain amount, it is very apt, among other injurious tendencies, to cause 
death in the way of coma. 

Dr. Abercrombie has given to that form of apoplexy, which destroys life, but 
leaves no traces behind it, the name of simple apoplexy. And this name, for its 
convenience, I shall retain. Of the other two kinds of quickly fatal apoplexy, 
that in which blood is found extravasated, is more common than that in which 
there is effusion of serum only. The one has been called sanguineous apoplexy; 
a better term is cerebral hemorrhage : the other has been named serous apoplexy. 

Thirdly, the apoplectic coma may terminate in partial or imperfect recovery. 
One or all of the cerebral functions may be left impaired; the mind enfeebled; 
the power of motion limited or lost in some parts of the frame; the faculty of 
sensation benumbed or extinguished : the unhappy subject of the attack remaining 
more or less crippled in body, and more or less maimed in intellect. In these 
cases, when at length we have an opportunity of examining the brain, we almost 
always find that there has been extravasation of blood, to a small or moderate 
extent. I say almost always, because I have myself, in more than one instance, 
carefully looked for such appearances, after such a series of symptoms, without 
finding them. Occasionally, instead of a clot of blood, we meet with circumscribed 
softening of the brain. 

The attack of apoplexy does not always occur in the same manner : and Dr. 
20 



306 



DISEASES OF THE BRAIN. 



Abercrombie has pointed out three several ways in which it is apt to come on. I 
am confident, from the result of my own observation, that the distinctions laid 
down by Dr. Abercrombie are just and true; and it is of importance that you 
should be aware of them. " In the first form of the attack, the patient falls down 
suddenly, deprived of sense and motion, and lies like a person in a deep sleep ; 
his face generally flushed, his breathing stertorous, his pulse full and not frequent, 
sometimes below the natural standard. In some of these cases convulsions occur ; 
in others, rigidity and contraction of the muscles of the limbs, sometimes on one 
side only." 

Now respecting persons seen in this condition, the immediate prognosis is 
uncertain. Some die in a short time, and much blood is found extravasated 
within the cranium. Some die after a rather longer interval, and then we often 
find serous effusion only, and that of no great amount. And in some that die 
early, no effusion either of blood or of serum can be detected. Some recover 
altogether, without any ill effect of the attack remaining. Others recover from 
the coma, but are left paralytic of one side, and with some imperfection of speech, 
or of one or more of the senses. And this paralysis and imperfection may dis- 
appear in a few days, or gradually subside, or remain for life. 

In the second form of the attack, the coma is not the earliest symptom. The 
disease generally begins with a sudden attack of pain in the head. The patient 
becomes pale, faint, and sick, and usually vomits; and sometimes, but not always, 
falls down in a state of syncope, or resembling syncope, with a bloodless and cold 
skin, and a feeble pulse. This also is occasionally accompanied by some degree 
of convulsion. Sometimes he does not fall down, the sudden attack of pain being 
accompanied only by slight and transient confusion. In either case he commonly 
recovers in a short time from these symptoms, and is quite sensible, and able to 
walk; but the headache does not leave him. After a certain interval, which may 
vary from a few minutes to several hours — and Dr. Abercrombie records cases in 
which it was even much longer — the patient becomes heavy, forgetful, incoherent, 
and sinks into coma, from which he never rises again. In some intances, paralysis 
of one side occurs; but perhaps more often, there is no palsy observed. 

The disease, when it comes on in this way, is much more uniform, and of much 
worse omen, than when it commences after the former fashion. It is of great use 
to know this ; for to an inexperienced eye the cases do not seem so terrible as those 
in which the patient becomes profoundly comatose from the very first. The appa- 
rent amendment is fallacious, and apt to lead one into giving a false prognosis. 
Very few persons come out of the coma, and a large quantity of blood is usually 
found extravasated in the brain. These cases are not, as Dr. Abercrombie well 
observes, apoplectic in the outset. They differ remarkably from the first set of 
cases. If there be at the very beginning some loss of sense or motion, it goes off 
again in a very few minutes, or perhaps in a few seconds : the prominent symp- 
tom, at the commencement, is sudden and violent pain in the head, with faintness, 
sickness, and often with vomiting. The pain continues, and is sometimes con- 
fined to one side of the head ; the face is pale and ghastly, the pulse weak, and 
often frequent or irregular; but the patient is quite conscious, and in full posses- 
sion of his intellect. At length he recovers his natural temperature, his counte- 
nance improves, and the pulse becomes stronger and steadier: then his face gets 
flushed, he feels oppressed, answers questions slowly, and at last sinks into stupor 
and fatal coma. The period between the first attack and the commencement of 
the coma is variable. Sometimes the stupor succeeds the pain and faintness so 
rapidly, that the case comes greatly to resemble those in which coma is the first 
symptom, and takes place suddenly ; but still a short period of sense, commonly 
with complaint of great pain, may be observed. But the interval may be a 
quarter of an hour, or many hours, or even two or three days. " Upon inspec- 
tion," says Dr. Abercrombie, " we find none of those varieties and ambiguities, 
which occur in the apoplectic cases, but uniform and extensive extravasation of 
blood." [I should state that he calls the first class of cases apoplectic cases, the 



APOPLEXY. 



307 



coma being present from the first: and the second class, which we are now con- 
sidering-, he calls cases not primarily apoplectic.'] The symptoms in this form 
of attack depend, no doubt, upon the giving way of some one of the cerebral 
vessels. At the moment when the vessel is ruptured, a shock is given to the 
brain ; a temporary derangement of its functions occurs ; but this passes off. The 
circulation then goes on as before, until such a quantity of blood has escaped from 
the ruptured vessel as is sufficient to produce coma. There is no part of Dr. 
Abercrombie's book more admirable and clearly put than that which is, occupied 
with these important distinctions, which I give you very much in his own words. 
He points out the close analogy which exists between this variety of apoplexy, 
and the result of external injuries, when they occasion extravasation of blood on 
the surface of the brain. The hurt person recovers from the immediate effects of 
the accident, walks home perhaps, and after some time becomes stupid, and at 
last comatose. The surgeon trephines the skull, and discovers blood upon the 
dura mater; and the blood being removed, the coma goes off. We cannot help 
our patients by a similar expedient; though the opinion has been broached that 
trepanning the skull will, at some future period, be a common practice in apo- 
plexy. Dr. Abercrombie conjectures that after the rupture has taken place, the 
hemorrhage is sometimes stopt by the formation of a clot at the orifice in the 
vessel, but at length the blood bursts out again, and proves fatal. He relates two 
cases in which this probably happened; in one of them an interval of three days, 
and in the other an interval of a fortnight, elapsed between the first attack, and 
the supervention of coma. The portions of blood extravasated at the two distinct 
periods may sometimes be distinguished by their appearance — their colour and 
consistence. 

The third form of attack is characterized by sudden loss of power on one side 
of the body, and frequently by loss of speech, without loss of consciousness ; or 
at most with a very temporary suspension of consciousness. The patient is sen- 
sible, listens to and comprehends your questions, and answers them as well as 
he is able, either by words, which in most cases he articulates imperfectly, or by 
gestures. The further progress of the cases that commence in this way is marked 
by considerable variety. Sometimes the hemiplegia passes gradually in a short 
time into apoplexy. Sometimes the patient soon gets well, the palsy leaving 
him entirely. Or a gradual recovery takes place, which is not complete for some 
weeks or months. Or the patient rallies up to a certain point, and there the 
improvement stops ; he regains the power of moving his leg, but it drags some- 
what after him ; or the leg recovers, but the arm remains feeble, or his speech 
continues to be inarticulate. And in another variety of this form the patient 
neither improves on the one hand, nor becomes apoplectic on the other, but is 
confined to his bed, paralytic, and perhaps speechless, though in possession of 
his faculties in other respects, and dies at last worn out and exhausted, some weeks, 
or months it may be, after the attack. In the outset of these cases there is not 
always complete hemiplegia, sometimes the arm only is affected, sometimes (but 
much more rarely) the leg only. Or some other voluntary muscles are the first 
to lose their power. 

Now the appearances discovered after death, in cases that have thus commenced 
(Dr. Abercrombie calls them the class of paralytic cases), are, as in the apo- 
plectic cases, inconstant. Much the most common of all — according to my own 
experience — is the extravasation of blood, to a moderate or small amount, and 
definite extent, in the substance of the brain. But sometimes nothing is found, 
upon dissection, to account for the symptoms, or slight serous effusion only. 
The same symptoms attend some cases of softening of the brain also; or inflam- 
mation and its consequences. In a vast majority of cases, I repeat, this sudden 
hemiplegia marks an attack of cerebral hemorrhage. 

You will not find that all cases of apoplexy commence exactly in the one or 
the other of the three ways which I have been describing. But most attacks 
range themselves in one of these classes, and by attending to the points of dis- 



308 



DISEASES OF THE BRAIN. 



tinction, I make no doubt that you will often derive much assistance from them in 
regard to diagnosis and prognosis ; and that the distinctions themselves will give 
a higher interest to your study of this complaint, than it would possess if all the 
forms of attack were jumbled together in one common description. 

In treating of this large subject, this multiform disease, the main points will 
best be made intelligible by my breaking what I have to say into separate heads. 
I have told you the different ways in which the disease may make its assault. I 
will next say something of the persons who are most liable, cseteris paribus, to 
attacks of apoplexy : and afterwards of the symptoms which in many cases, 
though not in all, precede the seizure, and lead us to fear that it may be impend- 
ing. It is of great importance to attend to these threatenings ; for, as you will 
readily conceive, the chief good that medicine can do in such cases, is in the way 
of prevention. After the attack has taken place, the effect of our treatment must 
be very uncertain. A large effusion of blood upon the brain will be fatal in spite 
of us : and a smaller amount of extravasation we cannot remove ; and the best 
that the patient can expect in too many cases, is long-continued or permanent 
palsy, a weakening of the mental powers, and sometimes a state nearly approach- 
ing to idiocy. Also, when once an apoplectic fit has happened, it is the more 
likely, on that very account, to happen again. These are quite sufficient reasons 
why we should not neglect the warnings; the symptoms which are apt to pre- 
cede and herald the attack of apoplexy. 

The classes of persons in whom, cseteris paribus, attacks of apoplexy are 
especially to be apprehended, are those whose ancestors have suffered the same 
disease ; those who possess a particular conformation of body; and, above all, 
those who have reached a certain period of life. No doubt apoplexy may and 
does occur in persons whose progenitors have escaped it ; in persons of every 
conceivable shape and make ; and in persons of all ages. But it is much more 
frequent in the classes I have specified, than it is among persons not comprehended 
in those classes. _ 

The first and second class sometimes concur, i. e., a particular conformation of 
the body is transmitted from parent to child, and with it is transmitted a proclivity 
to apoplectic disease. But even when there is nothing particular in their bodily 
form, or in their habits of life, practical men of large experience declare that they 
who come of an apoplectic stock are themselves more than ordinarily liable to 
apoplexy. 

The pattern of body which is most prone to apoplexy is denoted by a large 
head and red face, shortness and thickness of the neck, and a short, stout, squat 
build. This remark is as old as the time of Hippocrates. However, apoplexy 
is common enough in men and women who are thin, and pale, and tall. Cseteris 
paribus, corpulent people are more in danger of apoplexy than spare people ; but 
it attacks both the one and the other. 

Advanced life is certainly a very strong predisposing cause, and the reason of 
this will be apparent when we come to inquire more particularly into the morbid 
appearances presented after death by apoplexy. The disease begins to be com- 
mon after 50 : but it does sometimes occur even in young children. I am speak- 
ing principally of that form of apoplexy which depends upon cerebral hemorrhage, 
which is by far the most frequent of all its forms. 

Of sixty-three examples of cerebral hemorrhage, collected and carefully ex- 
amined by Rochonx (who has written a very good treatise on this affection), two 
only happened between the ages of 20 and 30 ; eight between 30 and 40 ; seven 
between 40 and 50 ; ten between 50 and 60 ; twenty-three (or more than one- 
third of the whole) between 60 and 70 ; twelve between 70 and 80 : and one 
between 80 and 90. To analyze this table a little further: it appears that of the 
sixty-three cases seventeen only took place before 50 ; forty-six after that age. 
There are also twice as many victims to the disease between the ages of 60 and 
70, as between 70 and 80. And from this fact Rochonx has drawn, I conceive, 
an erroneous conclusion ; and I mention it that, in case his treatise falls in your 



APOPLEXY. 



309 



way, you may not be led by it into what I imagine would be a mistake. There 
being twenty-three cases between the ages of 60 and 70, and only twelve between 
the ages of 70 and 80, Rochoux infers from this that the disposition to cerebral 
hemorrhage decreases after the age of 70 ; which would be a most unaccountable 
thing, and quite inconsistent with what I believe to be the true pathology of the 
disease. But I make no doubt that the difference in the actual numbers observed 
in these two decennial periods depended upon the number of persons alive, at the 
same time, of the ages of 60 and 70 respectively. There are always more persons 
living whose age ranges from 60 to 70, than from 70 to 80; and therefore more 
persons die of apoplexy in the former period. In all probability, if the exact 
truth could be ascertained, of a given number of persons, there are more attacked 
with apoplexy between 70 and 80 than between 60 and 70. 

All these three kinds of predisposition are beyond our power. We cannot ex- 
terminate the hereditary tendency; nor remodel the plan upon which the body is 
constructed ; nor arrest, or put back, the clockwork of human life. But we may 
guard and caution persons, thus predisposed by nature towards apoplexy, against 
many of its exciting causes. 

A strong predisposition to apoplexy is, moreover, engendered by certain other 
diseased conditions ; and over some of these conditions our art enables us to ex- 
ercise more or less control. 

One of these I referred to just now — the kidney disease discovered by Dr. 
Bright. 

Disease of the cerebral blood-vessels is a very common and a very pregnant 
circumstance of predisposition. I shall revert to this when I describe more par- 
ticularly the anatomical characters of cerebral hemorrhage. 

Diseases of the chest influence very materially and injuriously the circulation 
in the head. Without going into detail respecting complaints with which I am 
obliged to suppose that you are as yet unacquainted, I may state, by anticipation, 
that impediments to the free transmission of blood through the heart and lungs 
constitute the mode in which thoracic disorders predispose to apoplexy. The 
plethora capitis produced by such impediments is frequently visible in the turgid 
and livid features, and in the distended jugular veins. 

The cessation of habitual discharges, of the catamenia, of bleeding piles ; the 
drying up of old sores; the healing of long established issues and setons ; all have 
an unquestionable tendency, by causing or augmenting plethora, to generate a 
predisposition to apoplexy. 

And large observation of the habits of those who fall victims to this terrible 
malady, leaves no room for doubting that intemperance often paves the way for 
its invasion. The continued abuse of ardent spirits, in particular, lays the founda- 
tion of many of those morbid conditions of the sanguiferous system, and of the 
viscera, which constitute the predisposition we are now considering. 

Among ihe premonitory symptoms, headache is of frequent occurrence : but the 
same symptom is abundantly common in persons who are in no danger of apo- 
plexy : it derives its minatory character from the concurrent circumstances. 
Headaches awaken our fears when they begin to be troublesome in advanced life. 
They are, then, still more formidable if they are accompanied by vertigo ; or, 
without any other evidence of gastric derangement, by nausea and retching. 
Sometimes, as I just now told you, severe headache ushers in, and almost forms 
a part of, the apoplectic attack. 

Vertigo itself, even without headache, is a very common precursor or warning 
of an approaching seizure. It is sometimes slight and transient; sometimes 
almost habitual. Although vertigo may depend upon other causes than mischief 
within the head, we cannot regard it without apprehension when it often occurs 
in old persons. It should teach us to obviate as entirely as we can all the known 
exciting causes of apoplexy. The principle of these I shall by-and-by describe 
to you. 

Transient deafness, or transient blindness, blindness or deafness for a few 



310 



DISEASES OF THE BRAIN. 



seconds or minutes, is another of these warning symptoms. The late Dr. Gre- 
gory, of Edinburgh, used always to mention in his lectures the case of Dr. Adam 
Ferguson, the celebrated historian, as affording one of the strongest illustrations 
he ever met with of the benefit that may be derived from timely attention to the 
avoidance of those circumstances which tend to produce plethora and apoplexy. 
It is, perhaps, the most striking case of the kind on record. Dr. Ferguson expe- 
rienced several attacks of temporary blindness some time before he had a stroke 
of palsy ; and he did not take these hints so readily as he should have done. He 
observed that while he was delivering a lecture, his class, and the papers before 
him would disappear, vanish from his sight, and reappear again in a few seconds. 
He was a man of full habit; atone time corpulent and very ruddy, and, though 
by no means intemperate, he lived fully. I say he did not attend to these admo- 
nitions ; and at length, in the sixtieth year of his age, he suffered a decided shock 
of paralysis. He recovered, however, and from that period, under the advice of 
his friend, Dr. Black, became a strict Pythagorean in his diet, eating nothing but 
vegetables, and drinking only water or milk. He got rid of every paralytic 
symptom, became even robust and muscular for a man of his time of life, and died 
in full possession of his mental faculties at the advanced age of ninety-three ; up- 
wards of thirty years after his first attack. Sir Walter Scott describes him as 
having been, " long after his eightieth year, one of the most striking old men it 
was possible to look at. His firm step and ruddy cheek contrasted agreeably 
and unexpectedly with his silver locks ; and the dress which he usually wore, ■ 
much resembling that of the Flemish peasant, gave an air of peculiarity to his * 
whole figure. In his conversation, the mixture of original thinking with high 
moral feeling and extensive learning, his love of country, contempt of luxury, and 
especially the strong subjection of his passions and feelings to the dominion of 
his reason, made him, perhaps, the most striking example of the Stoic philoso- 
pher which could be seen in modern days." 

This anecdote, which I have made use of as a wrapper for some medical in- 
struction, will not be the less acceptable to you when I add that the remarkable 
man to whom it relates was the great-uncle of my friend and present colleague in 
this school, Dr. Robert Ferguson. 

Very frequently slight and partial paralysis is the forerunner of an attack of 
apoplexy. Double vision is one form in which such limited palsy is apt to show 
itself. It is evidently connected with some degree of squinting; i. some one 
or more of the muscles that move the eyeball are paralyzed ; the person cannot 
direct each eye to the same object at the same time. This is a very suspicious 
symptom. Dr. Gregory was acquainted with a sportsman who one day, when 
out shooting, disputed with his gamekeeper as to the number of dogs they had in 
the field. He asked how he came to bring so many as eight dogs with him. 
The servant assured him there were but four; and then the gentleman became at 
once aware of his situation, mounted his horse and rode home. He had not been 
long in the house when he was attacked with apoplexy, and died. 

Sometimes the slight and local paralysis shows itself in a faltering or inarticu- 
late mode of speaking. The rapidity of the movements of the tongue requisite 
for distinct utterance is so great, that the slightest weakness of any one of its 
muscles is rendered obvious. We see this in one very common form of what 
may in truth be considered a kind of apoplexy ; viz., in drunkenness. In many 
persons the very first symptom of their becoming intoxicated is their inability to 
speak plainly. "Clipping the King's English" is the slang expression for it ; 
and the same thing often takes place in respect to the more proper forms of 
apoplexy. 

It is a curious circumstance, by the way,, and one which is illustrative of what 
we meet with in disease, that different sets of muscles are chiefly affected by ine- 
briation in different persons ; the same sets being always the first affected in the 
same persons. Thus, some men, when drunk, lose (as I have just stated) the 
proper command over the muscles of the tongue, and falter in speech, while they 



APOPLEXY. 



311 



can walk very well : others reel and stagger, having lost, in a greater or less 
degree, the power of moving and governing their limbs, and of balancing them- 
selves, who yet can speak quite fluently and plainly : and in a few cases, drunken 
persons become delirious, who still retain trie power of distinct articulation, and 
of directing their steps aright. This being so, we need the less wonder at the 
variety in the nature of the warnings that precede the apoplectic attack. 

In many instances there is numbness or debility, or total palsy of one limb, or 
of a single finger, or even of a solitary muscle, as of the levator palpebral The 
patient cannot grasp your hand with firmness, or sign his name in his usual way. 
or pick up a pin, or snuff a candle, or manage an obstinate button, or tie a knot in 
a thread cleverly : or, perhaps, one of his eyelids droops, and the eye is half closed. 
Sometimes, on the contrary, the patient stares at you, frightfully, with one eye, 
which he cannot shut. 

The numbness also assumes various characters, according to its place and de- 
gree. One patient will tell you that he feels as if one of his limbs was muffled 
in flannel; another, that he is uncertain whether, in walking, his foot has reached 
the ground or not. A gentleman, since dead of apoplexy, assured me that, when 
sitting, he did not know how far his breech covered the seat of the chair. 

All these symptoms are modifications of the function of voluntary motion ; or 
of the function of sensation. Nor are manifestations wanting, among these pre- 
cursory circumstances, of a derangement of the other and nobler function, of which 
the brain and nervous system form the material instrument. I mean the function 
of thought. 

Thus one very deplorable warning is the loss of memory. All persons find, 
as they grow older, that they do not retain so tenaciously in their recollection 
things which have recently occurred, as things which happened when they were 
young. This partly depends upon the degree of attention which we pay to dif- 
ferent circumstances. Those events which strongly excite the curiosity, and rivet 
the attention of the boy, become familiar to the man, and he gives them but little 
notice, and is very apt to forget them. But the loss of memory that threatens 
apoplexy is something more than this. It is sometimes partial, and extends to 
certain sets of things only. For example, some persons entirely forget certain 
words, while they recollect others perfectly. Common words are often thus for- 
gotten, while unusual or remarkable words are remembered ; or a wrong word is 
chosen. One word is used for another that sounds something like it. Thus one 
of my patients, meaning to accuse a certain individual of perjury, always called 
it purging: and many other words he changed after the same fashion. But in 
truth the modifications of a partial loss of memory that have been known to pre- 
cede apoplexy are both odd and endless : some people forget their own names, or 
the names of their children. Dr. Gregory, who had paid particular attention to 
these precursory symptoms, and who had a large practice for a great number of 
years to furnish them, used to mention a case of this kind. After some efforts 
his patient could recall to his recollection what his Christian name was, but he could 
not think of his surname. About twelve months after his memory began to fail 
in this strange manner, he was found dead in his bed. Another gentleman, for 
some time before his death, could never recollect the name of the street in which 
he lived. Upon one occasion of his visiting Edinburgh, he called on Dr. Gre- 
gory, and partook of a hearty breakfast, having forgotten that he had breakfasted 
before he came out. On the same day he attended, with Dr. Gregory, the funeral 
of a young lady who had been his ward ; the funeral took place in the country ; 
and when they returned together in the carriage, the doctor found that his friend 
had forgotten all that he had been doing. Next day he met him in the street, and 
saluted him with all the kindness of an old acquaintance at first meeting; saying 
he was happy to have fallen in with him now that he was in town, and totally 
forgetful of their former interviews. 

Connected with this failure of memory, there is often an unnatural degree of 
drowsiness. Sometimes, without any permanent affection of the memory, there 



312 



DISEASES OF THE BRAIN. 



is a temporary confusion or suspension of thought ; the patient suddenly loses 
the train of ideas in which his mind had been occupied; stops short in the 
middle of a sentence, and endeavours, in vain, to recover the broken thread of 
his discourse. 

Among the mental conditions that bespeak a tendency to apoplectic disease, I 
have several times noticed a strange and vague dread, of which the person can 
give no reasonable explanation ; a sense of apprehension and insecurity not ac- 
counted for by the apparent state of his general powers and functions ; a painful 
degree of indecision and irritability; with a dislike and fear of being left alone. 
One patient of mine described his " nervousness " of this kind, by telling me that 
in descending a staircase, especially a winding one, he was obliged to turn round, 
and come down backwards, as one descends a ladder; or even to sit down, and 
so slip, stair by stair, from the top to the bottom. Yet with the assurance given 
him by a friend's arm, or by a convenient baluster, he could walk down stairs 
without difficulty. He had no actual vertigo. 

I say, all these, and many other signs that indicate a disposition to apoplexy, 
are well worth your study ; because a knowledge of them may enable you to 
ward off the threatened attack by medicine, by regimen, and by admonition to the 
patient on the subject of such exciting causes of the disease as are within his own 
control. They show that, even before the stroke descends, there is some morbid 
process going on within the head. 



LECTURE XXIX. 

Apoplexy continued. Symptoms characterizing the Apoplectic State. Pressure 
the ordinary Physical Cause. Hemiplegia. Affection of Involuntary Muscles. 
Anatomical Characters. Situation of the Clot of Blood. Disease of the Cere- 
bral Blood- Vessels. 

We were engaged with the subject of apoplexy. I requested your particular 
attention to the three-fold mode in which that fearful disorder has been observed 
to make its attack. In the first, the coma is sudden and deep; the condition of 
the patient, thus struck in an instant senseless and motionless, warranting those 
epithets which the ancients applied to the victims of this disease, of attoniti and 
siderati, as if they were thunder-smitten or planet-struck. In the second form of 
the attack, the earliest symptom is acute pain of the head, with sickness and faint- 
ness ; the coma supervening usually in no long time. The third form is ushered 
in by sudden hemiplegia, which may or may not lead to loss of consciousness or 
stupor. The cases which range themselves under the one or the other of these 
three forms of attack are called respectively, by Dr. Abercrombie, apoplectic cases ; 
cases not primarily apoplectic ; and paralytic cases: and so as you bear in mind 
what these terms really imply, they appear unobjectionable. 

I next pointed out the classes of persons in whom an attack of apoplexy is 
chiefly to be apprehended : those, namely, in whose families that disease has 
been known to be common : those who have large heads, thick necks, red faces, 
square shoulders, and a short stature ; although persons of quite the opposite con- 
figuration are by no means exempt from it: and lastly, and above all, those who 
have passed the middle period of life, and are advancing towards old age : and 
more particularly is apoplexy to be apprehended in people of this description when 
they have already suffered what are called hpad symptoms ; which symptoms have 
reference to the three great functions of the brain and nervous system: voluntary 
motion, sensation, and thought. Such symptoms consist, therefore, in slight and 
often transient paralytic affections, double vision, a dropping of one eyelid, occa- 
sional inarticulate speech, weakness, perhaps, of a single finger: headache, giddi- 



APOPLEXY. 



313 



ness, unnatural sounds in the ears, numbness or tingling of the extremities, which 
last are all modifications of sensibility : some impairment of the intellect, shown 
most commonly by partial and strange defects of memory, and - temporary con- 
fusion of thought. When several or any of these symptoms occur, and espe- 
cially when they become habitual in persons in the decline of life, we have reason 
to dread the supervention of apoplexy ; and to exhort and protect our patients 
against its ascertained exciting causes. 

When the apoplectic state is fully formed, in what manner soever the attack 
may have commenced, it is marked by most or all of the following circumstances. 
The patient lies totally unconscious of all that may be going on about him. He 
replies to no questions, he is unmoved by the cries and lamentations of his family ; 
in fact, he does not hear them. His pulse is infrequent, often full, perhaps inter- 
mitting. His breathing is peculiar, being slow, sometimes interrupted or irregu- 
lar, attended with snoring or stertor during inspiration, and a puffing out of the 
cheeks, like the action of one who smokes a pipe, during expiration. Both these 
peculiarities are referable to the same principle, and both denote a profound sensi- 
bility to all external impressions. There is no longer any voluntary attempt to 
breathe, yet the involuntary movements of respiration subsist: the medulla oblon- 
gata still responds to the impressions which reach it from the lungs and from the 
skin, still prompts contraction of the muscles that enlarge the capacity of thfr 
thorax; but the loose curtain of the palate, and the lips and cheeks, are passive. 
By the vibrations of the one the stertor is occasioned ; the mouth is closed by the 
mere elasticity of the others, and the flaccid cheeks flap outwards with the explo- 
sion of the air, as it escapes when the chest again collapses. The countenance 
is frequently turgid, and livid; the blood which tinges it is already but half 
arterialized; the pupils are commonly contracted. The limbs lie motionless: 
either they are all absolutely palsied; or (what probably is often the case) the 
capacity of motion remaining, the will to move them is wanting. If you raise 
one of them it falls passively down again, when you leave hold of it, like a dead 
limb. Sometimes, however, they are rigid and stiff. Sometimes one is'stiff, and 
the others limber. And sometimes one or more of them, or those of one side, 
tremble, or are distinctly convulsed. You find perhaps that the patient is unable 
to swallow. If you put fluids into his mouth, they appear to choke him, or they 
run out again at the corners of his lips. His bowels are usually torpid; but if 
they act, the evacuations are passed in the bed without his knowledge or concern. 
His urine also flows involuntarily ; or is retained in the distended bladder until it 
fairly overflows, and dribbles away perpetually. 

When the attack terminates in death, B that event is preceded, I believe in almost 
every case, by profuse perspiration, which bursts forth from every part of the 
surface, and is often cold and clammy. The pupils are sometimes at this period 
dilated: and I have more than once seen them of unequal size. The pulse 
becomes more frequent, the breathing more rare, and at last it ceases altogether. 

In this description you will perceive that something more is included than pure 
coma. The absence of consciousness — implying the suspension of thought, of 
sensation, and of volition— marks plainly the affection of the cerebrum. The 
symptoms which diversify the apoplectic state, and distinguish one case of the 
disease from another, proceed from an associated or consecutive affection of the 
spinal cord. There may, indeed, be merely coma ; profound and invincible sopor 
only. In this condition a morsel of food, or a spoonful of drink, passed far back 
into the pharynx, is instantly carried onwards by an act of deglutition : the excre- 
ments are duly retained, and duly voided: the limbs are simply passive and 
motionless; neither stiff, nor convulsed. But in the severe cases, inability to 
swallow, laxity of the sphincters, spasms, rigidity, tremors of the voluntary mus- 
cles — more or fewer of these adjuncts to the coma — are very apt to present them- 
selves : and they denote, I say, the direct or indirect extension of the morbid 
influence on which the apoplexy depends, to the cranio-spinai axis, 



314 



DISEASES OF THE BRAIN. 



An easy and interesting criterion of the degree in which the reflex apparatus 
may be concerned has been pointed out by Dr. Hall. The orbicularis is the 
sphincter muscle of the eyelid. Touch the eyelashes, and the lids involuntarily 
close; even during sleep the movements of the shut lids are apparent. If, in 
apoplexy, they do not respond to this mechanical stimulus, we know that the true 
spinal functions are gravely implicated. 

On the other hand, many of the morbid phenomena just mentioned may occur, 
without any affection, from first to last, of the intelligence. But to these forms 
of disease, although the nature of their exciting cause may be the same, the term 
apoplexy cannot properly be applied. 

This state, so appalling and painful to look upon, but fortunately so devoid of 
suffering for the patient — this suspension of the functions of animal life — depends, 
we have reason to believe, upon pressure applied to the brain, the organ subser- 
vient to those functions. 

That excess of pressure is a vera causa is obvious, and that it is adequate to 
the production of coma is capable of demonstrative proof. It is pot enough to 
show that they often exist together, for the coincidence might be casual. Neither 
does their occasional disjunction, real or apparent, furnish any conclusive argu- 
ment against the general proposition, that coma, in many and in most cases, is 
the result of pressure upon the encephalon. 

Coma may exist without pressure. In other words, coma acknowledges other 
causes also, besides pressure. It is produced by many narcotic poisons; by the 
circulation of venous blood through the arteries. In these cases we have no proof 
of any compression of the cerebral substance. 

The other disjunctive condition is much more puzzling, and has led some per- 
sons to question or deny the general proposition. Can there be unnatural pressure, 
yet no coma? It would seem so. Serum, pus, blood, have been met with in 
the brain, foreign matters have penetrated the cranium, and coma has not occurred. 

The force of this difficulty is lessened by the consideration that foreign sub- 
stances may be present within the skull, without occasioning any preternatural 
degree of pressure. We read of bullets being carried about for some time in the 
brain. In such instances it is probable that a portion of the contents of the skull 
was forced out at the time of the injury ; or that coma has come on, and gone off 
again, in consequence of the gradual absorption of the cerebral matter to make 
room for the foreign body. The same explanation may be applied to the chronic 
accumulation of water within the cranium, and to the slow growth of tumours. 

Further, it is open to conjecture that it is not on every part of the brain that the 
same degree of pressure made will produce the effect ascribed to it. It is stated 
in Mr. Mayo's Physiology, as the result of actual experiments on animals, that 
lateral pressure against the hemispheres of the brain produces no observable ill 
consequence; but that vertical pressure, pressure downwards, occasions stupor, 
«* which is attributable to the compression of the medulla oblongata." Now it is 
obvious that some injuries of the brain may tend more than others to cause pres- 
sure in that direction. 

I confess that the difficulty is not wholly relieved by these considerations. But 
it is a difficulty which cannot invalidate the evidence of numerous facts that attest 
the agency of pressure, as, at least, one cause of coma. The presumption of such 
agency arises whenever coma immediately succeeds to pressure; and it is con- 
verted into certainty if, upon the removal of the pressure, the coma immediately 
departs. Now the annals of physic are full of instances of that kind. In experi- 
ments upon animals, stupor has been brought on, and made to cease, at the plea- 
sure of the operator, by applying pressure to the exposed brain, and by remitting 
that pressure. Nay, the experiment has been tried on the human brain itself. A 
man who had undergone the operation of trepanning, and had recovered, was in 
the habit of exhibiting himself for money in Paris, where Haller saw him. He 
suffered the spectators to make pressure upon his brain, where it was covered by 
the integuments only. This always put him into a state of coma or deep sleep : 



APOPLEXY. 



315 



but sensibility and tbe power of voluntary motion returned at once when the 
pressure was taken off. 

A most remarkable example of the occurrence of coma from pressure upon the 
brain, and of the removal of the coma by removing the pressure, was afforded by 
a patient who was in St. Thomas's Hospital under the care of Mr. Cline. Mr. 
Green, who was Mr. Cline's nephew, was in the habit of relating the case in his 
lectures here. It is quite pertinent to my present purpose. One of Mr. Cline's 
apprentices was visiting the depot at Deptford, and discovered there a man who 
had been for some time in a state of unconsciousness : and he had him removed 
to St. Thomas's. His main symptoms were apparent insensibility to all surround- 
ing objects, and a total incapacity to make any communication to those about 
him ; except that his attendants learned to infer, from certain instinctive move- 
ments or gestures, that he felt hunger, or thirst, or a want to relieve his bowels. 
His fingers were permanently bent towards the palm of the hand, andhis eyes 
were turned upwards, so that the corneas were completely concealed beneath the 
upper lids. 

Upon examining this man's head, Mr. Cline found that there had been fracture 
with depression of one of the parietal bones. He trepanned that part, and elevated 
the bone. The patient seemed to feel the operation ; and as soon as it was con- 
cluded, his eyes and fingers were restored to their natural position. On the 
evening of the same day, he sat up in bed, and though at first stupid and inco- 
herent, soon became rational and well. 

When he had entirely recovered his senses, it was ascertained that the last thing 
he remembered was his serving on board a vessel which made a capture off 
Minorca. He was wounded in the engagement, and carried afterwards to the 
hospital at Gibraltar. All this happened upwards of twelve months before the 
operation. So that one whole year of this patient's life was a complete blank, 
because, during that period, a little piece of bone was pressing upon his brain. 

Cases of this kind show very convincingly, the connection that subsists between 
pressure on the brain and coma, and their relation to each other as cause and effect. 
The pressure and the coma begin together ; the coma continues as long as the 
pressure continues; and it ceases when the pressure is removed. The old defi- 
nition of the cause of a morbid condition is completely satisfied : " Prsesens 
morbum facit, mutata mutat, sublata tollit." 

From this digression — not altogether foreign to our subject — I return to the 
consideration of the pathology of apoplexy. 

If the patient recovers from the coma, he may live a few hours, or days, or he 
may live for many years. Sometimes, as the coma departs, all the natural func- 
tions are gradually restored; but much more commonly paralysis remains. You 
already know that it is apt to affect one moiety of the body only. If a line be 
drawn from the vertex to the perineum, dividing the body into two halves, which, 
as far as the exterior is concerned, are symmetrical, all the voluntary muscles 
that lie on one side will be found powerless ; or if they are not all so, those which 
are palsied are situated on the same side of the line. And this state of things is 
called hemiplegia. Paraplegia, that condition in which all the parts below a 
transverse line are palsied, though it sometimes results from cerebral disease, is 
much more commonly the consequence of mischief in the spine. 

Now, of this hemiplegia, when it is complete, there are several particulars 
worthy of your notice; and there are many things worthy of your notice when 
it is incomplete. But we will take one of these predicaments at a time. By 
complete hemiplegia I mean palsy of all the voluntary muscles of one side. The 
patient may will the motion of his leg, or arm, but they no longer obey the act of 
volition ; if they are lifted by another, and then let go, they drop down like logs of 
wood. You will find that, in well-marked cases, the intercostal muscles of the 
palsied side do not contract. The muscles of the face, also, are some of them 
inert on the same side, I have known many persons who have thought that the 
muscles of the face, in hemiplegia? when they were affected at §11, were affected 



316 



DISEASES OF THE BRAIN. 



on the opposite side of the body from that to which the palsied limbs belonged. 
But they never could have examined actual cases of hemiplegia with any attention. 
How the error arose I cannot tell, but I have known a professed anatomist make it. 
I guess that it may have arisen from one of two causes. An anatomist who had 
not looked closely upon disease, would expect, and not unnaturally, that the face 
and limbs would be affected on opposite sides of the body, seeing that the nerves 
which supply the muscles of the face are given off above the place where those 
fasciculi of nervous matter which are called the anterior pyramids, decussate each 
other. And a common observer, who was not an anatomist, would be apt to con- 
clude that the side towards which the mouth was drawn was the affected side: 
whereas it is just the reverse. The face is drawn to the healthy side, because the 
muscles on that side are no longer counteracted and balanced by the corresponding 
muscles of the palsied side. The blank half of the face is that which answers to 
the paralyzed limbs. On that side the patient cannot frown, or smile. He presents 
a singular spectacle, which I do not dwell upon now, because I shall return to it 
again when I have to speak of certain important varieties of local palsy. What I 
wish you to bear in mind at present is, that when the muscles of the face are 
affected in hemiplegia, the rule is that they are palsied on the same side with the 
limbs. But there is no rule, they say, without an exception: certainly the excep- 
tions to this rule are very uncommon. I have not had leisure to look over the 
records of the very many cases of this disease which my position as physician to 
an hospital has brought under my observation ; but I do not recollect more than 
two exceptions ; and one of them, as it happens, is now exhibited in the person of 
one of my patients in the Middlesex Hospital. Some of you have seen the women. 
It is a well-marked exception: but in this instance the hemiplegia followed a blow 
on the head, and I suspect that a double injury was inflicted; that the palsy of the 
face results from mischief on one side of the brain, and the palsy of the limbs from 
mischief on the other. This 1 only conjecture ; because the phenomenon is so rare.* 

Then, again, with respect to the tongue: when put out beyond the lips, its 
point is commonly turned to one side. To which side? Why towards the pal- 
sied side. For what reason 1 Clearly because the muscles that protrude the tongue 
are powerless on that side, and in full vigour on the other. That half of the tongue 
which corresponds with the sound side is pushed further out than the other half, 
and therefore the tongue bends to the palsied side. Such is the usual fact, and 
such the explanation of it. But there are more numerous exceptions to this than 
to the paralysis of the external facial muscles. Sometimes the tongue comes out 
straight; sometimes the patient cannot protrude it at all ; and sometimes, even, it 
deviates towards the sound side. But the rule is as I have stated it. 

This also has been noticed of the tongue in such cases; that the patient has 
been able, after some effort, to thrust it suddenly out, and then has required a 
certain interval of time before he could do so again ; as if the spent nervous power 
was slowly regenerated. With these different affections of the tongue, the pa- 
tient's speech is variously altered. His voice is thick, muttering, inarticulate, or 
unintelligible. Sometimes, even though he may be quite conscious and rational, 
he is unable to utter a syllable ; and seems vexed at finding that his attempts to 
speak are fruitless. 

Supposing the patient to recover, wholly or partially, from the paralysis, it is 
the leg, in nine cases out of ten, ay, and in a much larger proportion than that, 
which recovers first and fastest : sooner and quicker than the arm, I mean. And 
another fact, quite analogous to this, is, that when one of the extremities alone is 
affected with paralysis, it is, in nineteen cases out of twenty, the arm that is so 
affected. I give you again ihe rules ; they are liable to occasional exceptions. 
The reasons that have been assigned in explanation of this curious circumstance 
I shall lay before you by-and-by ; after I have had an opportunity of describing 
the morbid appearances discovered within the cranium in these cases. 

* This patient died afterwards, at her own home; and no opportunity was given of 
inspecting the body. 



APOPLEXY. 



317 



This, then, is one way in which the hemiplegia may become, or be from the 
first, incomplete: viz., in extent. One limb may be powerless and the other 
strong. But the palsy may also be incomplete in degree. The patient may be 
able to move and use his limbs, but they are feeble. He cannot bend his fist 
firmly; nor lift his arm beyond a certain height. Or his leg feels heavy to him, 
and trails a little behind as he walks: he is unable to stand upon that limb; or 
to plant his foot securely, or with the usual precision. In short, there are innu- 
merable gradations of paralysis, from slight weakness of the affected muscles to 
perfect immobility. 

Besides the palsy, there is often ansesthesia also. But this is by no means so 
constant a symptom as the paralysis. The function of sensation (wherefore I 
cannot tell) is less frequently abolished or perverted than the function of voluntary 
motion. When the sensibility is lost, or blunted, or any how modified, it is so, 
commonly, in the same parts that are affected with paralysis. But sometimes 
there is ansesthesia, and no palsy ; and, more strange still, there has been some- 
times anaesthesia of one side, and palsy of the other. As a general rule, the 
ansesthesia is less common, and less intense than the palsy; and is much sooner 
recovered from. 

The mental faculties are, in some few instances, quite unhurt by the attack: 
too frequently, however, they suffer irreparable damage. Of many persons, a 
striking alteration is evident in the whole character and temper. The brave man 
has become timid ; the prudent man foolish ; the calm and cheerful man peevish 
and impatient. There is no longer the same power of attention, the same capa- 
city for business, the same clearness and comprehension of thought. And what- 
ever other changes may be observable, there are two ways, especially, in which 
the patient, after he has emerged from the coma, is very apt to be affected : viz., 
by a defection of memory, more or less partial ; and by a peculiar tendency to 
emotion, particularly the emotion of grief: he will weep for very slight causes, 
sometimes long after the attack of apoplexy has passed over. This is very curious. 
I should have stated before that the same readiness to shed tears, and to be im- 
moderately affected by trifling causes of emotion, is sometimes noticed among the 
precursory symptoms of apoplexy. 

Tracing these cases onwards still further — such cases, I mean, as do not per- 
fectly recover — we find that the palsied limb wastes. Inaction of the muscles, 
according to the principle which I explained to you in a very early part of these 
lectures, leads to lessened nutrition, and a consequent diminution of bulk : in one 
word, to atrophy. Sometimes, indeed, the size of the helpless limb is main- 
tained, or even augmented, by the supervention of oedema. The motion of the 
blood in its veins not being aided by the play of its muscles, the areolar tissue 
becomes infiltered with serous liquid. 

Again, these palsied limbs are usually colder than their fellows. This pro- 
bably is owing to the diminished circulation of blood through the capillaries : 
there is not so much blood converted into venous from arterial ; and less animal 
heat is developed. This has been observed even when the main artery of the 
part has beat as forcibly as in the corresponding part on the other side. 

It is necessary to be aware that these palsied parts do not resist the influence of 
cold or of heat so well as the sound parts. When the sensibility is blunted, we 
can readily understand how the limb may become burned, from the absence of 
any warning pain that an injurious degree of heat is applied : but this is not all. 
A lower degree of temperature than would injure a sound part has often been 
found prejudicial to a palsied part : and if these palsied parts get chilled by frost, 
they more readily vesicate and inflame, on the return of heat, than other parts : 
merely warm water will sometimes act upon them like scalding water. I say a 
knowledge of this fact is of practical moment. That degree of warmth which the 
palsied limb fails to generate for itself, we must accumulate for it by warm cloth- 
ing : and we must take care that it is never exposed to any artificial temperature 



318 



DISEASES OF THE BRAIN. 



which exceeds a certain point. We sometimes see mischief done by applying 
hot bottles or bricks — too hot — to such limbs. 

In speaking of the palsy, I have dwelt especially on the loss of action and 
power observed in the voluntary muscles ; but the strictly involuntary muscles 
do not altogether or always escape. The pulse, as I have stated, will often be- 
come slow or irregular in the apoplectic attack : and the bowels are usually very 
obstinately costive ; their peristaltic motion, which results from the contraction of 
involuntary muscles, is suspended or diminished. Now the old writers on apo- 
plexy puzzled themselves with devising explanations of the fact that the involun- 
tary muscles are so little affected in this disease. But the true reason is not far 
to seek. The involuntary muscles — so called because they never acknowledge 
the mandates of the will — appertain to the functions of organic life. Their 
movements (as I have heretofore had occasion to show you) are not necessarily 
dependent upon any influence derived from the nervous centres; and might con- 
tinue, provided a due supply of arterial blood were kept up, though there was no 
brain at all. Foetuses having no brain, nay, some unfurnished with either brain 
or spinal marrow, have nevertheless grown, in other respects, to their full size. 
It is well known that the action of the heart may go on for some time, even after 
its removal from the body. 

In truth it seems, at first sight, more difficult to explain why the organs of 
involuntary motion are sometimes affected, in apoplectic and paralytic diseases, 
than why, in general, they are not. But some elucidation of this matter I have 
also attempted to give in a former part of the course. The organs of involuntary 
motion, though not dependent upon the brain and nervous system, are yet liable 
to be influenced through their medium ; as we know by the effect produced upon 
those organs by certain emotions of mind. Dr. Wilson Philip has shown clearly, 
by his experiments, that the way to affect the action of the heart, and of the other 
involuntary muscles, through the brain and nervous system, is to act upon a large 
portion of that system at once. Hence any disease which inflicts extensive 
damage upon the encephalon will be likely to disturb and weaken the functions 
of the heart and alimentary canal. 

Conversely, when we find, in a case of apoplexy, the involuntary muscles sen- 
sibly affected, we may infer, I believe, that the injury done to the nervous matter 
is great and serious. 

Let us next, with the view of further elucidating the pathology of this disease, 
direct our attention to the appearances which are met with after death, in the 
most common forms of the complaint. 

I shall pass over those cases in which no morbid condition is detected, simply 
reminding you that the altered relation of the venous to the arterial circulation in 
the brain may perhaps account for the symptoms, and for the extinction of life : 
or the altered velocity of the blood circulating in the brain may account for them : 
or, what is more probable still, a determination of blood towards the head, or a 
detention of blood in the head, sufficient, by tightening the full vessels, to occa- 
sion extraordinary pressure upon the nervous pulp, may account for them : or the 
presence of some poisonous substance in the circulating blood (such as urea) may 
account for them. 

I pass over likewise those cases in which serum only is found effused beneath 
the arachnoid, or into the ventricles. A moderate quantity of serous fluid poured 
out rapidly during life would certainly occasion a degree of pressure adequate to 
the production of fatal coma. How the serum comes to be so effused, it is not 
always easy to say. Yet there is one condition of the blood-vessels of the brain 
which, when it can be proved to exist in a given case, is sufficient to. account for 
the effusion. Any real or virtual retardation of the blood in the cerebral veins 
would lead to what is tantamount to dropsy, there, as well as in any other part of 
the body ; and intelligible causes of such retardation are known sometimes to be 
in operation. 

But I wish to consider more particularly the appearances that are met with in 



APOPLEXY. 



319 



the brain after death by cerebral hemorrhage, which, after all, is the most com- 
mon source of apoplectic and paralytic disorders. 

In the first place (as I have more than once stated before) the popular notion 
that hemorrhage is owing to the giving way of a considerable blood-vessel — 
although this notion seldom has reference to the brain, because the blood cannot 
reach the external surface of the body, and therefore does not strike the popular 
sense — 1 say this notion is more true of cerebral than of any other hemorrhage. 
Much more true, especially as regards the brain than as regards the lungs, to 
which latter organ the bursting of a blood-vessel is, in vulgar parlance, most com- 
monly ascribed. 

This comparative frequency of hemorrhage from the actual rupture of vessels 
may, in some measure, be accounted for by their peculiarities of texture and 
relation. The blood-vessels distributed within the cranium are long and slender. 
Excepting the sinuses, the coats of both arteries and veins are thinner and weaker 
than in other parts of the body : the middle tunic of the arteries has not more 
than one-half its ordinary thickness; and the outer or cellular coat is of such 
extreme tenuity that doubts have been entertained concerning its existence. 
These vessels, moreover, are not protected, as elsewhere, by investing sheaths 
of cellular membrane, and receive but slight support from the soft and delicate 
substance by which they are immediately surrounded. They are likewise very 
subject to a particular form of disease, by which their natural fragility is much 
increased : and lying near to the heart, and in the primary direction of the blood 
as it is driven from the left ventricle, they have been thought especially liable to 
sustain the additional momentum arising from the more forcible contractions of 
that chamber; whether these are determined by occasional transient causes, or 
depend upon permanent organic disease of the heart itself. On this point, how- 
ever, I shall have something more to say hereafter. 

Still there is no reason, I think, for doubting, that hemorrhage by exhalation 
may take place, though rarely, from the free surface of the brain, or rather of its 
investing membranes. But the rule is, that it proceeds from the mechanical rup- 
ture of a blood-vessel. 

In cerebral hemorrhage, the blood may be effused in one or other of three dif- 
ferent situations ; viz., upon the external surface of the brain, i. e., upon or be- 
tween the membranes ; or into one or more of its ventricles ; or into the very 
substance of the brain itself. In the two former situations it is sometimes, per- 
haps, poured out by exhalation: in the latter, which is infinitely the most com- 
mon, it always proceeds from the rupture of one or more blood-vessels. 

It is necessary to remember that even when blood is found spread over the sur- 
face, or distending the ventricles of the brain, it frequently has not been originally 
poured out in those situations. If the hemorrhage into the substance of the brain 
be considerable in amount, the blood generally forces a passage, by laceration of 
the cerebral tissue, either into the ventricles, or (less frequently) to the surface ; 
or even in both these directions at once. 

In some rare cases blood is found effused beneath or into the pia mater, over a 
small space only, as between one or two of the convolutions, and nowhere else. 
Sometimes it is spread in a thin layer over the whole of one hemisphere, and is 
found nowhere else. Sometimes blood is discovered in one or more of the ven- 
tricles, and nowhere else ; but all these are comparatively unfrequent events. 

When the blood is effused into the substance of the brain, and does not break 
a passage out, either in the one direction or the other, its pressure is not neces- 
sarily or immediately mortal. The patient, as I have already explained, may 
survive for weeks, or months, or years ; and the clot of blood will, in the mean 
time, undergo very remarkable changes. 

The cell, or cavity, in which the extravasated blood is contained, varies much 
as to its size. It is sometimes scarcely of sufficient capacity to receive a large 
pea : sometimes it occupies nearly the whole of one hemisphere. It is seldom, 
however, I repeat, that a communication is not formed between the original cavity 



320 



DISEASES OF THE BRAIN. 



and the surface in the one direction, or the ventricles in the other, when much 
blood has been shed. Frequently a direct opening is made by the blood from 
one lateral ventricle to the other through the septum lucidum ; sometimes it passes 
from the one to the other through the foramen of Monro ; and even the chamber 
of the septum lucidum itself has been found distended by a certain quantity of 
blood. 

If the clot of blood in an isolated cavity be examined soon after its effusion, it 
is found to be of a soft gelatinous consistence, and of a dark colour, much like 
black currant jelly. The sides of the cavity are irregular and ragged; and the 
cerebral substance of which they are formed is generally, to the depth of a line 
or two, moist, soft, and as if stained of a reddish or yellowish colour, which is 
fainter in proportion as it is more distant from the coagulum, and gradually loses 
itself in the natural tint of the surrounding parts. This latter condition would 
seem to depend upon a slow imbibition of the serous portion of the effused blood, 
mixed with some of its colouring matter. It begins to manifest itself about the 
third day from the attack, and is most apparent from the eighth to the twelfth day; 
at which period, under ordinary circumstances, the whole of the serum has been 
removed, and the process of absorption seems to be in active operation. By 
degrees this stain disappears; the coagulum becomes more and more compact; 
assumes first a brownish, and subsequently a pale red or even yellowish hue ; 
diminishes continually in magnitude ; and at length may be entirely reabsorbed. 

In the mean time the walls of the cavity are becoming less uneven, and clothe 
themselves, by degrees, as they contract upon the shrinking coagulum, with a 
distinct membrane of a yellowish colour, sometimes of extreme delicacy, and 
resembling the serous membranes ; sometimes thick and apparently fibrous. 
When the opposite sides of the cell at length meet, they adhere together, and 
a true cicatrix ensues, the place of which is marked by a sort of fibrous knot, 
forming a remarkable contrast with the softer texture around it ; or less frequently 
by a similar induration of a linear form. In this case, the sides of the collapsed 
cavity are sometimes found to be merely applied to each other, without actual 
adhesion. When, from the great extent of the original cavity, or from some other 
cause, its parietes are not ultimately brought into mutual contact, there remains a 
kind of cyst, lined by a smooth yellowish membrane ; sometimes traversed by a 
few slender threads of areolar tissue which cross each other in various directions ; 
sometimes filled with a soft, fine, orange-coloured spongy tissue, in which a num- 
ber of minute blood-vessels ramify ; sometimes containing a gelatinous or serous 
liquid; and sometimes apparently empty, having been occupied by some kind of 
aeriform fluid. 

It is impossible to assign the precise period within which these remarkable 
changes may be accomplished. Dr. Abercrombie has detailed an instance in 
which a coagulum, that must have been of very considerable size, had entirely 
disappeared in less than five months. In another of his cases it was seen to be 
partially absorbed at the end of three months. " On the other hand, Moulin 
found a small coagulum not quite gone at the end of a year: and Riobe observed 
some of the blood still remaining in a cavity of small extent after twenty months. 
In two cases Serres found a hard coagulum of blood remaining; in one at the end 
of two, and in the other at the end of three years." 

It has been said that the cicatrization of the cavity takes place much more 
slowly and imperfectly when the effused blood has passed across, and torn the 
fibres of the brain, than when it has been poured out in a direction parallel to 
those fibres, so as to separate without breaking them. 

Dr. Abercrombie states that he had never seen any thing to satisfy him that 
the cysts are capable of being obliterated by cicatrization. Neither have I. But 
Dr. Sims, Dr. Bright, and several of the French pathologists of approved credit 
and accuracy, agree in their description of this obliteration of the cells. And you 
should bear in mind that a small cicatrix in the brain may very easily escape 
notice, if not expressly sought for ; especially as the examination of that organ is 



APOPLEXY. 



321 



often conducted, viz., by cutting away thick slices from the hemispheres in rapid 
succession, in order to arrive as soon as possible at the lateral ventricles, and the 
base of the brain. 

It frequently happens that a patient has suffered, during life, several distinct 
attacks of apoplexy or of cerebral hemorrhage; and that as many ceils are met 
with after death, exhibiting respectively various stages of that process of repair 
which has just been described. 

These are the changes that mostly take place in the coaguluin, and its containing 
cell, when the hemorrhage does not prove fatal, and the patient recovers more or 
less completely. But the same changes do not always, or necessarily, occur. 
Instead of being gradually removed by absorption, the extravasated blood appears 
occasionally to become a solid, organized, and consequently living mass, deriving 
its nourishment from the arteries of the brain. A man, whose case is related by 
Andral, was smitten with apoplexy, and remained thenceforward, for many years, 
hemiplegic. At length he died, of some other complaint, in the wards of La 
Charite. When his brain was examined, there was found, in one of the hemi- 
spheres, a mass of a pale red colour and fibrous appearance, traversed by numerous 
small blood-vessels which anastomosed with those of the brain : the surrounding 
nervous matter retained its natural aspect; and there was no appearance of any 
cyst. 

I have yet to mention another, and a fatal consequence of hemorrhage into the 
substance of the brain. It is not, I think, a very frequent consequence ; yet it 
deserves attention the more, because the risk of its occurrence may perhaps be 
lessened by judicious treatment in the outset. The clot sometimes provokes sup- 
purative inflammation of the cerebral matter around it : or it may be that the 
nervous pulp, being bruised or torn by the first violent irruption of the blood, 
suppurates spontaneously afterwards. It is affirmed (by what French author I 
forget) that the patient cannot be considered secure against this consecutive mis- 
chief, until eight days of safety have elapsed from the period of the apoplectic 
seizure. 

Instances of this result of cerebral hemorrhage, according to my experience, 
are not, I say, very common. I have before me some memoranda of the last 
case of it that I saw. 

I received, on the 3d of September, a note, written in a remarkably clear and 
neat hand, desiring that I would call upon the writer, as he had had a severe 
attack of apoplexy a day or two before. 

I concluded that the note had been penned by some member of the patient's 
family, and I expected to see him in his bed, paralytic probably, or manifestly ill. 
But I found a stout active gentleman, walking about in his drawing-room, appa- 
rently in perfect health, and declaring that he felt so. He showed me, however, 
a paper written by a surgeon who on the previous day had brought him to town 
from a distance, and who had been obliged to return immediately. The paper 

stated that Mr. had suffered a sudden and decided fit of apoplexy on the 

30th of August; that he was then freely bled ; that perfect consciousness was not 
restored, nor the force of the pulse subdued, till twenty ounces of blood had issued 
from his arm ; and that on the evening of the same day sixteen ounces more were 
drawn. 

My patient spoke of going down to his country-house, where he had, he said, 
" a good deal of shooting to do." I dissuaded him from this, and enjoined perfect 
quiet for at least a fortnight to come. 

The next day, after a long and imprudent conversation with a friend, he snd^ 
denly lost the thread of his discourse, and could not recover it. Then he became 
confused, and misapplied words. I asked him how he felt. He answered, " not 
quite right," and this he repeated very many times, abbreviating it first into " not 
right," and at length into " n'ight." Wishing to mention " camphor," he called 
it " pamphlet." I mention these as specimens. On the 5th it was evident that 
his right arm and leg were weak in comparison with the others ; but their sensi- 



322 



DISEASES OF THE BRAIN. 



bility was unimpaired. By slow degrees the weakness degenerated into complete 
palsy, and the right side of the face became motionless. Gradually also he grew 
heavy, stupid, comatose, unable to swallow, with a fixed pupil ; and so, on the 
morning of the 15th of September, he died. 

We examined his head the next day. On the left side, the dura mater adhered 
to the skull-cap with morbid firmness. During the endeavour made to detach it, 
a tablespoonful, or more, of a dirty-looking, greenish, very offensive pus spurted 
forth. This was found to have proceeded from an abscess, which must have con- 
tained two ounces of pus, and which was situated in the upper part of the left 
hemisphere of the cerebrum. The walls of the abscess looked as if they were 
coated with a layer of yellowish plaster. In the centre of this cavity was a small, 
fibrous, tough mass of a dull red colour ; the coagulum, doubtless, of blood effused 
on the 30th of August. In front of the abscess the brain seemed natural, but its 
consistence was that of liquid custard. 

It has long been known that hemorrhage does not occur in all parts of the sub- 
stance of the brain indifferently. Morgagni had remarked the frequency of san- 
guineous effusions in or near the corpora striata and optic thalami ; and more 
extensive subsequent research has amply verified the general correctness of his 
observation. Rochoux, in the treatise on apoplexy which I mentioned before, 
published in 1814, has given a tabular account of the morbid appearances observed 
by himself in the heads of 41 persons, dead after attacks of cerebral hemorrhage. 

In so many as 24 of these, i. e., in three-fifths of the whole number, the blood 
was extravasated in the corpus striatum ; in two others in the optic thalamus ; in 
one it was effused into the substance of both the corpus striatum and the optic 
thalamus of the same side ; and in another, beneath the corpus striatum : so that 
altogether there were 28 cases out of 41, or seven-tenths of the whole number, in 
which the clot was confined to the corpora striata, optic thalami, and their imme- 
diate neighbourhood. In the remaining three-tenths the blood was found collected 
in several other parts of the cerebral mass ; five times in the middle of one of the 
hemispheres ; twice towards the posterior part of the ventricles ; twice in the inner 
and anterior, and three times in the inner and posterior portion of the hemispheres ; 
and once in the middle lobe. 

In Andral's Pathological Anatomy you will find a much more extensive table 
relating to the same subject, and constructed by him from various authentic sources; 
It leads to the same general conclusions. Thus, among 392 cases of hemorrhage 
into the nervous substance, there were 202 (or more than one-half) in which the 
blood was extravasated at once into the corpora striata, the optic thalami, and that 
part of the hemispheres of the brain which is on a level with those bodies. In 
61 cases (or about one-seventh of the whole number) it was confined to the cqrpus 
striatum. In 35 (or one-eleventh of the whole) it was limited to the optic thala- 
mus ; making, in all, 298 instances (or more than three-fourths of the whole 
number) in which the sanguine effusion occupied the corpora striata, optic thalami, 
and their immediate vicinity. 

The result of my own observation coincides entirely with this, although I can- 
not, at present, reduce it to a numerical statement. 

From the same table we may infer also the comparative infrequency of hemor- 
rhage into the cerebellum. It is mentioned as having occurred in 21 of the 92 
cases ; or in about 1 in 19. 

Dr. Craigie states that the parts which are the seat of the hemorrhage may be 
arranged, in the order of frequency, as follows: — the corpus striatum; the optic 
thalamus ; the hemispheres ; the pons varolii ; the crura of the brain ; the medulla 
- oblongata ; and the cerebellum. 

It is natural to seek for some physical explanation of the cause which deter- 
mines the extravasation of blood in certain parts of the brain more frequently than 
in others. Some light may, perhaps, be thrown upon this inquiry, by a con- 
sideration of the sources of the hemorrhage, in the various forms of its occurrence. 



APOPLEXY. 



323 



I stated before that the blood may sometimes be poured out by exhalation, in 
those less frequent forms of cerebral hemorrhage to which M. Serres has applied 
the term meningeal apoplexy, and in which the blood is found distending the 
ventricles, or spread, like a cap, over the surface of the hemispheres, without any 
laceration of the cerebral matter. This supposition rests, however, rather upon 
the analogy drawn from what is known to occur in other parts of the body, than 
upon any decisive and unequivocal evidence. Blood has not unfrequently been 
discovered in each of these situations, when the most careful scrutiny has failed 
to trace its source to any ruptured vessel. Yet we cannot doubt that such rup- 
ture may have existed — either in some one or more of the numerous vessels of 
the pia mater, in the one case, or of the plexus choroides in the other — and yet 
have escaped detection by the most vigilant eye. In Dr. Abercrombie's book 
there are two interesting examples of extravasation upon the surface of the brain, 
without any obvious source of the hemorrhage ; the one detailed by Dr. Hunter, 
of Edinburgh, the other by Dr. Barlow, of Bath. 

That the hemorrhage proceeds from rupture of some of the vessels composing 
the choroid plexus, rather than from the membrane that lines the inner surface of 
the ventricles, when the effused blood is confined to those cavities, is the more 
probable, because the vessels have been actually found broken (as in cases of ven- 
tricular hemorrhage, described by De Haen and Cruveilhier), and because they 
are liable to well-marked disease of a nature to render them more than usually 
fragile. The arteries, for example, which belong to that plexus, are subject to a 
peculiar kind of alteration that I shall presently mention as frequently pervading 
the whole arterial system of the brain; and its veins are often partially enlarged 
and varicose. This latter condition has sometimes been mistaken for a collection 
of small hydatids. 

But hemorrhage into the substance of the brain depends always upon rupture 
of some one or more of its blood-vessels; and it is to this fact of the rupture of 
vessels that we must chiefly look for an explanation of the peculiar liability to 
hemorrhage of certain portions of the brain; the corpora striata, namely, the optic 
thalami, and the parts immediately adjacent to these. The corpora striata are not 
only of much softer consistence than most other parts of the brain, but they are 
also traversed by more numerous as well as by larger blood-vessels than are other 
parts. These facts, and the conclusions to which they point, did not escape the 
sagacity of Morgagni. " On some occasions (says he) when I have cut the corpora 
striata into pieces horizontally, I remember to have observed in the external an- 
terior part of each, a little pit, as it were, across which lay a very conspicuous 
blood-vessel. And on other occasions, upon cutting obliquely and slowly, I have 
remarked, in the same situation, many red lines, like threads, which were in fact 
blood-vessels running parallel to one another, and of a larger size than elsewhere." 
In truth, you may often notice the open mouths of a cluster of such vessels that 
have been divided. Morgagni saw in this anatomical fact a probable solution of 
the pathological fact that the parts in question are the most common seats of extra- 
vasation. In corroboration of these views it is worth remarking that the corpora 
striata are especially subject to laceration and sanguine effusion, while the sur- 
rounding parts remain unhurt, in violent concussions of the brain. And when 
injections are forced into the cerebral blood-vessels in the dead body, it is in the 
very same parts, the corpora striata above all others, that a sort of factitious he- 
morrhage is produced, by the rupture of vessels, and the escape of their contents. 

I have mentioned some original peculiarities of texture and relation, which may 
be thought to predispose the blood-vessels of the brain, more than others, to lace- 
ration. But the main predisposing cause of that event is, doubtless, their great 
liability to disease. Except the commencing portion of the aorta itself, there are 
no arteries in the body so frequently found in a morbid state as the cerebral arte- 
ries. And the change to which they are most subject is that deposition between 
their tunics, sometimes of a substance resembling albumen or soft cartilage, some- 
times of actual phosphate of lime, to which we commonly apply the term ossifi- 



324 



DISEASES OF THE BRAIN. 



cation. This earthy or cartilaginous deposit exists usually in whitish patches of 
a roundish or oblong form, disposed at various distances from each. other: some- 
times in a succession of bony rings, with healthier portions of the artery between 
them. One effect of this morbid condition is to diminish the bore of the affected 
artery, and to make it of unequal capacity. And as this variation of calibre im- 
pedes the free passage of the blood, it tends indirectly to increase the pressure of 
that fluid against the sides of the vessel. Another effect is to deprive the coats of 
the artery of their natural elasticity, and to diminish their power of cohesion : and 
thus to render them weak and frangible, and at length unable to sustain the increased 
impulse of the blood. This condition occurs in the smaller ramifications as well 
as in the larger trunks of the cerebral arteries. 

There is yet another occasional cause of hemorrhage. The arteries at the base 
of the brain are subject to aneurism, and to consequent rupture. Morgagni has 
reported cases of aneurism affecting the internal carotid and basilar arteries. 
Serres has described a case of apoplexy resulting from perforation of the basilar 
artery, which was dilated, not far from its superior bifurcation, into an aneurismal 
pouch as big as a hen's egg. Dr. Baillie records an instance where both the in- 
ternal carotids, on the side of the sella turcica, were distended into little aneurisms, 
one of the aneurisms being about the size of a cherry, the other somewhat smaller : 
and similar examples are related by other writers. I have seen two such myself; 
a beautiful preparation of one of them is preserved in the museum of the College 
of Physicians. 



LECTURE XXX. 

apoplexy continued. Belations between the Symptoms and the Jippearanees 
found in the brain after death. Exciting Causes. Prognosis. Treatment. 

I left off in the last lecture, after having described the appearances discover- 
able within the head, at different periods subsequent to an attack of cerebral 
hemorrhage ; and pointed out the various sources of the hemorrhage ; and endea- 
voured to explain how it happens that the blood so much more commonly proceeds 
from a ruptured vessel in or near the corpus striatum and optic thalamus, than in 
any other part of the brain. 

Some account of the connection traceable, in these cases, between the physical 
injury done to the brain and the symptoms, has already been* given by anticipa- 
tion. I proceed to touch upon certain points, relative to that connection, which 
have not yet been noticed. 

One of the most remarkable circumstances which dissection teaches us, when 
there has been partial palsy, is, that the palsy is on the one side of the body, and 
the hemorrhage of the brain on the other. This is a very general law. But 
exceptions to it are said to have been observed. Morgagni mentions such. Dr. 
Bright has recorded a somewhat doubtful case of exception. I have never met 
with any : and I cannot help suspecting that in some of those which are said to 
have occurred, mistakes have been made : that either they have been incorrectly 
observed, or inaccurately described. You may consider the rule as almost, if not 
altogether, universal. 

This crossing over of the morbid effect of the extravasated blood, or of any 
other diseased state, has long been attributed to that crossing over of nervous fibres 
which takes place at the upper part of the spinal cord. Just where the medulla 
oblongata and the medulla spinalis unite, the anterior pyramids decussate each 
other, and send their fibres mutually to the opposite side of the body. All this 
of course you know. The right anterior pyramid is continued into the centre of 
the left half of the spinal cord ; and the left anterior pyramid into the centre of 



APOPLEXY. 



325 



the right half of the cord. Now supposing, as we have every reason to suppose, 
that the nervous influence, whatever may be its nature, travels in the course of the 
fibres of the brain, we see in this decussation of the anterior pyramids an easy 
and pleasing solution of the phenomena in question. But then comes this serious 
difficulty. How does it happen that the muscles of the face and tongue — which 
are supplied by nerves that arise from the nervous centres above the place of de- 
cussation — how does it come to pass that these muscles sustain the same cross 
injury, and are paralyzed on the same side on which the limbs are paralyzed? 
And again, how does it happen (as it certainly does) that hemorrhage into the 
cerebellum should have a similar cross influence ? 

These seeming anomalies have never been satisfactorily explained. Indeed I 
do not know that any one has undertaken to explain them except Mr. Mayo : 
whose peculiar speculations concerning hemiplegia — first promulged, as they 
were, in this place; coming, as they do, from so eminent a physiologist; and 
being, as I deem them, in many respects, erroneous ; — demand here a brief con- 
sideration. 

He takes some pains, in the first^place, to show that the morbid influence is 
communicated from one side of the brain to the limbs of the other side of the 
body, by means of the fibres of decussation already described. This point did 
not, I think, require any laboured demonstration ; but he has made a happy use 
of two facts previously ascertained, which, taken together, afford a very neat 
proof that the transference of the morbid influence, or privation of influence, from 
one side to the other, actually takes place in that very part of the nervous system 
where the decussating fibres meet. The facts are stated by Dr. Yelloly, in the 
Medico- Chirurgical Transactions. Sir Astley Cooper divided the right half of 
the spinal cord of a dog, in the space between the occiput and the atlas; imme- 
diately, that is, after the cord has emerged from the skull through the foramen 
magnum : the result of this division of the cord was hemiplegia, paralysis of the 
limbs, on the same side with the injury. The bridge by which the morbid effect 
crosses over must therefore be above that point. We have got a limit on one 
side. And a case observed by Dr. Yelloly gives us a limit on the other. He 
examined the head of a man who had died hemiplegic ; and he found a tumour, 
as big as a filbert, imbedded in and pressing upon the right side of the annular 
protuberance. The palsy had existed on the left side. The bridge of communi- 
cation must consequently lie below that point. It must lie, therefore, between 
the two points now indicated ; i. e., it must be either in the medulla oblongata, or 
just at the junction of the medulla oblongata with the medulla spinalis. Now 
in this very interval, and here alone, a decussation of the nervous filaments is 
found to exist. There can be no doubt that the decussating fibres form the chan- 
nel of communication. 

Supposing (what perhaps is questionable) that the prevalent notion respecting 
the uses of the anterior and posterior columns is correct, Mr. Mayo next explains, 
more clearly than I have,, found it explained by any previous writer, that the 
decussation of the anterior pyramids accounts both for the palsy and for the anaes- 
thesia, which are apt to accompany cerebral hemorrhage into the opposite side 
of the brain ; inasmuch as the decussating fasciculi, on plunging into the opposite 
column of the spinal marrow, strike into its centre; and implicate themselves 
nearly as much with the posterior, as with the anterior, i. e., nearly as much with 
what is thought the sentient, as with what is thought the motor portion of the 
cord. The wonder seems to be why the numbness is not more constant; why 
it is infrequent in comparison with the affection of the voluntary muscles. 

Mr. Mayo holds that palsy does not result from "the interruption of the ordi- 
nary supply of nervous stimulation furnished by the brain" — for this reason, that 
in living animals the brain has been gradually removed, sliced away, yet sensa- 
tion, and the power of voluntary motion, have subsisted ; and that instances of 
acephalous human infants, which have survived their birth, show the medulla 
oblongata and spinal cord to be sufficient, without the brain, for the production 



326 



DISEASES OF THE BRAIN. 



of sensation and voluntary motion. He conjectures, therefore, that the immediate 
cause of the hemiplegia is " a depressing influence, or shock" (a withering 
influence he elsewhere calls it,) " originating in the brain when in certain states of 
lesion, and propagated from it to the medulla oblongata and the spinal marrow." 

Now it can scarcely be doubted, at least I cannot doubt, that the inference here 
drawn from the movements observed in acephalous monsters, and in animals after 
amputation of their brain, is a wrong inference. They are purely automatic 
movements, independent of sensation and of the will, and derived from the reflex 
endowment of the cord : and if this be so, the main foundation of Mr. Mayo's 
argument is cut away. His prime error, which has led him still further astray, 
is that of attributing sensation and volition to the spinal cord. For my own part, 
I can form no distinct conception of any positive and persistent depressing in- 
fluence, except pressure. But mere pressure Mr. Mayo repudiates; asserting 
that in many cases of hemiplegia from cerebral disease there is no pressure. And 
this may be granted : although even in cases of softening, such as he refers to, 
the mere absence of support in some parts of the brain might lead to the subsidence 
or settling down of other parts, so as to cause pressure upon the medulla oblongata. 
I took some pains, in the course of the last lecture, to show you that pressure is 
adequate to the production of coma and general paralysis ; and pressure on a 
nerve in its course we are sure is capable of occasioning local paralysis : so that 
the theory would not seem very wild, which should ascribe the hemiplegia result- 
ing from cerebral hemorrhage, or cerebral disease, to the benumbing influence of 
pressure. 

Now, if Mr. Mayo's notion, that some " shock" or " withering influence" is 
transmitted from the injured brain, could be proved to be true; or, on the other 
hand, if it could be established that this influence is no other than the benumbing 
influence of pressure; either supposition would plausibly account for these facts, 
viz., that "in general hemiplagia from cerebral lesion, the palsy of the leg is 
(commonly) less complete, and is sooner recovered from, than palsy of the arm," 
and that when one of these limbs only is affected, it is (commonly) the arm alone. 
The shock, or the pressure, would be most felt in proportion as the part was 
nearer the origin of the pressure ; and less felt in proportion as we receded from 
the source of the injurious influence. 

But, unfortunately, I was obliged to insert the word [commonly) in the state- 
ment just made of (he facts: which word Mr. Mayo does not employ. To make 
either his theory, or the theory of pressure, perfectly satisfactory, either the arm 
alone should be affected ; or the affection of the arm should always accompany 
and be more intense than, or at any rate not less intense than, the affection of the 
leg. But this is not the case. Since Mr. Mayo's observations were published, 
I have met with two or three instances and pointed them out to him, in which the 
leg alone, or the leg first, has been palsied, from cerebral disease. And Andral, 
among seventy- five cases of cerebral hemorrhage collected for another purpose, 
which I shall presently advert to, met with twelve in which the leg only was 
affected. It is a great pity that these stubborn facts should thus cross and thwart 
what might else be esteemed a very pretty theory. 

I confess that, to my mind, the phenomena of hemiplegia are the most easily 
accounted for by the very hypothesis which Mr. Mayo rejects ; viz., that the 
paralysis depends upon a simple interruption of the nervous influence, a breaking 
up, or an obstruction, of the road by which the changes leading to sensation travel 
in the one direction, and the mandates of volition in the other. We may easily 
conceive that the conducting fibres which lie between the sensorium and the 
muscles of the leg may alone be torn across, or severed by a process of softening, 
or strongly compressed, while the residue of the conducting apparatus is entire. 
This notion, of some breach, or other impediment in the channels of communi- 
cation, seems more consonant with what we know both of the physiology and of 
the pathology of the brain, than any other that I am acquainted with. 

I must not omit to give you Mr, Mayo's explanation of the other and main 



APOPLEXY. 



327 



difficulties to which I referred — viz., that when one side of the cerebrum is in- 
jured, the muscles of the other side of the face are paralyzed; and that hemiple- 
gia, resulting from disease of the cerebellum, affects also the opposite side of the 
body : — and having given you it, I shall leave it, without further comment, to 
your consideration. 

Mr. Mayo's words are: "Where the decussating fasciculi of the anterior py- 
ramid plunge into the opposite half of the spinal marrow, they are implicated, in a 
wonderful closeness of intertexture, with fibres which, in their upward course, 
bend towards the places of origin of the ninth and seventh, and of the eighth and 
fifth nerves of the palsied side. May it not be supposed that this interlacement 
may be a sufficient means of communicating the palsying influence to the ascend- 
ing fibres, which are in close relation to the affected cerebral nerves ?" 

Again, " How is the fact to be accounted for, that hemiplegia of the opposite 
side is produced by lesion of one hemisphere of the cerebellum ? I have little 
doubt that the following explanation of the phenomenon will eventually prove to 
be correct. The fibres of the anterior pyramids pass through the pons varolii. 
The pons varolii consists in great part of filaments which issue from each 
hemisphere of the cerebellum. These filaments may easily be supposed to con- 
vey a depressing influence from the diseased hemisphere. But in their course 
they come immediately upon the filaments of the anterior pyramid of the same 
side ; and they are so implicated with the latter, with such a singular closeness of 
reticulation, and often with so much that looks like an actual interchange of fila- 
ment, that it is far from unlikely that they may transmit to the descending fasci- 
culi of the pyramid a shock which may thence be communicated to the same part 
at which a cerebral lesion exerts its paralyzing force." 

I will only say further of this hypothesis, that if the explanation it furnishes of 
the facts in question be not the best and most satisfactory in the world, it is the 
best and most satisfactory that we yet possess : and that, at any rate, we may 
make use of it to bind those facts to our recollection, until some better theory 
shall be devised. 

There is one very curious law asserted, by Andral, in respect to hemorrhage 
of the cerebellum. If the blood is effused into one side of the cerebellum, and 
nowhere else, the palsy that ensues follows, I repeat, the general rule ; it takes 
place in the limbs of the opposite side of the body. But supposing hemorrhage 
to take place on one side of the cerebrum, and on the other side of the cerebellum, 
simultaneously: what then, think you, happens? Doubtless you would expect 
that there should be palsy on both sides of the body. Hemiplegia on the one 
side, from the effusion into the brain proper; hemiplegia on the other side, from 
the effusion into the cerebellum : double hemiplegia ; that is to say, general palsy. 
But it is not always so, in fact. The cerebral affection seems to overpower and 
master that of the cerebellum. Whatever the explanation may be, the palsy has 
been found to occur on the side opposite to the lesion in the brain proper ; and 
not to occur on the side opposite to the lesion in the little brain. This is a very 
singular fact, of which Andral relates four or five examples. But I suspect that 
they will ultimately take their place among the " anomalous" cases. As facts 
multiply, the law will, I conjecture, be found to be a different one. 

The complex structure of the brain, and the dissimilar consequences that en- 
sue, in different cases, from its injury or disease, leads directly to the belief not 
only that the organ subserves several distinct functions, but also that separate 
parts or sections of it hold peculiar and definite relations with other portions of 
the body. Ingenious men have even attempted to settle these points experi- 
mentally. By wounding or removing various portions in succession of the cere- 
bral mass in living animals, and comparing the results, they have endeavoured to 
assign to each portion its particular province and function. But to say nothing 
of the remarkable differences which exist between the cerebral functions in man 
and in the inferior animals, there is an unavoidable source of fallacy common to 
all such experiments. We cannot reach the particular spot in the brain upon 



328 



DISEASES OF THE BRAIN. 



which the contrived injury is to be inflicted, without penetrating and hurting 
various other parts : and from these combined injuries (dangerous, indeed, and 
often fatal in themselves) arise symptoms which the experimenter may erro- 
neously conclude to be characteristic of the lesion originally in his contemplation. 

Much more accurate and satisfactory data for the determination of this interest- 
ing class of questions, would seem to be furnished by the spontaneous operation 
of disease, and especially of the disease we are now considering. The injury 
done to the cerebral substance by the irruption of blood is not less sudden, nor 
less mechanical, than in the experiments or contrived observations to which I 
have alluded. It is capable, also, in many instances, of exact appreciation in 
regard to its extent; the parts which lie round the seat of the effusion remain 
undisturbed ; and above all, the organ that is the subject of our observation is the 
human brain itself. 

Attempts have accordingly been made to connect particular symptoms with the 
disorganization of particular parts of the brain. These attempts can boast, as yet, 
it must be confessed, but little success. Very few, if any, of the conclusions 
hitherto advanced upon this intricate subject can be relied on. Yet it is proper 
that you should be informed of them. 

Because palsy of the arm is, in general, more complete, and more persistent, 
than palsy of the leg, it has been maintained that the former, the paralysis of the 
arm, is to be ascribed to hemorrhage of the corpus striatum, which seems to be 
more common than any other ; and upon similar grounds hemorrhage of the optic 
thalamus has been supposed to determine paralysis of the leg. So much have 
these distinctions been confided in, that the honour of having first pointed them 
out has actually, in France, been made a subject of dispute. Now it is plain 
that one example of the contrary effect of these particular lesions, would suffice 
to upset the whole theory : but many such exceptions have, in fact, been no- 
ticed. It was with the view of settling this question that Andral collected and 
collated the seventy-five cases of cerebral hemorrhage to which I lately referred. 
In each of these seventy-five cases the clot of blood was sufficiently limited to 
allow of that case being applied towards the solution of the controverted points. 

In forty of the seventy-five, both the leg and the arm were paralyzed together. 
And where was the place of the hemorrhage in these forty cases? Why, in 
twenty-one of them the corpus striatum was the only part injured; and in nine- 
teen of them the optic thalamus was the only part injured. Thus you see, ac- 
cording to the theory just explained, in about one-half of the cases the arm alone 
should have been palsied ; and in about half, the leg alone : whereas both leg and 
arm were palsied in them all. 

Again, in twenty-three of the seventy-five cases the palsy was confined to the 
arm. Therefore, according to the theory, the injury should have been confined 
to the corpus striatum. What was the fact? Why, in this class of cases also 
there was as nearly as possible an equal sharing of the injury between the two 
parts. In eleven of the twenty-three the corpus striatum alone suffered ; in ten 
the optic thalamus alone ; in two the space between them. 

Once more: there were, as I slated before, twelve out of the seventy-five cases 
in which the leg alone was palsied. Consequently, in all of these twelve, if the 
theory were sound, there should have been damage of the optic thalamus only. 
But in ten of them the mischief was confined to the corpus striatum ; in two only 
to the optic thalamus. 

Gall had conjectured that the faculty of speech'was placed under the governance 
of the anterior lobe of the brain : and Bouillaud has endeavoured to support that 
opinion by a number of facts observed in connection with cerebral hemorrhage; 
but Cruveilhier has brought forward several curious instances in which the loss 
of speech was a prominent symptom, while the disease was not found in the ante- 
rior lobe, but in some other part of the brain. 

Andral, with his accustomed industry, has accumulated evidence upon this point 
also. 



APOPLEXY. 



329 



In thirty-seven cases of cerebral hemorrhage observed by himself, or by others, 
in which the morbid condition occupied one or both of the anterior lobes, the 
power of speech was abolished twenty-one times, and unaffected sixteen times. 

On the other hand, he has collected fourteen cases, in which the power of 
speech was lost, yet no alteration had taken place in the anterior lobes. In seven 
of these fourteen cases the lesion was situated in the middle lobes ; and in the 
other seven in the posterior lobes of the brain. 

There can be no doubt that there are certain distinct parts of the brain which 
influence respectively the upper and lower limbs; inasmuch as they are often 
separately palsied : and since the loss of speech is occasionally the only, or the 
most prominent symptom, while in other cases the speech is not affected at 
all, we cannot but believe that this faculty is under the special guidance of some 
definite part within the cranium. But the facts that I have just been quoting, 
show, in the most convincing manner, that we are not able, as yet, to allot these 
separate functions to their proper spots in the cerebral mass. 

I dwelt some little time, in a previous lecture, upon the circumstances that give 
warning to the patient, or to his physician, that the former is in danger of being 
smitten with apoplexy. The great use of being acquainted with these circum- 
stances, and of looking out for them, consists in the opportunity and the authority 
which they furnish, for enforcing, upon the person in whom they manifest them- 
selves, the absolute necessity of avoiding all the avoidable exciting causes of the 
disease. But our means of advising him will be very imperfect if we have not 
carefully considered what these exciting causes are. I propose to devote a few 
minutes, therefore, to the consideration of the circumstances that are apt to bring 
on the attack. There are many cases of apoplexy in which we cannot trace the 
operation of any such causes : but in many other cases their influence is decidedly 
marked; and the avoidance of them, while it is important to all who show a dis- 
position to apoplectic disease, is especially so to those who, having once suffered 
an attack, have reason to dread a repetition of it. 

In the first place, any thing which is calculated to hurry the circulation, and to 
increase the force of the heart's action, is likely to operate as an exciting cause of 
apoplexy : simply by augmenting the momentum of the blood against the sides of 
the cerebral vessels, which in advanced life are so often diseased and weak. 
Strong bodily exercise, therefore, is a thing to be avoided by all persons in whom 
the predisposition to apoplexy has declared itself. It is of much importance to 
make patients aware of this ; for many persons think, when they labour under 
uncomfortable bodily feelings of any kind, they may get rid of them by a brisk 
walk ; or by galloping some miles over the country on horseback. 

Another dangerous state for such persons arises whenever the free escape of the 
blood from the head is suddenly obstructed. I have adverted to this before. 
Certain diseases, chiefly thoracic, which tend to keep the veins of the head 
inordinately full, rank among the predisposing causes of apoplexy. But, upon 
the very same principle, various conditions, which are temporary only, may 
operate as exciting causes. By what is called "holding the breath," whether 
upon an inspiration or expiration, the transit of the blood through the lungs is 
impeded: and the check is felt (through the pulmonary artery, right chambers of 
the heart, and great veins) in the vessels of the head. And this effect is increased 
when straining is at the same time performed ; that is, when a deep breath is 
taken and retained, while some muscular forcing effort is made. 

Under this principle fall a number of bodily acts, which, however harmless in 
a healthy frame, are not without peril to a person having a predisposition to apo- 
plexy. The motion of the blood in the lungs, and therefore in the head, is 
checked in the acts of coughing, vomiting, sneezing, laughing, crying, shouting, 
and so forth. You cannot have looked at a person in a violent paroxysm of 
coughing without seeing that it produced a determination of blood to the head, or 
rather a congested state of the veins of the head. The jarring pain in the head 



330 



DISEASES OF THE BRAIN. 



which is apt to follow each succussion of the cough depends upon this principle: 
which is often strikingly illustrated in young children labouring under hooping- 
cough. They turn purple in the face, and become giddy ; and not uncommonly 
ecchymosis of the conjunctiva occurs, giving fearful evidence of what might just 
as readily take place within the cranium. It is not very unusual for the whole of 
the white part of the eye to become suddenly blood-shot in these violent fits of 
coughing; and convulsions even have happened under the like circumstances. 

Straining at stool is a common exciting cause of apoplexy in those who are 
predisposed to it. And this is one of the worst dangers attending costiveness of 
the bowels in old people : but it is one which it is often in our power effectually 
to obviate. It is more within our control than a bad cough could be. Any kind 
of straining, indeed, is equally perilous. A very good proof of this danger was 
recently afforded by a patient of my own. He was attacked with apoplexy on 
his way to Ascot races ; and upon recovering somewhat, was found to be paralytic 
on one side of the body. He was brought back to town, where I saw him. After 
some time he regained the power of using the affected limbs to a very considerable 
extent; so as to be able to walk about and follow his business, which was that of 
a job-master, or proprietor of a livery stable. I cautioned him seriously, inter alia, 
against straining : but I suppose he forgot my caution. For, while dressing one 
morning, he tugged violently in attempts to pull on a damp boot, and in the midst 
of his efforts fell back insensible : and from this relapse he never fairly recovered. 

To the same principle is to be referred a variety of things from which a 
patient, in danger of this disease, must most carefully abstain. Lifting heavy 
weights; leaping; striking a hard blow; playing on wind instruments; even 
long and loud talking. Dr. Abercrombie relates two instances of fatal apoplexy 
brought on (as it would seem) by a sustained exertion of the voice : one of the 
attacks happened to a clergyman during the delivery of his sermon ; the other to 
a literary man while speaking in a public assembly. In both cases a large quan- 
tity of blood was found extravasated within and upon the brain. Dr. James Gre- 
gory used to mention a patient of his, an officer in the army, who had apoplexy, 
and in whom the attack had been preceded by pains of the head and giddiness, 
upon his giving the word of command, and particularly when dwelling upon the 
last sound ; that is, when he made a long expiration. Precisely of the same kind 
is a case told by Van Swieten, of a singer who was obliged at length to abandon 
her vocation by reason of gradually increasing vertigo whenever she had to hold 
a high note. Violent emotion is another exciting cause. Large fires, crowded 
rooms, the heat even of the sun, favour the access of apoplexy, and therefore 
ought to be shunned by those who have a tendency to that disease. The warm 
bath is not without hazard to such persons. This is so well known, I under- 
stand, at Bath, that the physicians there will not allow paralytic patients, in whom 
the paralysis has been connected with apoplexy — hemiplegic patients, for exam- 
ple — to go into their hot baths. The excitement of drunkenness, and the vene- 
real excitement, are not uncommon causes of apoplexy, especially in old persons. 
I had a man of middle age under my care during the spring of 1837, in whom a 
most awful attack of apoplexy came on under circumstances such as I have just 
referred to. He had dined at a large festive party, and afterwards accompanied a 
woman, with whom he was acquainted, to a brothel ; and he was struck with 
palsy during the act of intercourse. He was long unable to speak ; and he still 
remains, and probably will ever remain, a cripple ; incompletely hemiplegic. 

- I have been since consulted upon the case of an old gentleman residing in 
France, in whom an attempt at sexual connection was attended with similar con- 
sequences : 

"The Gods are just, and of our pleasant vices 
Make instruments to scourge us." 

Posture, again, has no small effect upon apoplectic people. Giddiness, and 
some degree of confusion of thought, are apt to be occasioned, in most persons, 
by long stooping. There is one peculiar posture or position mentioned by Dr. 



APOPLEXY. 



331 



Folhergill as being very unsafe, especially for short-necked persons, viz., that 
position which is assumed when we turn the head to look backwards for any 
length of time, without turning the rest of the body ; in fact, a twisting of the 
neck. In this attitude the jugular veins are more or less obstructed. He gives 
an account of a man who was seized with apoplexy as he was crossing the Thames 
in an open boat; he having kept his eye fixed upon a particular ship until, and 
after, he had been rowed past her. On the very same principle, tight ligatures 
worn about the neck, and compressing the jugular veins, may bring on apoplexy; 
the wearing a tight neck-cloth, for example. A continental writer informs us that 
a Swedish officer, who was desirous that his men should look well in the face, 
caused them to wear tight stocks, and the consequence was, that in a short time 
a great many in that regiment died of apoplexy. Dr. Abercrombie quotes from 
Zitzilius the case of a boy who had drawn his neckcloth very tight, and was whip- 
ping a top, stooping and rising alternately. After a short time he fell down apo- 
plectic. The neckcloth being loosened, and blood drawn from the jugular vein, 
he speedily recovered. 

There is one very powerful exciting cause of apoplexy, in those predisposed 
to it, which I need only refer to now, because the facts that have been observed 
in proof of its agency were fully detailed in a former part of the course; I mean 
exposure to cold. You will recollect my telling you that the number of deaths 
in London from apoplexy and palsy in the month of January, 1795, which was 
a bitterly cold month, very much exceeded the number in the month of January, 
1796, which was a remarkably mild month. The cold operates in two ways, in 
the production of apoplexy. In the first place it drives the blood from the sur- 
face, and accumulates it in the large vessels of the interior of the body, and so 
increases the stress upon the cerebral arteries. And in the second place, the cold 
has a great influence in causing or aggravating affections of the chest ; and the 
return of the venous blood from the head is impeded, in the manner just now 
explained, by fits of coughing and obstructed respiration. 

This influence of external cold, and probably certain barometric conditions also 
of the atmosphere, help to explain, what I am sure I have several times had 
experience of, namely, the epidemic prevalence, now and then, of apoplectic 
seizures. 

There is an alleged exciting cause of cerebral hemorrhage, which I think it the 
more necessary to consider, because I believe that very erroneous notions prevail 
about it, even among pathologists of eminence. I allude to the imputed depend- 
ence of cerebral hemorrhage upon hypertrophy of the left ventricle of the heart. 
It has been supposed that the powerful contractions of a ventricle thus morbidly 
strong may drive forwards the blood with such unusual force, as to strain and 
burst the cerebral arteries. Dr. Hope, in his very complete work upon Diseases 
of the Heart, uses these words : — " Instances of apoplexy supervening upon 
hypertrophy have been so frequently noticed, that the relation of the two, as cause 
and effect, is one of the best established doctrines of modern pathology." Similar 
opinions are entertained by the most distinguished of the French writers on this 
subject; Andral, Bouillaud, Cruveilhier. I think they are all wrong: or that at 
least they state their proposition much too broadly and generally. 

I fully admit, no less from my own observation than upon the testimony of 
others, the frequent coincidence of hemorrhage of the brain and hypertrophy of 
the left ventricle of the heart ; but I distrust the reasoning which would always 
connect these events with each other as cause and effect. They may sometimes 
have that relation : but I have long thought that in most cases, if not in all, the 
coincidence is capable of being explained upon other and more satisfactory prin- 
ciples. 

In the first place, hypertrophy of the left ventricle of the heart is very frequently, 
far more frequently than not, accompanied by other structural changes of that 
organ: changes which imply some impediment to the circulation: changes which 
involve or influence its right chambers also. In fact, disease of the right heart is 



332 



DISEASES OF THE BRAIN. 



not very often seen, without disease of the left; and one of the commonest forms 
of alteration to which the left side is liable, is hypertrophy of its ventricle. Now 
I have already pointed out to you the connection which sometimes subsists between 
cerebral hemorrhage and such disease of the heart as obstructs the ready and 
regular descent of the blood from the head through the veins. Many of the cases 
of apoplexy occurring in persons who have previously had cardiac hypertrophy 
are, I really believe, cases of this kind. The brain affection is dependent, in 
part, upon disease of the heart, but not upon the preternatural strength of its left 
ventricle. The heart acts morbidly upon the brain through the veins, and not 
through the arteries. 

But there is another reason for the coincidence ; and here the arteries are con- 
cerned. 

No one can doubt that the momentum, with which the blood reaches the cere- 
bral arteries, in healthy persons, under violent bodily exercise or mental excite- 
ment, must often exceed the momentum produced by a hypertrophic heart in the 
cerebral arteries of persons who are tranquil and at rest. But apoplectic seizures 
are frequent under the latter circumstances, infrequent under the former. We 
must look, therefore, for something more than the mere hypertrophy to explain 
the coincidence. Now (supposing the absence of any check to the flow of blood 
from the head through the veins) that something is to be found in disease of the 
arterial system. 

When the arteries of the brain are ossified, or changed, and rendered brittle in 
the way I yesterday described, the commencement of the aorta also is found, in a 
great majority of cases, to be the seat of similar alterations; and, often, to be 
sensibly dilated. Now the mere albuminous deposit beneath its inner tunic must 
seriously impair the elasticity of the vessel; and in this way the free passage of 
the blood out of the heart will be impeded. Dilatation of the aorta at that part 
will produce the same hindrance more certainly and in a greater measure. Still 
more effectually and obviously will any contraction of the outlet prove an impedi- 
ment. It is in consequence of these mechanical obstacles to the free exit of the 
blood from the left ventricle, that the walls of that chamber, urged to more vigor- 
ous contraction, become thicker and more powerful. The hypertrophy is the 
natural compensation for the morbid state of the aorta ; without it the heart would 
much sooner become unable to propel its contents at all: and the hypertrophy 
does not often, I fancy, become greater than is needful for its purpose. The 
strength of the left ventricle, therefore, in such cases, is not a true measure of the 
force with which the blood is driven into the distant arteries. Quite the contrary. 
It is a measure of the difficulty with which the blood is circulated through the 
primary branches, and therefore through the entire system of the arteries. It 
indicates the diminished force with which the blood is likely to reach the cerebral 
vessels. And in point of fact, you will find in many cases of hypertrophy of the 
left ventricle — I do not say in all, but certainly in very many — you will find the 
pulse at the wrist to be disproportionately small and feeble. So that, in these 
cases, instead of regarding the cerebral hemorrhage as the effect of the hypertrophy, 
(acknowledging, as I do, the frequent coexistence of these morbid conditions,) I 
have been accustomed to look upon the apoplexy and the hypertrophy as concomi- 
tant effects of the same cause ; viz., of disease pervading the arterial tree. The 
hypertrophy of the left ventricle is the effect of the diseased condition of the aorta 
at its mouth ; the cerebral hemorrhage is the effect of the same diseased condition 
of the arteries in the brain. When you find each of these lesions, and nothing to 
retard the venous current, you may, I believe, safely apply this explanation of 
the occurrence of apoplexy. 

Having again referred to the frequent existence of disease in the cerebral arteries 
as a predisposing cause of hemorrhage within the brain, I will just point out, 
before I leave this part of the subject, the light which that fact throws upon the 
circumstance that sanguineous apoplexy is so peculiarly a disease of advanced 
life. Earthy concretions in the coats of the arteries are so frequent in the later 



APOPLEXY. 333 

periods of existence, that they are met with, according to Bichat, in seven indi- 
viduals out of ten of those who die beyond the age of sixty ; and Dr. Baillie con- 
sidered ossification to be much more common in old persons than a healthy state 
of the arteries. 

In the account which I have endeavoured to give you of the symptoms of apop- 
lexy, of the different modes in which the attack may commence, and of the various 
morbid appearances discovered within the cranium in the fatal cases, I have 
already embodied almost all that can be stated, with any confidence, respecting 
the special diagnosis and the prognosis of the disease. The one of these follows the 
other : the exact diagnosis being known, the prognosis is seldom difficult. By the 
diagnosis, however, I do not now mean simply the recognition of the disease as a case 
of apoplexy : of that general diagnosis, of the means of distinguishing the coma of 
apoplexy from the coma caused by opium or alcohol, I told you all that I know 
in a former lecture. But I use the term diagnosis now in a stricter sense, and in 
reference to the distinctions that exist between one case of apoplexy and another; 
and I say, that in proportion to the accuracy with which we may be capable of 
determining the precise condition of the contents of the skull, will be the facility 
of predicting the issue of the complaint. Let me remind you, then, that when a 
patient suddenly becomes apoplectic, we cannot tell whether there be effusion of 
blood, or effusion of serum, or no effusion at all within the cranium : and there- 
fore the diagnosis must be precarious and uncertain. If, after the use of suitable 
remedies, the coma persists for many hours, the prognosis becomes worse. In 
those cases which begin with pain of head, faintness, and nausea, and which pass 
on to coma, the prognosis is positively bad ; for the diagnosis is easy, and we are 
tolerably certain that a blood-vessel has given way, and that a large quantity of 
blood has ploughed up the substance of the brain. In the paralytic cases also, if 
coma supervenes, the prognosis is gloomy; but frequently coma does not super- 
vene, and then our prognosis, so far as life is concerned, may be pronounced 
favourable. 

Among the symptoms that belong to the apoplectic condition itself, there are 
some which experience has selected as being most especially of evil omen ; and it 
is well worth your while to remark that these discouraging signs relate, almost all 
of them, to the automatic functions of the cranio-spinal axis. The open, fixed, 
unwinking eye; the explosive flapping of the cheeks in expiration ; the inability 
to swallow ; the slow, sighing, interrupted breathing ; the loosening of the sphincter 
muscles of the bladder and anus ; these are fearful, and too often fatal symptoms, 
and they all depend upon the excito-motory portion of the nervous system. Per- 
haps the profuse sweat that so often attends the process of dissolution may be 
referred to the same source ; the whole tone of the various tissues being lost or 
relaxed. I would not say that no one of these symptoms is ever recovered from : 
but I may say that of twenty patients in whom such phenomena occur, nineteen 
will die. 

Now symptoms of this kind may be expected to arise, if there be hemor- 
rhage in or near the medulla oblongata ; or if there be mischief so extensive in 
the brain as to cause pressure upon the medulla oblongata. We should reason 
out the likelihood that such symptoms would be of bad augury. But the fact that 
they are so was ascertained long before the theory which accounts for them was 
devised. The fact is independent of the theory, and for that reason helps won- 
derfully to confirm it. 

The older writers entertained some very false notions in respect to the distinc- 
tion between sanguineous and serous apoplexy. They laid it down that apoplexy 
resulting from extravasation of blood within the cranium was denoted by flushing 
of the face, and strength of the pulse ; and that it was a disease of persons in the 
vigour of life : while apoplexy resulting from the effusion of serum was marked 
by paleness of the countenance, and weakness of the pulse ; and occurred in the 
old and the infirm : and they directed their practice according to this distinction. 



334 



DISEASES OF THE BRAIN. 



After what has already been said, I need not tell you that this classification of 
apoplexies could not have been founded upon the actual observation of disease: 
and that our treatment, now-a-days, is not regulated by any such erroneous theory. 

Nevertheless, I do not mean altogether to praise the modern practice in apo- 
plexy ; for it is often one of mere routine. Practitioners are too apt, in this as 
in other instances, to be guided in their choice of remedies by the name of the 
disease, and to treat all cases of apoplexy alike. I remember being much amused 
by the perplexity which a friend of mine once told me he had felt on being sum- 
moned by letter many miles into the country to see a gentleman who had been 
struck with apoplexy. As he posted down he earnestly revolved in his mind 
what he might be able to advise when he should reach the house of sickness. He 
felt confident that the patient must already have been copiously bled ; cupped, or 
leeched; blistered; and thoroughly dosed with calomel, senna, and croton oil. 
Mustard poultices had doubtless been applied to his legs. My friend was dis- 
tressed to think that while much would be expected, nothing would be left for 
him to do worthy of so long a journey, and so heavy an expense to his client. 
A clyster of turpentine might yet, perhaps, be an untried expedient. His cogi- 
tations were cut short, however, and his cares relieved, by an express which met 
him half-way on the road, to announce that the patient was dead. Now this is 
the routine of which I speak : most proper in many cases ; unnecessary in others ; 
pernicious in some. There are persons who seem to think that they have not 
done their patient justice if any part of this active intermeddling has been omit- 
ted. Others regard depletion as being worse than useless, and trust entirely to 
stimulants and cordials. These are still more dangerous routiniers than the 
others : but they are fewer in number. 

Our practice would indeed be much easier than it is, if we could thus make one 
plan fit all cases which are nominally the same. But I need not now tell you 
that diseases alike in name — aye, and alike in their essential nature — are often 
widely different in their circumstances. I formerly explained to you that certain 
symptoms tell us what the disease is ; but that we are often obliged to look to 
other symptoms, which may inform us what we are to do. I know of no rule so 
likely to guide you aright as that laid down generally by Cullen, of obviating the 
tendency to death. You must examine and judge to which of the several modes 
of dying there may be any obvious approach. If the tendency be, as in cases of 
apoplexy it mostly is, to death by coma, then blood-letting and the evacuating 
plan will generally be requisite. If, on the other hand, the tendency be to death 
by syncope, you must withhold the lancet, and even have recourse to stimulating 
and restorative measures. The question is of the last importance ; involving often 
(as Celsus taught) the alternative of life and death : " sanguinis detractio vel occi- 
dit, vel liberat." Now the distinction between these modes of dying is to be 
made by attending to the state, not so much of the nervous, as of the sanguiferous 
system. Insensibility and unconsciousness are common both to syncope and to 
coma : and cases which fall under the class of apoplexies, and which we cannot 
separate from that class, are sometimes really more like cases of concussion than 
any thing else ; the shock having been of internal instead of external origin. If 
the pulse be full, or hard, or thrilling (sometimes it feels like a tense vibrating 
rope), or if there be obvious external signs of plethora of the head, you must ab- 
stract blood. You are not to refrain from bleeding the patient because he is pale, 
if his pulse warrants it; nor may you omit taking blood if the head and face be 
turgid, although the pulse be small ; for that smallness may depend upon organic 
disease of the heart. 

On the contrary, if his skin is pale and cold, and his pulse feeble and flickering, 
you would probably ensure your patient's death, or determine the accession of 
palsy, if you withdrew from the failing heart and blood-vessels a portion of their 
natural stimulus. I can only invite your attention to these broad features of dis- 
tinction. Being once taught to look for and attend to them, your own judgment 
must instruct you as to what may be needful in particular cases. To this, as to 



APOPLEXY. 



335 



most other diseases, the remark of Boerhaave is strictly applicable, who declares 
that he knows of nothing which can be called a remedy, " quin solo tempestivo 
usu tale fiat." 

Having made up your mind as to the general indications of treatment, you will 
pursue them steadily in detail. If the patient to whom you are summoned be 
stupid and drowsy rather than faint, and his pulse and appearance warrant the 
conclusion of plethora capitis, the first thing to be done is to place him in a semi- 
recumbent position, with his head raised; to loosen any tight parts of his dress, 
especially his neckcloth and shirt-collar, and whatever might press upon the 
neck; and then as quickly as possible to bleed him from the arm. We know 
that in some cases the apoplectic state occurs, when as yet no injury has been 
done to the brain ; no effusion, no laceration of its texture ; and we may hope, by 
timely and vigorous measures, to prevent these terrible evils. We never can be 
sure that there is blood extravasated in such cases, and we must act, in the first 
instance, upon the presumption that there is not. We are especially encouraged 
to take away a considerable quantity of blood by venesection when we perceive 
external signs that the vessels of the head are full ; redness and turgescence of 
the face, throbbing and prominence of the temporal arteries, distension of the 
superficial veins of the neck and forehead. Our object is to take off the strain 
upon the internal vessels by bleeding in such a manner and to such an amount as 
shall produce a decided effect upon the general circulation. Sometimes the good 
consequence of the bleeding is very marked indeed, so that no doubt of its pro- 
priety can be entertained ; the patient being so insensible; as not to feel the 
puncture of the lancet, and yet emerging from his coma while the blood is still 
flowing. It is seldom, however, that we can expect such manifest and immediate 
melioration as this. 

After one sufficient bleeding from the arm, the vessels of the head may be 
further relieved by cupping the nape of the neck, or the temples ; and venesection 
may be repeated if the condition of the pulse, and the symptoms generally, should 
require its repetition. It is seldomer, however, in cases of apoplexy than in cases 
of acute inflammation, that a second or third recourse to the lancet becomes 
advisable: unless, indeed, the first blood-letting has been mismanaged. Enough 
blood must be taken, in the first instance, to produce some evident effect; and 
therefore no precise rules can be laid down respecting the absolute quantity to be 
drawn ; nor can we make any sure estimate beforehand as to the whole amount 
of blood which it may be necessary to remove. 

Even if we could be certain that a blood-vessel had given way, and that blood 
was already poured out upon the brain, there are good reasons why (no adverse 
circumstances withstanding) we ought to bleed our patient largely, and at once. 
I will enumerate briefly the benefits we seek to obtain by the abstraction of blood 
in such cases. 

1. The effusion from the ruptured artery may be slowly going on. Bleeding 
from a vein, so as to make a sensible impression on the general circulation, will 
diminish the stress upon the cerebral arteries, and so tend to put a stop to the 
hemorrhage. Both of these two objects are of primary importance. 

2. By early and free bleeding we lessen the hazard of inflammation supervening 
upon the mechanical injury done to the brain by the sudden tearing and contusion 
of its texture by the effused blood ; and 

3. We thereby bring the system into the most favourable condition for the 
rapid absorption of the extravasated blood, and for expediting the patient's recovery 
from those symptoms which depend upon the presence of the clot in the brain. 

But although, in that form of disease which we are now considering, bleeding 
is our sheet-anchor, it may be carried too far, or repeated too often. We must 
not lose sight of the fact that many of these patients are old, and will not survive 
undue depletion ; and that if they survive at all, they will need all the strength that 
we dare suffer them to retain for carrying on the vital actions, when the chief 
instrument of the most important of the animal functions is so greatly damaged: 



336 



DISEASES OF THE BRAIN. 



nor of the fact that if there be blood extravasated, we cannot touch it, except indi- 
rectly, by the abstraction of more blood from the arm : nor of the fact that a patient 
may be Wed into convulsions, and fatal syncope. In short, after the first free 
bleeding, you must be guided by the special circumstances of the case, and par- 
ticularly by the pulse. The woman at present in the Middlesex Hospital, with 
paralysis of the limbs on one side, and of the face on the other, attributes her palsy 
(erroneously most likely) to her having been cupped. She had had a blow some 
weeks before, and suffered headache from that time. At length she was cupped, 
from the neighbourhood of the head ; and the next morning she was paralytic. 
This might have been an accidental coincidence. But I remember being sent for 
a few years ago to see a patient at Greenwich, who had already three physicians 
about him, and was apparently in danger of apoplexy, of which he had for some 
time experienced distinct warnings. The three physicians had agreed that he 
ought to be cupped from the back of the neck ; to which I assented ; and while 
blood was being rapidly extracted in that manner, he became all at once hemi- 
plegic. Similar cases have been noticed by other persons. Therefore we are 
not to bleed without measure or discretion. 

The pulse may be small, and the arterial action feeble, while yet the veins are 
turgid, and the capillaries of the head and face loaded with blood. Changes may 
have occurred in the heart, such as to obstruct the stream which it is its healthy 
office to transmit. These are cases to which the local abstraction of blood from 
the head, by leeches and cupping-glasses, is peculiarly adapted. 

Again, the whole state of the patient may approximate more or less nearly to 
the state of syncope; the pulse being weak, the aspect pinched and bloodless, 
and the skin cool. In this condition, no good, but the contrary, is to be expected 
from blood-letting of any kind. You will do better to apply^warmth, cautiously, 
to the surface, and cautiously to administer what are called diffusible stimuli, of 
which the preparations of ammonia afford the most eligible forms. Five grains 
of the sesquicarbonate or half a drachm of sal volatile, mixed with camphor julep, 
are ordinary doses. Stand by till the first stunning effect of the internal shock 
passes off ; and carefully watch meanwhile for symptoms of reaction. 

In more ambiguous cases, when you scarcely can tell which way the balance 
inclines, I would advise you to wait the effect of the next remedies I have to men- 
tion, viz., purgatives, about giving which you need not entertain the same doubt 
and hesitation. 

Purgative medicines are of signal service in apoplexy. They empty the intes- 
tines, which are oftentimes loaded, and which, by distending the abdomen, have 
occasioned, perhaps, undue pressure against the diaphragm, embarrassed the 
breathing, and through it the cerebral circulation. Another very important pur- 
pose of hard purging, which I have frequently pointed out before, is the producing 
of copious watery discharges from the bowels, whereby the blood-vessels are 
drained, and the tendency of blood to the head especially relieved. If the patient 
can still swallow, you may give him half a scruple of calomel, and follow it up by 
a black dose. If the power of deglutition be lost, the croton oil becomes a most 
valuable remedy. Dr. Abercrombie suggests that it may be conveniently intro- 
duced into the stomach, suspended in thick gruel or mucilage, by means of an 
elastic gum tube. But really this is not necessary. If two or three drops of the 
oil be put upon the tongue, as far back as is possible, it will produce its specific 
effect very readily and well. But we are not to wait for the operation of aperi- 
ents given by the mouth. Strong purgative and stimulating enemata must be 
thrown into the rectum : half an ounce or six drachms of turpentine suspended, 
by the help of the yolk of an egg, in gruel or warm water. We very often wit- 
ness decided signs of amendment upon the free operation of a purgative. I may 
. mention one instance of this while it is fresh in my recollection. I was asked a 
few evenings ago, by a medical friend, to see an old general, a patient of his. I 
found him in bed, comatose, though capable of being roused when loudly spoken 
to ; but he presently fell off again into stupor. His respiration was peculiar. For 



APOPLEXY. 



337 



a minute or two he would breathe, snoring strongly : then the breathing would 
cease altogether for half a minute or thereabouts : and then the stertorous respi- 
ration recommenced : and so on alternately. 

He had been found by his servant on the floor, nearly insensible, in the morn- 
ing, having fallen either out of, or upon rising from, his bed. He had very pro- 
perly been cupped; and calomel and aperient medicine had been given: but the 
coma had been growing more profound all the afternoon. His bowels had been 
but scantily moved; and the feces and urine were passed as he lay. His extre- 
mities were coldish. The pulse was neither full nor strong. 

I learned that for four or five years he had had some very significant warnings ; 
and within that period had suffered one or two slight apoplectic seizures, which 
had left him with impaired mind and memory. 

I recommended blisters behind the ears, and two drops of croton oil, with two 
drachms of castor oil, in a draught. The next morning I expected to hear that 
he was dead; but I found him quite conscious, speaking somewhat inarticulately, 
with the right side of his face chopfallen and inexpressive. There seemed no 
particular weakness of the corresponding extremities. The oils had been fol- 
lowed by copious evacuations from the bowels. The day afterwards he was 
sitting up, and so well that I took my leave. 

In combination with blood-letting and purgatives, cold lotions to the head are 
often found useful in this disease, especially if its surface is hot. I need not 
trouble you by rehearsing the modes in which the application of this remedy may 
be managed. Blisters near or upon the head, are also frequently of service, after 
due abstraction of blood, in rousing the patient from his state of coma. 

Formerly, at the suggestion, I fancy, of Dr. Fothergill, it was much the fashion 
to give an emetic in the outset of the treatment of apoplexy. But this also is % 
ticklish remedy, capable of doing good or harm according as it is well or ill timed. 
If there be already extravasation of blood, or even plethora capitis, the act of 
vomiting will be likely to increase the existing mischief, and to enhance the 
danger. On the other hand it may rouse and rally the nervous power when the 
patient is pale, and cold, and faint. Yet this can never be regarded as a legitimate 
purpose of emetics in apoplexy. They can safely be recommended in those 
cases only in which the coma may appear to depend, wholly or in part, upon a 
loaded stomach. Hence the propriety of giving an emetic will deserve consider- 
ation whenever an attack of apoplexy follows close upon a heavy meal. 

When the immediate danger has passed by, and paralysis remains, we are not 
to be over busy. If the palsy is to get gradually well, it must be by virtue of 
lime, and the resources of nature. To young and strong persons I should, under 
such circumstances, give small and repeated doses of mercury : and in all cases I 
should prescribe aperient medicines, so as to keep the bowels freely open twice 
or thrice a day; enjoin perfect quiet ; and put the patient upon very short com- 
mons. Diuretics are also very proper when the urine is not plentiful without 
them. 

You will often have to contend against the ignorance and impatience of the 
sick, or of their friends, on these occasions. They think that weakness is to be 
remedied by strengthening food ; by meat and drink, and tonic medicines ; or if they 
are not so foolish as this, they will want to be electrified, or to be put into a warm 
bath. Certainly in the earlier states of the palsy that remains after apoplexy, none 
of those measures ought to be permitted. If, after some time, when all febrile 
action has ceased, the palsy seems stationary, it may be warrantable and right to 
attempt to stimulate the torpid nerves, and to accelerate the acquirement of power 
by the mind over the muscular contractions ; but when any means for attaining 
these objects are employed at all, they must be used with the utmost caution ; for 
they are much more likely to stimulate the vascular system, and so to do harm ; 
or even to renew the apoplectic attack. Electricity, and strychnia, are the reme- 
dies most relied upon. In cases of long-standing palsy, it may also, no doubt, be 
proper to try to awaken, by stimulating frictions, the dormant powers of the mus- 
22 



338 



SPINAL HEMORRHAGE. 



cles, which by protracted inaction become forgetful, as it were, rather than inca- 
pable, of their natural office : and in these old cases we sometimes are able to 
benefit our patient's condition by the cautious exhibition of some of the prepara- 
tions of iron. 



LECTURE XXXI. 

Spinal Hemorrhage. Paraplegia. Facial Palsy and Facial Jlnsesthesia ; their 
Symptoms, Prognosis, and Treatment. Other Forms of Local Paralysis, 
and Local Anaesthesia. 

I have done with apoplexy as it respects the brain; which is the same thing as 
to say that I have done with apoplexy. You will find the same term applied, 
indeed, to effusions of blood in other organs of the body ; but this use of the word 
is a perversion of language. Apoplexy, as I have frequently observed before, is 
the abolition of the functions proper to the brain; of sensation, voluntary motion, 
and thought. In short, it is coma, coming on under certain circumstances. 

I shall not speak therefore of spinal apoplexy (though that would be less im- 
proper than pulmonary apoplexy, or hepatic apoplexy), but of spinal hemorrhage. 
Of this I really have little to say, except that it is well known occasionally to 
occur; and that the symptoms to which it gives rise are by no means peculiar or 
distinctive. They consist of pain in some part of the spine ; convulsions ; palsy ; 
that is, they are the very same symptoms which inflammation, softening, me- 
chanical injury, and other disorders of the same part may produce. Spinal 
hemorrhage is much more rare than cerebral hemorrhage. Dr. Abercrombie had 
met with only one case of it. He gives the heads of seven others which have 
been recorded by different authors. Dr. Bright has never seen it: but he pub- 
lishes the particulars of one case, which were communicated to him by Dr. 
Stroud. 

I will read you one or two short examples of spinal hemorrhage, as specimens. 
A girl, fourteen years old, was attacked with headache, pain in the back, and a 
tendency to sickness when in the erect posture. At the end of a week the pain 
in the back became suddenly and very greatly aggravated ; and this was followed 
by general convulsions, which proved fatal in five or six hours. The spinal canal 
was found filled with extravasated blood, in the lumbar region, where she had 
felt the pain. The brain and all the other viscera were sound. The case is 
detailed by Mr. Chevalier in the third volume of the Medico- Chirurgical Trans- 
actions. 

Take one more instance from Ollivier, whose work on the spinal marrow you 
may read hereafter, when you have leisure, with advantage. 

A gentleman, aged sixty-one, had just arrived in Paris after a long journey, 
when he was seized with pain of the back, all the way down from the cervical 
vertebras to the sacrum. In the course of a few hours he became paraplegic, and 
was unable to retain his urine or feces. He then sent for a physician, and died 
while talking to him. A very extensive extravasation of blood was found in the 
spinal canal, beneath the membranes of the cord. The lower part of the canal 
was filled with a bloody mass, in which the substance of the cord could not be 
distinguished. Above the third dorsal vertebrae the cord was entire, but of a 
deep-red colour, and very soft. 

The suddenness of the symptoms may lead you to suspect the true nature of 
these cases; but I cannot pretend to point out any other feature by which they 
may be distinguished from other morbid conditions of the spine, already spoken 
of. I show you one preparation ; of which, however, I do not know the history. 



PARAPLEGIA. 



339 



I have nothing to add, to what I have already said, respecting that species of 
palsy which is called hemiplegia: and I have only a very few further observa- 
tions to make in regard to paraplegia. 

The cause of this kind of palsy is sometimes obvious; sometimes most obscure. 
If we find, in the spinal canal, blood effused, softening of the substance of the 
cord, traces of inflammation of its investing membranes, tumours pressing upon 
it, pressure from disease or displacement of the bones, we have a sufficient expla- 
nation of the paralysis of those parts of the body, the nerves of which come from 
the spinal marrow at or below the place of the disease. There are three prepara- 
tions on the table of tumours that pressed upon the cord ; scrofulous tumours I 
believe they are : each of the three persons from whose bodies they were respect- 
ively taken was more or less completely paraplegic. 

But in very many cases we detect no alteration that seems adequate to explain 
the paraplegia. The palsy creeps on slowly and insidiously, without any par- 
ticular pain, or violent symptoms: there is no tenderness or bending of the verte- 
brae. The weakness commences mostly in the legs, which appear to the patient 
heavier than usual, and of which the healthy sensations are often perverted. The 
toes tingle, or are numb: he experiences a feeling in them as if a number of ants 
were crawling on the skin. This is so common a circumstance as to have given 
a name to the symptom, formication. The patient straddles as he walks. His 
legs are lifted awkwardly, the toes being often the last part to quit the ground : 
they are then flung obliquely forwards and outwards, and the feet flap down 
heavily and uncertainly at every step. By degrees the weakness of the lower 
limbs increases: the palsy creeps upwards, affects the bladder and rectum, at 
length invades the arms, and ultimately the patient dies: yet very faint traces of 
disease, or no traces at all, may be visible upon inspecting the brain and spinal 
cord. The commonest morbid condition is softening of some portion of the 
cord ; and this is also the condition which is the most liable to be overlooked. 

Very recently I had a patient with these symptoms in the Middlesex Hospital. 
He went out contrarily to my wishes ; he was discharged, in fact, by mistake : 
he took refuge in St. Bartholomew's, where he died after a few days. I have 
been informed that serum was found beneath the arachnoid, and that the whole 
brain had a wasted appearance ; but nothing satisfactory was made out. The 
palsy had by slow degrees ascended from his legs to his arms ; he had had no 
head symptoms beyond some occasional confusion and vague uneasy feelings 
there. At this present time a patient in a similar condition comes to the hospital 
every Thursday, dragged by a friend in a hand-chair. He looks very well in the 
face, but is helpless below. 

It is in these cases that you may expect to witness the very remarkable phe- 
nomena which I mentioned before as evincing the separate existence of a " true 
spinal marrow," distinct from the brain and its prolongations into the spinal canal, 
endowed with special and peculiar properties, and performing functions that are 
independent of sensation, of consciousness, and of the will. If you pinch or tickle 
the surface of th>e paralytic members, or apply a hot spoon to the sole of one foot, 
the limbs will, in many cases, start up and move strongly, not only without any 
voluntary effort on the part of the patient, but in spite of him ; or even (in those 
instances in which there is anaesthesia as well as palsy) without his knowing it. 
The legs often spring up of their own accord as it seems; but, no doubt, the . 
apparently spontaneous movement is frequently an excited movement, and takes 
place in obedience to the law that governs the automatic motions of the body. 
Some impression, made first upon the peripheral extremities of afferent nerves, 
runs through the nervous arc of communication, and exhibits its ultimate effect at 
the extremities of the corresponding efferent motor nerves. We can imagine 
many such accidental and unsuspected sources of excitement ; a casual touch, the 
varying contact of the bed-clothes, the bite of a flea, for aught 1 know to the con- 
trary, may suffice. Even the passage of faeces or of flatus along the lower bowel, 
or of urine through the urinary passages, may be enough (as we are taught by 



340 



PARAPLEGIA. 



unquestionable facts) to produce these movements. They are more readily ex- 
cited, casteris paribus, in proportion as the interfering influence of the will is more 
completely cut off. 

I knew a gentleman, who had retired from the medical profession, and who, 
though not paraplegic, laboured, I believe, under some morbid condition of the 
spine. He had been, in early life, a hard drinker, and had suffered delirium 
tremens. Every night, sometimes more than once or twice, the trunk of his 
body, and all his limbs, became for a while fixed and stiff, from rigidity of the 
muscles. A few days before his death, he told me this curious fact. Whenever 
he scraped his shoes on the scraper at the door, his leg flew up, with a spasmodic 
suddenness, from the iron, notwithstanding his endeavour to prevent it. He died 
suddenly. I believe he was found dead in his bed. 

In some cases of paraplegia involuntary retractions of the palsied limbs can be 
excited ; in some cases they cannot. When the influence of the cerebrum is quite 
excluded by the operation of disease affecting the spinal cord itself, then is the 
susceptibility of excited movements the most lively. But the increased suscepti- 
bility which has this inverse relation to the voluntary power, is limited to that 
portion of the body, the nervous arcs belonging to which lie beyond the seat of 
the disease; more distant, I mean, from the brain. Hence it follows that we 
may determine, approximately, the place of the disease, by the test of these reflex 
actions. The mischief may be situated, or may extend, so low down, that there 
are no uninterrupted nervous arcs below it. Supposing it to lie as low as, or to 
reach, the commencement of the cauda equina, we should have no involuntary 
movements. Conversely, when no involuntary movements can be excited, the 
spinal disease is, at least, as low as the upper lumbar vertebrae. Thus, I say, we 
have another mode, in addition to those pointed out in a former lecture, of deter- 
mining, in a given case of spinal palsy, whereabouts, or to what extent, the cord 
is implicated in the disease. 

We do not so often observe these reflex movements in cases of hemiplegia; 
apparently Tor this reason, that in hemiplegia the sensorial influence is not, 
usually, so completely shut out as it is apt to be in paraplegia. Yet I have seen 
some of these phenomena in several hemiplegic patients. One of them, whose 
right hand and arm were quite passive under the strongest efforts of his will to 
stir them, took notice himself, as did his nurse, that whenever he yawned and 
stretched himself the fingers of the palsied hand participated in the action, and 
were thoroughly extended : and I could, by tickling the sole of his foot, excite 
some starting of the leg, long before any power ^of voluntary movement returned. 

Emotion has sometimes the same singular effect upon limbs and muscles over 
which volition has no dominion whatever. An artist with whom I am acquainted, 
and whose arm was almost completely powerless after a recent attack of paralysis, 
so that no effort of his will sufficed to raise it from his side — was one day startled, 
as he was hobbling across a road, by the unexpected approach of a carriage. He 
noticed, with wonder, that during his endeavours to get out of the way, the pal- 
sied arm was suddenly jerked up above his head. But he could not again lift it 
there after the fright was over. 

Paraplegia has been ascribed to some primary morbid condition of the nerves 
which belong to the spinal cord. That the functions of the efferent, or motor, 
nerves may be impaired, and even arrested, by exposure to cold, and by other 
injurious influences, is both possible and probable. But a diseased or disordered 
state of the afferent nerves has been assigned as a cause of the palsy. This is 
less clearly conceivable. Coexisting disease of the kidneys, and coexisting 
enteritis, have been thought sufficient to produce and keep up a paralytic condition 
of the lower limbs. The extremities of certain incident nerves being affected, a 
morbid impression is transmitted to the cord, suspensive of its central function. 
The efforts even of volition, which come from the brain, are no longer successful. 
Such is the theory. I do not say it is an erroneous theory; but I am bound to 



PARAPLEGIA. 341 

tell you that I think it unproven. My own experience has furnished me with no 
facts which go to support it. 

Do not forget the important fact that, in many, nay, in most cases of paraplegia, 
the urine at length becomes ropy, alkaline, and stinking; and that the bladder, 
after death, presents appearances such as chronic inflammation might produce ; 
roughness and redness of its inner surface, and thickening of its coats. What 
may be the order and relation of these changes, I confess I do not know : whether 
the quality of the urine is first altered, and then the bladder suffers from the 
perpetual contact of this unnatural secretion ; or whether the bladder becomes 
diseased in consequence of the palsy, and pours forth unhealthy mucus, whereby 
the quality of the urine is affected ; has not, I believe, been clearly ascertained. 
The minute particulars of such cases require more careful investigation than they 
have hitherto received. In support of the latter proposition I have heard the fol- 
lowing facts affirmed. The urine voided being alkaline, the bladder was washed 
out by the injection and withdrawal of warm water. Then the next portions of 
urine that descended from the kidneys were immediately removed and tested, and 
found to be acid. So also, after death, the urine has proved to be alkaline and 
mucous in the bladder, acid in the pelvis of the kidney. But in other instances 
of paraplegia, the urine is said to have been secreted alkaline. Disease, in these 
last cases, may perhaps have been propagated from the bladder, backwards. Or 
the disorganization of the bladder, and the alkaline quality of the urine, may both 
have been common results of the interruption of the nervous influence. I would 
suggest to you to inquire, whenever opportunities occur, at what period of the 
spinal disease or injury the urine began to be secreted alkalescent. 

We have reason to believe that the defect in some of these cases of paraplegia 
is merely functional: independent, I mean, of any such change in the nervous 
matter as is cognizable by our senses. It may be brought on by various 
causes : by cold ; by intemperance in drinking ; by excessive sexual intercourse : 
or, still more surely, by self-abuse. I have had the last cause assigned to me 
voluntarily by patients themselves. In such cases we may presume that the loss 
of function is confined to the spinal marrow. But there is another way in which 
paraplegia may be accounted for, although its physical cause is very liable to be 
overlooked. It may result from serous effusion into the spinal canal ; which 
effusion may have originated there, or, what seems sometimes to be more proba- 
ble, may have been poured out ivithin the cranium, and descended by the force 
of gravity to the lower part of the cavity of the spine. Dr. Baillie read a paper 
on this subject before the College of Physicians: it is contained in the sixth 
volume of the Medical Transactions. He was not the first person to whom this 
mode of explaining certain obscure cases of paraplegia suggested itself ; but he 
was the first I believe who published upon it. This effusion may very readily 
be overlooked. Commonly the brain is examined first; and no great attention is 
paid to the escape of fluid from the vertebral canal. It would be better to lay 
open the spinal cavity first, at its lowest part, and to puncture the theca, and then 
to observe what quantity of fluid runs out when the body is placed upright. There 
should be a certain quantity: but if much serum so escaped, we might conclude 
that it had existed in hurtful abundance during life, and had caused the paraplegia. 
In most of these obscure cases you may trace some head symptoms ; giddiness, 
transient confusion of thought, loss of memory ; and it really will be worth your 
while to make the examination in the way I have pointed out, whenever you have 
occasion to inspect the body of a patient who has died paraplegic. 

I regret very much that I had not the opportunity of doing this in the case of 
the man whom I had been for some time watching in the hospital. 

Cases, such as I have now been describing, are by no means uncommon. They 
are usually slow and tedious ; and you will be called upon to administer to their 
relief. I need not repeat the caution which I have several times given, in respect 
to the condition of the bladder; you must take care that it does not become over 
distended with urine; and you must enjoin strict attention on the part of the nurse 



342 



FACIAL PALSY. 



as to keeping the patient clean and dry. Friction along the course of the spine ; 
blisters to the loins or sacrum, frequently repeated; issues; and electricity: all 
these means you will generally have opportunity enough for trying, and for re- 
gretting their inutility. In such cases it may sometimes be warrantable and proper 
to employ strychnia ; a poison which mainly affects the spinal cord ; causing, 
when given in a sufficient dose, tetanic spasms of the limbs, with very little or no 
affection of the sensorium. I have heard of some striking instances of recovery 
from paraplegia under the exhibition of this drug. I wish I could tell you that I 
had ever seen such. Let me caution you against its indiscriminate use ; or rather 
its abuse. No good can reasonably be expected from it, but much harm, unless 
the cord be free from organic disease. Even then I would not advise you to begin 
with a stronger dose of strychnia, or of the sulphate of strychnia, than the twelfth 
part of a grain every six hours : this may be gradually and cautiously increased, 
until it gives rise to twitchings of the limbs, or to some other obvious effect. The 
twitching is usually confined to the palsied limbs. This shows that it results from 
the agency of the remedy upon the excito-motory system, or true spinal marrow; 
of which the reflex function is always more readily excited when the sensorium 
has lost its customary controlling power. When this symptom occurs, you had 
better go on with the same dose ; it would be unsafe to increase it: and the pro- 
gress of the case will soon inform you whether any benefit is likely to accrue from 
a continuance of the medicine. The out-patient now attending has taken the 
strychnia. It made the palsied limbs start and extend themselves; but no perma- 
nent power has been gained. 

There is one other drug which I should recommend you to try in such cases, viz. : 
the tincture of cantharides. It certainly has sometimes a very beneficial effect. 
Generally, when it does good, it acts as a diuretic ; and Dr. Seymour has thrown 
out a suggestion that it is most likely to be useful in those cases of serous effusion 
into the spinal cavity, of spinal dropsy, which I just now described. He recom- 
mends the tincture as a good diuretic in several forms of dropsy : and supposes 
that it benefits paraplegia by tending to produce absorption of the serum effused 
within the vertebral canal. 

Moreover, there is another principle upon which this medicine may be some- 
times advisable. Cantharides are well known to have a peculiar effect upon the 
bladder; which effect is doubtless produced through the corresponding part of the 
spinal cord. If, by means of the Spanish fly, we can excite, though but from 
time to time, the function of that part, we may obviate, in a great degree, the 
distressing consequences of incontinence of urine, arising from paralysis of the 
■sphincter vesicee. Dr. Marshall Hall relates a very interesting fact, bearing di- 
rectly upon this point. A young lady had a tumour within the tenth and eleventh 
dorsal vertebrae. It gradually, but completely, severed the spinal marrow, and*' 
induced perfect paraplegia. The bladder lost its power of retention. But on 
giving a dose of the tincture of cantharides, the power of retaining the urine was 
always restored for the time. That power would cease, and again be restored, on 
suspending and repeating the medicine. 

Dr. Hall remarks that the cantharides obviously acted through the segment of 
the excito-motory system left below the division of the spinal marrow. 

The tincture may be given in half-drachm doses. 

The forms of paralysis that have hitherto been noticed are forms of partial 
paralysis. When the palsy is still more limited, although the epithet partial 
would be equally applicable, the term local palsy is more commonly used. 
There is one of these local palsies which is exceeding interesting, and of much 
importance: I mean palsy as it affects, exclusively, one side of the visage; facial 
palsy. It is sometimes called, not very correctly, paralysis of the portio dura of 
the seventh nerve. The most common kind of facial palsy is indeed paralysis 
of the muscles supplied by that nerve. But the word paralysis is misused when 
it is intended to express any other loss of function than that of the faculty of motion 



FACIAL PALSY. 



343 



in muscular parts. It is incorrect to speak, as some authors do, of palsy of the 
kidney ; it is equally inexact to speak of palsy of a nerve. 

I say that facial palsy, and facial anaesthesia (for the two should be considered 
together), are very interesting affections, because they elucidate, in the human 
subject, some of the most curious speculations of modern physiology : and they 
are important affections for you to study and understand, inasmuch as, though 
always distressful and alarming to the patient and his friends, and sometimes, 
indeed, indicative of extreme danger, they often are merely inconvenient and dis- 
figuring, and bespeak no peril at all. 

Let us first consider that affection in which the majority of the muscles on one 
side of the face alone are palsied. I have already briefly touched upon this form 
of palsy when it constitutes a part of hemiplegia. But it is of more consequence 
to attend to it when it occurs without any similar affection of the limbs. If the 
arm, or leg, or both, are paralyzed at the same time with one side of the face, we 
know that the whole results from disease in the brain, or in the upper end of the 
spinal cord. But it is not necessarily so when the face alone is palsied; and it is 
often of great moment to the comfort and the safety of the patient, that we should 
be able to tell whether the palsy does imply disease within the skull, or not. 

The appearance presented by patients affected with facial palsy is peculiar, and 
very striking. From one half of the countenance all power of expression is gone; 
the features are blank, still, and unmeaning. The other half retains its natural 
cast, except that, in some cases, the angle of the mouth on that side seems drawn 
a little awry. This is apt to be mistaken for proof of a spasmodic condition of 
that part; but it is owing simply, as I stated before, to the want of the usual 
balance or counterpoise from the corresponding muscular fibres of the palsied side. 
The patient cannot laugh, or weep, or frown, or express any feeling or emotion 
with one side of his face, while the features of the other may be in full play. 
One half of the aspect is that of a sleeping, or of a dead person : the other half is 
alive and merry. The incongruity would be ludicrously droll, were it not so 
frightful also, and distressing. To the vulgar, who do not comprehend the pos- 
sible extent of the misfortune, the whimsical appearance of such a patient is 
always a matter of mirth and laughter. On the other hand, his friends and rela- 
tions imagine that he has had a fit, and are in great alarm for his life. In the 
majority of these cases there is not, however, any real danger of that kind to be 
apprehended ; a circumstance which, of itself, would render the exact diagnosis 
of the complaint peculiarly interesting. In general there is no deficiency of sen- 
sation. And, vice versa, we sometimes have loss of sensibility in the same parts, 
without any diminution of the power of motion. The best way, I believe, to 

«lace the phenomena of these curious affections plainly before you, will be by 
xamples. 

A housemaid, Jane Smith, by name, twenty-eight years old, became one of 
my out-patients at the Middlesex Hospital, with the following symptoms. She 
had lost all power of moving the right side of her face. When she endeavoured 
to raise her eyebrows, the right side of the forehead remained smooth, and the 
left was wrinkled. When she attempted to close her eyes, the right eye was but 
partially covered, the eyeball rolling upwards, and carrying the cornea within 
the curtain of the upper lid, which descended a little to meet it. When she tried 
to snuff in air through the nose, not being able to keep the right nostril stiff and 
open, its sides came together, and no air passed up on that side. When she 
smiled, the right side of the face remained perfectly still, like a mask ; and it wore 
at all times a vacant and inanimate character. When she was told to perform 
the action of blowing, her right cheek was puffed out like a loose bag, and the 
breath issued, whether she would or no, at the right angle of her mouth. The 
same thing happened with her food and drink ; she could not prevent their escaping 
at the right corner of her mouth : nor could she convey morsels of food from the 
right to the left jaw, without the aid of her hand applied externally in support of 
the paralyzed cheek. The masseter and temporal muscles, however, acted as 



344 



FACIAL ANESTHESIA. 



strongly on the one side as on the other ; she could chew perfectly well on the 
palsied side, and the sensation of the palsied parts remained perfect ; and there 
was no paralysis of any other part of the body. 

All these phenomena are invariably met with in all complete cases of this kind. 
I will contrast them with the phenomena presented by another of my patients, 
who was in the hospital, and whose name was Ann Church. I give their names, 
that I may the more readily distinguish the one from the other. When this 
woman, Church, applied for admission, she complained of intense pain, with 
some swelling in the right temple, and extending thence generally over the right 
side of the face and head. It was soon discovered, however, that although she 
complained of most severe pain in these parts, they had entirely lost their ordinary 
sensibility to external impressions. She felt nothing when her forehead, or cheek, 
or nose, or chin, was touched on that side. In short, there was complete arises- 
thesia of the right half of the face; just as in Smith's case there was complete 
palsy. The insensibility was very exactly limited to the right half, and termi- 
nated abruptly at the middle line. It was remarkably evident in a part in respect 
to which the bystanders could scarcely be deceived, even if there had been any 
reason (which there was not) for distrusting the patient's own statement. The 
surface of the eyeball is proverbially sensitive, even to slight impressions. But 
you might place your finger upon this woman's right eye, or you might brush it 
with a feather, without giving her the smallest pain, or producing any sensation 
at all: whereas, on the left side, the lightest touch caused involuntary shrinking, 
and closure of the eyelids, and a gush of tears. She declared also that she had 
no feeling in the right half of her mouth; she neither tasted sapid substances, nor 
was she at all conscious, from any sensation produced by them, that they were 
placed there. Her lips on the same side, were equally destitute of sensibility; so 
that when she drank, having no perception of the contact of the cup with her lips 
beyond their middle point, she felt as if she were drinking from a vessel with a 
broken rim. This is a circumstance which all persons who are thus affected 
are much struck with: and it almost always forms a part of their voluntary account 
of themselves. 

Besides this defect of sensibility, the power of contracting the masseter and 
temporal muscles on the right side was entirely abolished in this patient. You 
may deceive yourselves on this point, if you do not investigate it carefully, and 
with certain precautions. At least I have known persons doubt, because, having 
directed the patient to open and shut his mouth, they have confounded the move- 
ment of the whole jaw with the action of the masseter muscle. But if you tell 
the patient first to close his mouth, and then to perform the action of grinding 
with his teeth, placing your fingers at the same time on the corresponding muscleg 
on each side, the difference, when it exists, will be very striking. In the woman 
of whom I speak, no swelling of the masseter or temporal muscle on the affected 
side took place when she forcibly closed her jaws. There was no other paralysis. 

Now we cannot separate the physiology from the pathology of such affections 
as these. Nor ought we. The morbid conditions of which the two cases just 
described furnish samples, illustrate in a very beautiful manner the modern doctrine 
respecting the special uses of particular nerves. In the first of the two cases the 
palsy resulted from suppression of the function of the hard portion of the seventh 
pair of cerebral nerves; and the anaesthesia, in the last of the cases, depended 
upon suspension of the function of the fifth pair. You know the experiments 
performed upon living animals have proved that the division, by the scalpel, of 
the portio dura, before it spreads out into that remarkable nervous net-work on the 
side of the face, paralyzes all the muscles the combined play of which gives variety 
and significant expression to the countenance ; and that, on the other hand, the 
division of the fifth nerve deprives the same parts of their sensibility. In these 
two cases, and in such as these, for they are by no means infrequent, a similar set 
of experiments upon the same nerves, in the human living body, is performed 
before our eyes by the agency of the disease, or accident: and the result justifies 



FACIAL PALSY. 



345 



most completely those conclusions which had been deduced in the first instance, 
from contrived observations made upon the lower animals. 

There is one point in the history of these cases upon which I must dwell a 
moment longer ; for it is a most interesting point. That the condition of the 
temporal and masseter muscles should be reversed in two patients so oppositely 
situated, was no more than might have been expected. But in each these muscles 
were afFected in a manner the very contrary of that which the general circum- 
stances of the case would, a priori, have prepared us to anticipate. Where the 
superficial muscles were paralyzed, and the principal movements of the face sus- 
pended, there the masseter and temporal muscles were in full power and action ; 
and where the loss of sensation was the predominant phenomenon, and the ordi- 
nary motion and expression of the countenance remained, there these muscles 
were in a state of complete palsy. 

A few years only ago, this difference and apparent inconsistency would have 
been quite inexplicable. The progress of modern science has removed the diffi- 
calty, by establishing a general agreement between the functions of different 
nerves, and certain observed peculiarities in their anatomical relations and 
arrangements. 

Suffer me to remind you (for I know that these interesting points of physiology 
must have already been taught you) that the nerves which proceed from the spinal 
column on each side are connected with it by two fasciculi of nervous fibrils — two 
roots, as they are metaphorically called — of unequal size ; that when the larger 
of these, which is situated posteriorly, and is furnished with a ganglion, is divided 
in a living animal, the parts to which the nerve is distributed lose the faculty of 
sensation while the power of voluntary motion remains unimpaired ; and that 
when the smaller and anterior, which has no ganglion, is alone cut, the same parts 
are instantly palsied, but retain their sensibility. In other words, the posterior 
fasciculi minister to the faculty of sensation, the anterior to that of motion. 

Now the fifth pair of nerves was observed to have a similar origin ; to be com- 
posed, that is to say, of two fasciculi or roots, one larger than the other, and 
invested with a ganglion ; the other smaller, and having no ganglion. It was 
natural to infer that the function of these roots would be analogous to those of the 
corresponding portions of the spinal nerves ; that the ganglionic fasciculus would 
relate to sensation, and the other to motion. And such is found to be the case ; and 
the arrangement here is really very curious. The smaller portion of the fifth nerve 
is exclusively expended upon a very few muscles ; viz., the masseter, the temporal, 
two pterygoid muscles, the circumflexus palati, and the tensor tympani. The 
action of the first two of these, of the masseter, and temporal muscles, is obvious 
to common observation ; and therefore their condition is noticed in such cases as 
I have related. Again, these very same muscles have been shown, by careful 
dissection, to receive no nervous branches from the seventh nerve, which is a 
motor nerve, and which ramifies so abundantly upon the superficial muscles of the 
face. 

It was to be expected, therefore, that any diseased state confined to the portio 
dura of the seventh nerve, would leave the temporal and masseter muscles fully 
effective : and that disease involving the fifth nerve, but leaving the seventh un- 
touched, would destroy, not only the general sensibility of the face on that side, 
but also the power of contracting these particular muscles. And this was tho- 
roughly exemplified in the two cases that I have detailed. The girl Smith had 
total palsy of the superficial muscles ; but sensatjon, and the action of the deeper- 
seated muscles, continued perfect : while in the woman Church there were default 
of sensibility, and paralysis of the temporal and masseter muscles : but the move- 
ments of the superficial muscles were unimpeded. 

Total interruption of the function of the portio dura will paralyze these super- 
ficial muscles of the face : and such interruption may be occasioned either by 
sudden injury done to the trunk of the nerve ; or by disease affecting its proper 
structure; or by pressure, the consequence of disease in the parts contiguous to 



346 



FACIAL PALSY. 



it. And it is of great importance to observe that the morbid condition which 
causes the interruption may be situated in any part of the course of the trunk of 
the nerve : while it is yet within the cranium ; or during its passage through the 
petrous portion of the temporai bone ; or after it emerges upon the face, through 
the stylo-mastoid foramen, to be ultimately spread in meshes over the cheek and 
temple. The nerve is often compressed or hurt while still within the skull ; but 
in most cases of this kind other portions also of the nervous matter are involved 
in the mischief, and other sets of voluntary muscles testify this by their immo- 
bility or their irregular action. This is sometimes the case when facial palsy 
occurs as a part of hemiplegia. In many instances, however, of hemiplegia, there 
is but slight distortion of the countenance, a mere hanging of the cheek, with no 
paralysis of the orbicularis muscle of the eye. In these cases, it has been sug- 
gested to me by my colleague, Dr. Todd, that the seventh nerve is probably not 
affected at all, but the motor branch of the fifth nerve only. When the facial 
muscles alone are paralyzed, it happens in a great majority of instances that the 
nervous function is interrupted in that part of the portio dura which lies incased 
in the bone, or in the more exposed part which issues in front of the ear : and 
hence it arises that this particular form of palsy is, in general, unattended with 
any danger to life. 

The physical cause of this remarkable disfigurement, and the true explanation 
of its prevailing immunity from danger, were first pointed out by Sir Charles 
Bell: but both the existence of the malady as a distinct form of disease, and its 
comparative harmlessness of character, had been observed and described some 
years previously : although the reason neither of the one nor of the other was at 
that time understood. Dr. Powell had narrated, in the fifth volume of the Trans- 
actions of the College of Physicians, three marked instances of this form of local 
palsy ; and had noticed at the same time its apparent independence of any apo- 
plectic tendency, or cerebral disease. 

The exciting causes of the complaint are various. Sometimes it is the conse- 
quence of mechanical violence, by which it is plain that the nerve has been lace- 
rated, or otherwise injured. Sir Charles Bell, to whom we are indebted for much 
information on the subject, mentions several examples of this kind. In one a 
man was shot by a pistol ball, which entered the ear and tore the portio dura 
across at its root. In another, the patient was gored by an ox ; the horn of the 
animal entered beneath the angle of the jaw, and came out in front of the ear, 
tearing the nerve across. In a third, the nerve was divided by a surgeon's scal- 
pel, in an operation for the removal of a tumour which lay above and around its 
course. In all these cases the injury was external and obvious. In a fourth the 
palsy followed a blow on the ear which caused hemorrhage from that part: here 
probably the nerve was hurt in its passage through the bone. Some time ago, a 
man was brought into the Middlesex Hospital who had fallen from a height, upon 
his head. The muscles of the left side of the face were paralyzed. He died in 
a few days ; and examination of the head showed a fracture in the base of the 
skull, passing through the petrous portion of the temporal bone, and rending the 
seventh nerve at its entrance into the meatus auditorius internus. In the year 
1832 I had a patient (Richard Hills) in the hospital with the same kind of para- 
lysis, which seemed, in him, to have been occasioned by a mere shock or jar. 
He was a coachman, and one day, when he was off his box, his horses started 
away, and he ran to their heads to stop them, but was thrown down in the at- 
tempt, striking his hip and elbow. He received no blow on the head at all. Three 
hours afterwards he found that he could not spit properly. The affection is not 
unfrequently discovered by that circumstance. He could not avoid spitting on his 
clothes on one side ; and he could not whistle. Another circumstance worthy of 
notice took place in this man, which often, though not always, happens in these 
cases, and which I did not mention before. He remained for about two months 
in the hospital ; and regained during that time in some degree the power of ex- 
ercising the affected muscles; but he still was unable to bring the right eyelids 



FACIAL PALSY. 



347 



together. The eye itself was unharmed. After he was made an out-patient he 
resumed his functions on the coach-box ; and his eye, permanently half-open and 
unprotected, was more exposed to cold and to currents of wind than it had been 
when he was an in-patient. Moreover he got drunk; and he soon presented him- 
self again with universal redness and inflammation of the conjunctiva. Sometimes 
the inflammation in such cases produces opacity of the cornea and a total loss of 
vision. This is one of the worst consequences of facial palsy. Fortunately it is 
only an occasional consequence : and it will occur or not, according to the quan- 
tity of motion which remains to the eyelids, and the degree of exposure to the 
ordinary causes of inflammation. 

Sometimes the palsy depends upon manifest external disease ; sometimes upon 
disease which is hidden, and probably internal, in the bony canal. Sir C. Bell 
describes an instance in which it accompanied the disorder called the mumps. 
Dr. Maiden, of Worcester, witnessed another in which a fixed, hard, indolent 
tumour had formed between the ramus of the lower jaw and the mastoid process 
of the temporal bone. As this tumour gradually subsided, the palsy disappeared. 
In each of Dr. Powell's three cases the affection was apparently caused by expo- 
sure of the side of the head for some time to a stream of cold air. A medical 
acquaintance of mine residing in London, had a patient at Greenwich, whom he 
visited daily. It was cold weather; and on one occasion, as he was returning in 
the cabin of a steamboat, he was sensibly incommoded by a keen east wind, which 
blew through an open window directly upon his ear. The next day he presented 
himself to me with that side of his face fixed in the manner I have been describing,, 
Exactly the same mishap befell a Scottish physician while traveling to London 
by a coach; and sent him in great alarm to Sir C. Bell. Some years ago a 
marked example of facial palsy occurred in one of my hospital patients ; it ap- 
peared to be owing to his having been constantly in the streets for some days 
without shoes or stockings, during a cold thaw. It may be presumed that m 
these instances some swelling was produced in the soft parts around the nerve,, 
compressing it where it lies within the unyielding bone. Exposure to cold in 
this way is the commonest of all the exciting causes of the complaint, and cases 
thus arising are more obedient to treatment than most others. Probably some of 
you saw a female patient who came under my care in the hospital in May 
last (1838), in whom facial palsy had existed on one side for eighteen years. 
When about three years old she had the measles ; and a scrofulous tumour formed 
behind the ear, and broke; and after some time, a portion of carious bone came 
away. Then the wound healed (of which deep traces are still visible) ; and the 
peculiarity of her features was observed. There are still other cases in which we 
fail to discover any direct explanation of the paralysis, either in the history of the 
patient, or in his physical condition. In the girl Smith, whose symptoms I stated 
in detail as an example of the appearances uniformly present, the malady came 
on without any obvious cause, and it resisted all the means employed for its 
removal. 

That the greater number of cases of this kind are free from serious peril, is a 
fact of great practical importance. It enables us to quiet the alarm of the patient 
and of his family : and it regulates in many instances the treatment ; rendering it 
less severe than it might and ought to be, if the palsy were really the harbinger 
of apoplexy. At the same time you should not be ignorant that a similar limita- 
tion of paralysis to the particular muscles supplied by the portio dura is sometimes 
(though rarely) observed, when the disease has a more inward origin ; when it 
affects and involves the brain itself. The following case caused me much anxiety, 
for the subject of it was a personal friend of mine.— -I was summoned to his house 
in the autumn of 1829, and found him with complete palsy of the left side of the 
face. It had existed a day or two. I shall not describe the appearances and 
symptoms that resulted from the paralysis; for they were precisely the same as 
were presented by the girl Smith ; and they are always, and necessarily, very 
much alike. But though the palsy was strictly limited to this set of muscles, 



348 



FACIAL PALSY. 



there were other symptoms present which indicated that the interruption of the 
functions of the portio dura was connected with some morbid condition within 
the cranium: nausea and vomiting, twitching of the muscles of the other side of 
the face, great drowsiness, and a slow pulse, 48 only in the minute. He lurched 
also, and staggered as he walked; but he distinguished this from the reeling of 
vertigo, and denied the latter sensation altogether. He was deaf, too, on the 
affected side. 

His previous history did not tend to diminish the fears which his actual state 
excited. 

In the preceding February, he had been attacked, rather suddenly, with intense 
pain just above the right eyebrow, and became extremely drowsy. Being 
desirous, on account of these feelings, to excuse himself from a dinner engage- 
ment, he found that he was unable to write a proper note : he could not remember 
how he ought to express himself. 

All these symptoms soon passed off; after the operation, I believe, of an emetic. 
But he had another attack of the same kind in the subsequent May: the same 
severe pain over the right brow, with great drowsiness and confusion of mind. 
He could not recollect the first line of the iEneid. He wished a friend to look 
at the signatures of some letters that had arrived : and though he knew the root, 
he could not tell how the word he wished to use was formed ; whether it was 
signition, or signation, or signature. The digestive organs on this occasion were 
made the object of treatment, and he soon got well. 

There was another instructive part of his history ; and therefore I mention it. 
Before these attacks he was in the habit of eating and drinking freely ; and his 
power of digestion was supposed to be enormous. After the attack in May he 
commenced a strict course of temperance. He drank no wine till three or four 
days before the occurrence of the facial palsy : he had then taken it again, and 
had about four glasses daily ; and on one of the days he drank two glasses of 
champagne. 

It was of some moment to this gentleman, not only that he should recover, 
but that he should recover quickly. He had been appointed by government to 
a mission to Ceylon, and all his equipment was already on board a vessel, which 
would sail in a fortnight. 

Cupping behind the ears, blistering, purgatives, and small doses of calomel 
continued till the gums were slightly sore, removed the paralysis, and all the 
other symptoms, in about ten days. He went to Ceylon, and performed his mis- 
sion so ably that after his return the government appointed him to one of far 
greater importance in India, where he now is. He has remained perfectly well ; 
and possesses one of the clearest and strongest intellects that I am acquainted with. 

I must trouble you with one more case, to complete the history of this disease : 
a case in which the cause of the facial palsy was situated within the cranium and 
proved fatal, and became visible after death. 

Samuel Dobey, a tailor, fifty-seven years old, was admitted under my care into* 
the hospital, in February, 1833, with complete palsy of the muscles supplied by 
the portio dura on the right side ; and of no others. There were symptoms 
enough, however, to show that some serious michief was going on within the 
skull. He suffered intense headache, more on the left than the right side ; was 
dizzy and staggering ; and could not get to the ward without being led. 

The palsy had come on about ten days before, in the night. He found when 
he came down stairs the next morning that he could not spit as usual ; and his 
friends observed the unnatural state of his features. He had had no fit, nor loss 
of consciousness ; but he thought his memory was failing. At the time when the 
paralysis was first noticed, he had some numbness and tingling of the right arm, 
extending to the last two fingers. He was quite deaf in the right ear. This is a 
point deserving attention in such cases. The deafness, when it occurs, marks an 
affection of both the portions of the seventh nerve : and therefore indicates the 
probability of an internal cause. 



LOCAL ANAESTHESIA. 



349 



The whole progress of this case was very interesting ; but I must confine myself 
to those circumstances which bear upon our present topic. He lived about a 
month after his admission, and during that interval he suffered great pain in the 
head, was delirious at times, and at other times in a state of coma : at one period 
he suddenly presented the ordinary symptoms of apoplexy, from which he partly 
recovered. 

I found a cancerous tumour occupying the right hemisphere of the brain ; at 
its under part was an apoplectic clot, as big as a hazel-nut. I found, also, a very 
satisfactory explanation of the deafness and of the facial palsy which had been 
noticed during his lifetime. The portio dura and the portio mollis, where they 
emerge as distinct cords from the medulla oblongata on the right side, were 
adherent to each other. The portio dura was both harder and larger than the 
corresponding nerve on the opposite side, while the portio mollis was wasted and 
diffluent. The same change was traced up to their entrance into the petrous por- 
tion of the temporal bone. Immediately over the medulla oblongata, and in a 
vertical line above the point of emergence of the seventh pair of nerves, a nipple- 
like portion of brain projected downwards, and had apparently communicated 
pressure to these nerves ; and this projection from the lower surface of the brain 
seemed to have been produced by the general pressure resulting from the growth 
of the tumour. 

The remarks which I have been applying to palsy of these parts hold true also 
in respect to their loss of sensibility. The anaesthesia may or may not portend 
danger to life, according as the interruption of nervous function on which it 
depends is situated more or less near to the origin of the fifth pair of nerves in 
the brain. The patient, Church, whose case I have several times referred to in 
this lecture, left the hospital with the sensibility of her face nearly as perfect as 
ever. The treatment consisted in local blood-letting and counter-irritation. She 
had erysipelas of the head while in the hospital, and was in some danger from 
that complaint, which was attended with a good deal of fever and delirium. With 
the exception of the delirium, which belonged no doubt to the erysipelas, there 
was no reason to suspect any affection of her brain. 

I have incidentally adverted to the plan of treatment to be pursued in these 
cases of facial palsy. When the complaint is recent, and has an obvious cause, 
the appropriate remedies will readily suggest themselves. When, for example, it 
has come on after exposure to a current of cold air, or after a blow, or any cir- 
cumstance likely to give rise to inflammation, you must treat the case as you 
would treat inflammation ; bearing always in mind that a small amount of disor- 
ganization, a little thickening or induration of the parts around the nerve, may 
render the deformity and the inconvenience permanent. If there be inflammatory 
fever, bleed from the arm: if there be not, take blood from the neighbourhood of 
the affected nerve by cupping : apply fomentations ; or, what is better in these 
cases, conduct the steam of hot water against and into the ear : and administer 
mercury so as just to touch the gums. I should always take this latter precau- 
tion, lest any effusion of lymph should cause abiding pressure on the nerve. If the 
palsy gives way before the gums become tender, the mercury need not be pressed 
further. 

Where there is any ground to suspect that the brain is implicated, the treat- 
ment just described must be pursued with greater diligence, and with such modi- 
fications as the nature of the case may require. If there be evidence of chronic 
disease in the petrous portion of the temporal bone, such as tenderness of the 
mastoid process, deafness, a protracted discharge from the ear, and an imperfect 
state of the membrana tympani, we can scarcely expect much good from very 
active treatment. We must then have recourse to counter-irritation, and such 
other measures as I spoke of when the subject of otitis was briefly considered. 

The examples which are met with, of local palsy and local anaesthesia, are 
numberless ; but those which I have mentioned are the most common and the 
most important. They are always deserving of attention ; but more so when 



350 



REMARKABLE CASES. 



any suspicion arises that they may be connected with cerebral disease. Some- 
times they evidently have no such connection. In the month of November, 1834, 
a coachman became my patient in the hospital, with incomplete paralysis afTectino- 
some of the muscles of the right leg alone, with numbness of the foot. He could 
both stand and walk; but on advancing that leg, his foot flapped suddenly down, 
and he could not deliberately direct and plant it, like the other. His general health 
was quite good ; he had no headache, nor giddiness, nor palsy of any other part. 
But a month ago he had been sitting with the right leg thrown over the opposite 
knee ; and he continued in that position until the foot felt numb and tingling, and 
was (what is called) asleep ; and it had remained in the same condition from that 
time. After some general treatment (cupping and purgatives) before he came to 
the hospital — treatment which was quite proper in the way of precaution, but 
which was probably, in truth, unnecessary — I had his leg electrified ; and in 
about ten days the sensation and the power of the limb were almost restored. 
Mr. Swan mentions a somewhat similar case, in which anaesthesia of the hand 
was produced by strong pressure made upon the wrist. 

There are some very curious facts connected with anaesthesia, showing that the 
voluntary exercise of the muscles is regulated in some measure by the sensations 
of the limb that is employed. The sense of resistance prompts to such contraction 
of the muscles as is required to balance that resistance ; reminding the will (so to 
speak) of the necessity that exists for its perpetual and vigilant operation. Con- 
tinued volition is essential to the continuance of the muscular tension. Thus Dr. 
Yelloly describes a woman who had no power of feeling in her hand and fingers, 
although the power of moving them, and of grasping any objects, was entire. 
This woman found that she could carry glasses or plates in that hand very well 
and safely, if she continued to look at and attend to them : but if her eyes were 
turned another way, as she did not feel what she held, she was very apt to drop 
it. Dr. Ley met with just such another case. A woman had defective sensi- 
bility on one side of the body : she could hold her child in the arm of that side so 
long as her attention was directed to it ; but if surrounding objects diverted her 
from taking notice of the state of her arm, the flexor muscles soon began to slacken, 
and the child was in danger of falling. All this is exceedingly curious. 

Andral has recorded a most singular example of local anaesthesia, which pre- 
ceded an attack of apoplexy. The patient lost, from time to time, all sensation in 
certain isolated parts of the skin upon the thorax ; there were five or six of these 
insensible spots, each about the size of a five-franc piece. You might pinch the 
skin in these places without producing the slightest feeling in the patient. In all 
other parts the sensibility was perfect and lively. 

There are other cases also on record, more remarkable still ; in which the 
patients have lost both the power of motion and the faculty of sensation in almost 
every part of the body, and yet have survived for a considerable time. Thus one 
person (whose case is related in the Bulletin des Sciences Medicales for January, 
1828,) became first amaurotic, then deaf, and then by degrees lost all power of 
sensation and motion except in the tongue and in the muscles of deglutition and 
respiration. His speech and intellects were unimpaired. It was accidentally 
discovered that a small patch on the right cheek retained its sensibility ; and by 
tracing letters on this sensible spot, his wife and children were enabled to inter- 
change ideas with him. He died at length, and his body was not examined. 

I shall finish what I have to say on this head, by relating a case of the same 
kind, which occurred under Dr. Abercrombie's notice ; and which we are sure 
therefore would be observed with care, and recorded with fidelity. 

A servant girl, about 20 years old, sprained her back in lifting some heavy 
article of furniture. She felt no great inconvenience at the time ; but some little 
while after, weakness of the legs came on, and gradually increased to complete 
paraplegia. After an interval, the affection extended to her arms, and she then 
had not a vestige of motion of any of the parts below the head, except a very slight 
movement of one of the fingers : but the internal functions were all perfect, and 



TETANUS. 



351 



her speech was distinct, except that in speaking she was sometimes seized with 
spasmodic twitches of the lips and lower jaw. She lived in that state, without any 
change of the symptoms, and her general health continuing good, for about twenty 
years. In the morning she was taken out of bed, and placed in a chair, so con- 
trived as to support her in a sitting posture. Her arms rested on a cross board 
which passed before her ; and if by any accident one of them slipped from this 
support, she had no resource but to call for the assistance of another person to 
replace it. Having been on one occasion left alone for about two hours after one 
of her arms had thus slipped down, the hand had become extensively oedematous. 
In the same manner, if her head fell forward upon the thorax, it remained in that 
position until raised by an attendant. Her mind was entire. She died after four 
days' illness with symptoms of low typhus fever. You may suppose that Dr. 
Abercrombie looked with the greatest interest for the cause of these most remarka- 
ble symptoms. " I examined the body with the utmost care, (says he,) along 
with Dr. Pitcairn, who had been in the habit of seeing her for several years ; and 
we could not discover any disease either in the brain or in the spinal cord." 

It is much to be regretted that when this case was under observation, the excito- 
motory functions were not understood, nor attended to. 

I shall next proceed to consider those diseases (and there are several of them) 
which are marked by definite symptoms, which consist Essentially in some dis- 
turbance or disorder of the nervous system, but which are not accounted for by 
any physical changes that we can appreciate in any part of that system. After 
some of these diseases we do, to be sure, sometimes meet with morbid appear- 
ances in the brain or the spinal marrow : but none that are constant, or uniform. 



LECTURE XXXII. 

Tetanus. Us Symptoms and Varieties. Causes. Diagnosis. Pathology. 
Treatment: Opium; Blood-letting; the Warm Bath; the Cold Bath. 

In those diseases of the nervous system which have hitherto engaged our atten- 
tion, the function of voluntary motion, when it has been affected at all, has mostly 
suffered in the way of diminution, or suspension ; the power of moving has been 
impaired, or lost; there has been complete or incomplete palsy. Sometimes, indeed 
convulsion, or an irregular and involuntary action of the muscles, has also occurred. 
But, distinct from the paralytic affections, there is a class of spasmodic diseases, 
of which it is the main and leading feature, that the function of voluntary motion 
is (not morbidly heightened, as in the preternatural strength of a madman ; nor 
lowered, as in palsy; but) perverted: performed in an irregular and unnatural 
manner. 

There are two sorts of spasm. One of these is marked by a long-continued 
contraction of the affected muscles, not rapidly alternating with relaxation : the 
relaxation taking place slowly, after some time: and then, perhaps, the contraction, 
after another interval, coming on again. This is called tonic spasm; and, by Cullen, 
spastic rigidity. A very familiar example of it is the common cramp of the leg. 
In the other form of spasm, the contractions of the affected muscles take place 
repeatedly, forcibly, and in quick succession ; and the relaxation is, of course, as 
sudden and frequent. This has been named clonic spasm. We find illustrations 
of it in convulsions. 

Sometimes the two are mixed together in the same disease ; certain muscles 
undergoing convulsions or clonic spasm, and certain other muscles being affected 
with rigidity or tonic spasm. But it is convenient to keep the distinction in mind. 

We recognize these disorders by the unnatural conditions of the muscles; but 
you will please remember that the fault lies in the nervous system. 



352 



TETANUS. 



With regard to spasmodic diseases generally, I may say that some of them 
constitute the most appalling and fatal maladies to which the human body is 
liable ; and some of them, though frightful to look upon, and productive of extreme 
distress to patients and to their friends, are trivial in their consequences, and 
scarcely ever attended with any peril to life. 

I propose first of all to consider one of the most formidable and worst of these 
spasmodic diseases, viz., tetanus; of which tonic spasm is essentially characteristic. 
Its name is derived from tfstfw, to stretch. 

In respect to all those diseases concerning the exact pathology of which we are 
ignorant, and which we identify by the group of symptoms they present, rather 
than by any organic changes of structure in any part of the body, the most con- 
venient mode of proceeding will be, first to describe the distinctive symptoms. 

Tetanus, then, is characterized by an involuntary, long-continued, violent, and 
painful contraction — in one word, by cramp of the voluntary muscles of various 
parts, or of nearly the whole body. 

There is no difficulty in recognizing the disease when it is fully formed. But 
it is of much importance to be aware of the marks of its approach, and of its 
earliest symptoms ; in respect of the treatment to be then adopted. 

In general, the muscles that seem to be the earliest affected are those of the 
neck, jaws, and throat.** The patient feels a difficulty and uneasiness in bending 
or turning his head ; and supposes that he has got what is called a stiff neck. He 
finds also that he is unable to open his mouth with the customary facility. At 
length the jaws close: sometimes gradually, but with great firmness; sometimes 
(it is said) suddenly, and with a snap. In four cases, perhaps, out of five, the 
disease begins in this way, with trismus or locked jaw ; so that this last is the 
vulgar name for the complaint. Along with this symptom, or very soon after it, 
the muscles concerned in swallowing become affected ; and in a short time there 
comes on, what is often the most distressing part of the disorder, an acute pain 
at the lower part of the sternum, piercing through to the back. This depends, it 
Gan scarcely be doubted, upon cramp of the diaphragm. The pain is subject to 
aggravation in paroxysms ; and each paroxysm of pain is attended with increased 
contraction of the other parts also that are implicated. The spasm extends to the 
muscles of the trunk; to the large muscles of the extremities; the muscles of the 
face; and last of all, in general, to the muscles of the tongue, and of the hands and 
fingers, which often remain movable at the will of the patient, after all the other 
voluntary muscles of the body have become fixed; and frequently the muscles of 
the wrists and hands escape altogether. 

With respect to all the muscles involved, from the time when they are first 
affected to the time when the disease is relieved, or the patient dies, they con- 
tinue in a state of contraction, and are swelled and hard in their centres. The 
jaw, for instance, can never be completely opened ; and the muscles of the abdo- 
men are so rigid as to make it as hard as a board. But, besides this, they are all 
subject to aggravations or exacerbations of the spasm, which occur perhaps every 
ten minutes, or quarter of an hour, and last for two or three minutes at a time ; 
and then the muscles fall back into the minor degree of contraction in which they 
were prior to the exacerbation. In a very few instances only has a perfect remis- 
sion of the spasm been observed. The exacerbations usually begin by an increase 
of the pain felt at the sternum. Sometimes there is no obvious exciting cause of 
their occurrence ; but frequently it is evident that they are brought on by exertions 
of the body ; even by slight movements, such as belong to a change of posture, 
to the attempt at swallowing, or speaking. As the disease advances, these parox- 
ysms of aggravation become more frequent, and a rapid increase in the frequency 
of their recurrence is one of the most unequivocal signs that the case is severe and 
dangerous. The more speedily the intervals between the paroxysms shorten, the 
worse. 

It is a curious thing, that the spasm is observed to give way, sometimes at least, 
and the muscles to be relaxed, during sleep. To be sure, in the severer cases, the 



TETANUS. 



353 



patient is seldom able to sleep ; and it may be that in the less violent instances, 
the spasm abates or ceases, and the exhausted sufferer sinks into repose, in con- 
sequence of this abatement. However, a similar phenomenon occurs in at least 
another of these spasmodic diseases, as we shall see hereafter. Mr. Mayo had a 
boy afflicted with tetanus, in the Middlesex Hospital. On visiting him one day, 
he found him asleep, and remarked that he lay perfectly relaxed. The abdominal 
muscles were soft and yielding, and had not the least tension. The boy was 
awakened, and at the instant the lull tension of the muscles returned. Not being- 
further disturbed, he fell asleep again in a few minutes, when the muscles again 
slackened ; and again, upon his being a second time roused, resumed the state of 
spasm. 

In most cases the strong muscles of the back are the most affected, and they 
overcome those on the anterior part of the body ; so that sometimes the patient 
during the paroxysm rests only upon his head and his heels, while his body is 
raised into the shape of an arch. This form of the complaint is called opistho- 
tonos, a bending backwards. The sterno-mastoid muscles of the neck have been 
so stretched and misplaced as to become powerful extensors of the head. In a few 
instances the body is bent forwards, so that the head and knees are in contact, and 
the patient is rolled together like a ball. This is called emprosthotonos. In the 
only example of emprosthotonos which I ever saw, these two conditions alter- 
nated with one another. The patient was a girl, in Edinburgh, under the care of 
a friend of mine, who took me to see her. It was a case of hysteria rather than 
of tetanus; but all at once she would be drawn into a position such, that the top 
of her head, and her feet, were alone supported on the bed, while her body was 
bent backwards, like a bow; then, after a time, with equal suddenness, the oppo- 
site posture was assumed, her forehead and knees being brought together. Still 
more rarely the body is bent to one side. This is pleurosthotonos, or tetanus 
lateralis ; and this I never saw. Sometimes, again, in the height of the spasm, 
the antagonist muscles counteract each other exactly; and the head and trunk are 
rigidly extended : and the term tetanus is by some writers confined to this form 
of the disease. It is called trismus when the jaw only is affected. 

It is well to know that these varieties occur, and may be looked for; but in all 
of them — trismus, opisthotonos, emprosthotonos, or pleurosthotonos — it is the 
same disease : and the prognosis is not altered, any more than the diagnosis, by 
the variety that happens. 

During the fit of exacerbation, the aspect of the sufferer is often frightful. The 
forehead is corrugated and the brow knit, the orbicularis muscle of the eye rigid, 
the eyeball motionless and staring, the nostril spread, the corners of the mouth 
are drawn back, the set teeth exposed, and all the features fixed in a ghastly grin 
— the true risus sardonicus. The tongue is apt to get between the teeth, and to 
be severely bitten. 

All the contractions are attended with intense pain. You may form some notion 
of the severity of this pain, if you have ever been troubled by spasm of the gas- 
trocnemius, or cramp of the leg, and if you can bring your mind to conceive that 
the same sensation which you then felt in the calf, involves nearly all the volun- 
tary muscles of the body. The pain is worst during the exacerbations, and that 
which is experienced at the sternum is commonly the most complained of. Even 
to this, however, there are occasional, though very rare, exceptions. Sir Gilbert 
Blane has described a case of tetanus, which ran the usual course, and terminated 
fatally, yet the patient suffered no pain: the sensation excited by the violent mus- 
cular contractions was a sort of tingling, of rather a pleasurable kind. 

So violent are the contractions sometimes, that the teeth have been broken by 
them. There is one case related in which the thigh-bones were fractured by the 
forcible action of the femoral muscles; and another in which the psoas muscles 
were found, after death, to have been torn across. Dr. Latham tells me that he 
once saw one of the recti muscles, in front of the abdomen, thus rent asunder. 

With all this disturbance of the muscular system, there is commonly very little 



354 



TETANUS. 



derangement of the other functions of the body. The disorder is almost always 
attended with obstinate costiveness ; partly, perhaps, from the spasmodic closure 
of the anus, partly, perhaps, in some cases, from the medicines that are given. 
When stools are obtained, they are usually very offensive and unnatural. There 
is no fever. The pulse and respiration are quickened, and a sweat frequently 
breaks out during the exacerbations, from the pain and anxiety then experienced; 
but this is not the case during the intervals between the paroxysms. In the last 
stages of the fatal cases, the pulse becomes quick and feeble, and the sweat is 
cold, as in other instances of approaching dissolution. 

What is still more worthy of observation is that the mental functions are un- 
affected. There is seldom any delirium, or coma, or disturbance of the intellect. 
These symptoms only appear (if they appear at all) when other indications of the 
failure of the powers of life come on. 

The mode of death in this disease seems to be of a mixed nature. Partly it 
appears to result from apncea; the thorax being held as in a vice by the spasm of 
the muscles, and the breathing for a time suspended, or much embarrassed : partly, 
and chiefly, it occurs from asthenia: the power of the heart flags and is exhausted 
by the continuance of the suffering, by the fatigue and expenditure consequent 
upon the muscular action, and by the patient's inability, in many cases, to take 
sufficient nourishment. When death happens suddenly, as it sometimes does, in 
a paroxysm, it is owing, in all probability, to spasm of the respiratory muscles, 
and perhaps of those of the glottis among the rest. 

Most cases of tetanus may be traced to one of two causes : which are, exposure 
to cold, especially to sudden alternations of temperature, and bodily injuries. In 
many instances both these causes co-operate in producing the disease. When it 
supervenes upon some bodily hurt, it is called traumatic tetanus ; when it arises 
spontaneously, or after exposure to cold, it is held to be idiopathic. In this coun- 
try, and I believe in every other, the traumatic variety of the disease is much 
more common than the spontaneous. But in what manner soever it may origi- 
nate, tetanus is far more frequent in hot than in temperate climates and seasons. 
In this case, however, as in so many others, the heat appears to act as a predis- 
posing cause only ; the exciting cause, in addition to the wound in the traumatic 
species, being the application of cold (particularly, according to Hennen, of cold air 
in motion) after the heat or during the prevalence of hot weather. Thus it is stated 
that after the battle of Muskan, in the midst of great heats, very few of the French 
troops were affected with tetanus ; whereas those who were wounded in the battle 
of Dresden, when the weather was cold and wet, just after a very hot season, 
were decimated by that complaint ; which did not spare even those who under- 
went immediate amputation. 

Idiopathic tetanus is extremely rare in this country. Dr. Gregory, of Edin- 
burgh, used to mention in his lectures the case seen and treated by himself, of a 
man who, having fallen asleep in moist grass, awoke with a stiff neck, which 
afterwards went on into regular tetanus. A good example of well-marked tetanus, 
arising from exposure to cold, is narrated in the Edinburgh Medical and Surgi- 
cal Journal, by Dr. Hall, of Berwick. 

The history of that species of tetanus which occurs in connection with wounds 
and injuries, presents nothing constant or uniform. The disease is liable to fol- 
low hurts of any parts of the body, and of every kind, degree, and extent ; from 
a slight cut or scratch, to a compound fracture, or a severe surgical operation. It 
comes on also in various stages and conditions of the injury. Sir James M'Grigor 
tells us (in the sixth volume of the Medico- Chirurgical Transactions) that in 
the Peninsular war the complaint supervened " in every description, and in every 
stage of wounds, from the slightest to the most formidable ; the healthy and the 
sloughing ; the incised and the lacerated ; the most simple and the most compli- 
cated." Sometimes, however, the discharge from the wound has been observed 
to be remarkably diminished, or suppressed, at the coming on of the tetanic 
symptoms ; and sometimes the wound has healed completely before the com- 



TETANUS. 



355 



mencement of the attack of tetanus. To show you how very trivial the injury 
may be, how various in kind and in place, I may mention a few instances that 
have been collected, in illustration of the manner in which this terrible disorder 
may originate. It has been known to arise from the sticking of a fish-bone in 
the fauces; from a slight wound of the ear by a musket-shot ; from the mere 
stroke of a whip-lash under the eye, although the skin was not broken; from cut- 
ting a corn ; from a bite on the ringer by a tame sparrow ; from the blow of a 
stick on the neck and on the hand ; from a seton in the chest; from the extraction 
of a tooth ; from the injection of a hydrocele ; from the operation of cupping. 

Nevertheless there are some sorts of injury, and some parts of the body, more 
frequently than others concerned in the pathogeny of tetanus. The disorder more 
often supervenes upon injuries of the extremities, than of the trunk, head or neck ; 
and upon wounds made by puncture than upon most other hurts. Penetrating 
wounds in the sole of the foot, such as are not seldom inflicted by treading upon 
a nail or a splinter; and laceration, or other violence done to the muscles that con- 
stitute the ball of the thumb, are very apt to be followed by tetanic spasm. Some 
have supposed that the disease has some special connection with injuries of tendi- 
nous parts ; but there can be no doubt that it is essentially a malady of the nervous 
tissue. 

The tetanic symptoms occur at no fixed period after the reception of the injury. 
Professor Robinson, of Edinburgh, was once at table, when a negro servant lace- 
rated his thumb by the fracture of a china dish. He was seized with convulsions 
almost instantly, and died with tetanic symptoms in a quarter of an hour. Such 
a rapid progress as this is, however, quite out of the usual course of the disease : 
probably fright had something to do with it. Hennen, in his work on Military 
Surgery, states that terror is frequently the immediate antecedent of the attack. 
In general, the tetanus supervenes between the fourth and the fourteenth day after 
the infliction of the injury: some time in the second week is the most common 
period of all. In the Peninsular war it did not commence later than the twenty- 
second day. In some rare instances its accession is still longer deferred. " Of 
the nature of the changes that take place in the interval (justly remarks Dr. Ali- 
son) we have no information whatever.*' The longer, however, that the disease 
delays its assault in these traumatic cases, after the reception of the local injury, 
the milder, in general, does it prove, and the more room is there for hoping that it 
will end favourably. 

When the disorder arises from exposure to cold and damp, it comes on much 
earlier; often in a few hours. If, for example, the exposure takes place during 
the night, the complaint may begin to declare itself the next morning. 

Although tetanus may be excited by a wound, independently of any exposure 
to cold, or by cold without any injury, there is good reason for thinking that, in 
many instances, one of these causes alone would fail to produce it, while both 
together call it into action. 

After the disease has set in, its rate of progress is various. Almost all writers 
divide it into acute and chronic tetanus. But the difference is merely in the degree 
of severity. When the spasms come on suddenly, recur often from the beginning, 
and increase in frequency and violence, the chance of recovery is but small. The 
patient, in these cases, sometimes dies on the second, and generally before the 
fifth day. If he lives to the ninth day of the disease, his prospect is somewhat 
better, and the spasmodic symptoms may gradually abate and disappear. Some, 
however, have died as late as the sixteenth, the twentieth, and even the thirty-fifth 
day : but this last is very rare. 

The idiopathic tetanus, or that which is produced by cold, although it com- 
mences earlier, is more generally of a chronic character than the traumatic : that 
is to say, the spasmodic contractions take place more slowly, and the paroxysms 
do not increase in violence, and in rapidity of recurrence, as they are apt to do in 
the symptomatic variety : and accordingly this form of the malady is much oftener, 
I dare not say cured, but recovered from, than the other. 



356 



TETANUS. 



With respect to the diagnosis of tetanus, there is only one point in which it is 
at all ambiguous or important. There is no other disease that is likely to be con- 
founded with it, except, perhaps, that extraordinary disease, hysteria, which some- 
times mimics its phenomena. I have already alluded to one example of this kind 
that I myself saw. But there is a form of poisoning that may easily be mistaken 
for tetanus. The symptoms produced by a poisonous dose of strychnia, or its 
salts, or the vegetables from which it is procured, are the symptoms of tetanus. 
And as this drug is now readily obtained, and its noxious qualities are well known, 
it is not unlikely to be made an instrument of suicide, or of murder. It is neces- 
sary, therefore, that you should be acquainted with the effects of this poison, which 
constitutes the active principle of the nnx vomica, the faba S u Ignatii, and the upas 
tieuie. Dr. ChrUtison has excellently well described these effects as they are 
observable in brutes ; and I have once, by accident, had an opportunity of wit- 
nessing them in the human body. I shall not be wandering from our present 
subject, if I enumerate the symptoms to he expected from a large dose of strychnia, 
especially as I have lately been advising you to make trial of it as a remedy in 
certain forms of disease. Dr. Christison, who had made experiments with it 
upon animals, tells us that the creature "becomes agitated, and trembles, and is 
then seized with stiffness and starting of the limbs. These symptoms increase, 
until at length it is attacked with a fit of general spasm, in which the head is bent 
back, and the spine stiffened, the limbs extended and rigid, and the respiration 
checked by the fixing of the chest. The fit is then succeeded by an interval of 
calm, during which the senses are quite entire, or unnaturally acute. But another 
paroxysm soon sets in, and then another and another, till at length a fit takes place 
more violent than any before it, and the animal perishes suffocated." 

Some time ago I had occasion to prescribe the strychnia for two patients in the 
Middlesex Hospital, both of whom had paraplegia. I directed one grain to be 
intimately mixed with crumb of bread, so that it might be divided into twelve 
pills : and one of these pills, or one-twelfth of a grain of strychnia, was to be 
taken by each patient every six hours. Unluckily, through mistake or negligence 
of the person who was at that time the dispenser, a grain of the poison was 
administered at once to each patient. It was given about seven in the evening. 
At half-past seven it began to produce its characteristic effect upon one of the 
patients. He was suddenly seized with tetanic spasms; his legs were separated 
widely from each other, and rigidly extended : and his head and trunk bent back- 
wards. He was, in fact, in a state of opisthotonos. His abdomen was quite hard, 
and his limbs were stiff, even when the violence of the paroxysms abated. He 
cried out with the pain at the coming on of these spasms. Any attempt at move- 
ment, even the touching him by another person, brought them on. This is just 
what happens in the disease. The opening of a door, a sudden current of air, 
the smallest bodily effort, the act of swallowing, nay, even the imagination of 
these influences, will be sufficient to renew the spasmodic- tightening of the 
affected muscles. My patient spoke of a particular sense of constriction all over 
the abdomen, as if it were drawn in. His intellect was quite unaffected. He had 
two extremely violent attacks of the kind I have been describing, in which he 
thought he should have died: and to say the truth I was myself horribly afraid of 
the same catastrophe. Afterwards, from half-past eight o'clock to between eleven 
and twelve, he had several slighter and shorter fits. He was left weak and 
exhausted by them : but he soon recovered. I may as well tell you that his 
paraplegia was not a whit benefited by this violent action of the remedy. 

You may suppose that when I found one of my patients in this alarming stale, 
I became very anxious to ascertain the condition of the other, who had taken the 
same quantity of the strychnia, and lay in another ward. He told me that he had 
been for a short period very dizzy, and had trembled all over; and at the time 
when I saw him, he had a weight or uneasy sensation at the nape of his neck, 
which drew his head backwards; and he experienced some difficulty in opening 
his mouth, and in articulating his words. But he thought these symptoms were 



TETANUS. 



357 



diminishing rather than increasing. He was perspiring profusely. It is stated 
by Dr. Christison that if the spams do not come on within two hours after the 
poison was swallowed, the patient is safe. It was more than two hours since this 
patient had taken the strychnia. I gave him a full dose of purgative medicine, 
which acted as an emetic : and, after he had vomited, the unpleasant sensations 
about his head and neck left him. 

I scarcely knew what to do with the other patient, in whom the spasms had 
commenced. There is nothing satisfactorily made out, that I know of, concerning 
the mode of treating such cases. Of course, if one saw the patient early, and 
knew what he had swallowed, the first thing to be done would be to procure its 
evacuation from the stomach. But hei;e it had had full time to get into the circu- 
lation : and no emetic could have withdrawn that part of it at least, which had 
already found its way into the blood-vessels. When I reached him, though the 
spasms were strong, they were less violent than they had been, and their violence 
seemed upon the wane : but they were brought on by any, almost the slightest, 
muscular effort, or change of position. I hoped therefore that the most dangerous 
period was passing off (and so it turned out), and I was fearful of doing harm by 
exciting those movements of the body which accompany the act of vomiting. I 
recollected, too, that another patient in the hospital, under the care of one of my 
colleagues, had once been attacked with opisthotonos after taking half a grain of 
strychnia; and that brandy and water had been given to him; and that he got 
well from that time, without having another paroxysm. So I gave my patient 
some brandy and water; and he seemed the better for it: but whether or no it 
contributed much to his recovery I cannot be sure. 

Now how are we to tell, when we meet with such symptoms as these, whether 
they are the result of disease, or of poisoning ? The symptoms are the symptoms 
of tetanus; I know of no means of distinguishing them from the symptoms of 
tetanus caused by exposure to cold, or supervening upon a wound. Dr. Christi- 
son has suggested that the cases of fatal poisoning by strychnia that are quickly 
fatal, are fatal in a shorter time than the disease ever is. But if the case related 
by Professor Robinson, in which the negro was dead in fifteen minutes, is to be 
regarded as a genuine instance of tetanus, this distinction, drawn from the rapidity 
with which the poison kills, will scarcely hold. Again, persons who have taken 
an over dose of strychnia sometimes survive the tetanic symptoms, but die after- 
wards from the irritant effects of the poison upon the mucous membrane of the 
alimentary canal. This we do not observe in the disease. In suspicious or 
questionable cases, we must look into the history of the patient; inquire whether 
he were likely to wish to destroy himself; what he last swallowed, and when it 
was taken ; whether he lias lately been exposed to the injurious influence of cold, 
especially to a stream of cold air while he was perspiring ; and whether he has 
recently received any bodily hurt. By a careful investigation of all the circum- 
stances, we shall generally be enabled to decide the true nature of the case ; but 
it is clearly necessary that our eyes should be open to the possibility of a case of 
poisoning, by some of the preparations of strychnia, being palmed upon us for a 
case of natural disease. 

The pathology of tetanus is undoubtedly obscure : but not more so, I con- 
ceive, than that of those nervous diseases in general which produce violent symp- 
toms, and even death itself, wiihout leaving any traces of their operation inscribed 
upon the dead materials of the body. Nay, it is not so obscure as several others. 
I think we may fairly come to the conclusion that the symptoms result from irri- 
tation of the spinal cord, or of its afferent nerves ; and that the brain is not in- 
volved in the disease. The French (at least some of the most modern writers on 
tetanus) hold that it is always an inflammatory complaint ; and that it consists 
essentially in inflammation of the spinal marrow: and some of them have sought 
to remedy it by enormous blood-lettings; from fourteen to fifteen pounds of blood 
being taken in the course of a few days by one practitioner ; and another bleeding 
his patient eight times, and applying 792 leeches along the course of the spine, 



358 



TETANUS. 



and to the epigastrium. But this doctrine of inflammation being at the bottom of 
every case of tetanus is contradicted by the plainest facts ; and the practice 
founded upon it has been pushed to a most extravagant and absurd extent. Num- 
berless instances occur of inflammation of the spinal cord and its membranes 
without any tetanus ; and equally numerous examples of tetanus have been met 
with, when no unnatural appearance at all could be discovered within the verte- 
bral canal. I say we must content ourselves with referring the phenomena of the 
disease to irritation, direct or indirect, of the spinal cord ; or its nervous appen- 
dages ; and I am quite proof against all sneers against the alleged vagueness of 
that term. 

If you irritate, mechanically, by means of a pair of forceps, the exposed spinal 
cord of a recently decapitated animal, a turtle, for example, you produce spasmo- 
dic contraction of the limbs. What difficulty is there in supposing that some 
mechanieal irritation existing within the spinal canal of a living man may have a 
similar effect ? It may be, and probably is, sometimes, the mechanical irritation 
caused by the altered state of the blood-vessels under inflammation ; for we some- 
times find traces of such inflammation in the spinal marrow after death by tetanus. 

Again, if you irritate, by pinching, one of the spinal nerves of a turtle whose 
head has just been cut off — if you thus irritate one of these nerves in any part of 
its course, what happens 1 why the muscles of the limbs contract spasmodically; 
those on the side to which that nerve belongs become rigid, and those on the 
other side also. That property of the cord comes into play which I have so often 
mentioned : a property which it possesses independently of the brain ; which it 
evinces when all communication with the brain is cut off ; a property, therefore, 
which may be manifested without any exercise of volition, and even in spite of 
efforts made by the will to restrain its manifestation : I mean, of course, the pro- 
perty whereby it is capable of receiving impressions through the medium of its 
afferent nerves, from parts at a distance, and of originating motion in the muscles 
of the trunk and limbs through the medium of its efferent nerves. By the courtesy 
of Dr. Marshall Hall I have been afforded the opportunity of witnessing, in the 
headless turtle, the phenomena that I have been describing to you. Surely they 
throw a broad light upon the pathology of tetanus, and of sundry other affections. 
We infer from them, most legitimately as it seems to me, that the tonic spasm 
which characterizes the disease we are considering may be caused by a diseased 
state of the spinal marrow itself; or by a morbid condition of the nerves that 
belong to it. In the latter case, irritation is set up at the free extremity, or some- 
where in the course, of incident nerves ; along these nerves an influence is con- 
ducted to the cranio-spinal axis, in which a process or change takes place, where- 
by an answering influence is reflected to the muscles along the motor nerves : and 
the whole circle of action and reaction is run through with the suddenness and 
swiftness of lightning, or of thought. You cannot expect that visible marks of 
the irritating cause should, in all cases, be left upon the body ; any more than 
you could discern the pinch made by the forceps after they were withdrawn. 

When, in the experiments to which I have referred, Dr. Hall plucked or com- 
pressed one of the denuded spinal nerves, spasmodic motions were excited in the 
muscles of both sides ; and above, as well as below, the junction of that nerve 
with the cord. This shows that the change (whatever it be) that is wrought in 
the cord by impressions made upon one of its afferent nerves, is not necessarily 
confined to the corresponding segment of the cord ; but may be instantly com- 
municated, in both directions, throughout its entire course: the whole of this 
centre of the excito-motory system, responding to the influence conveyed by a 
single nerve, as completely as a tight string vibrates from end to end, when struck 
at any one point. We frequently, indeed, find that the excited motions are more 
limited; but it is important to mark this ready consent of the whole cord, under 
sufficient excitement. 

Dr. Hall has given certain distinguishing epithets to tetanus, according to the 
supposed source and locality of the irritation. When the irritating cause operates 



TETANUS. 



359 



directly upon the spinal cord itself, he calls the disease centric tetanus: when it 
resides in some part of the body distant from the spinal cord, he calls the disease 
eccentric tetanus. These are good and intelligible names ; and I shall take leave 
to adopt them. 

Observe now how well this explanation meets the facts of the case. We some- 
times find the spinal cord or its membranes inflamed, when there has been tetanic 
spasm. We then refer the spasm to the centric irritation. But in a far greater 
number of cases we can detect no marks whatever of disease in the spinal canal, 
while we know that an irritating cause has been appplied to parts at a distance. 
Often we have evidence which is visible, that a nerve has been injured, torn across 
perhaps, or half torn, or compressed in some way or other; just as we might 
compress a nerve, with a pair of forceps, in a decapitated turtle. That experi- 
ment shows us that very slight irritation may be enough to produce the spasmodic 
action; and we find that slight injuries, as well as severe, will bring on the dis- 
ease, when, by the operation of certain injurious agencies, the frame has been 
predisposed, and rendered morbidly susceptible. There is no part of the trunk 
or limbs which is not supplied with nerves from the spinal cord ; and we find that # 
injuries of various parts, or of almost any part, in an individual predisposed to 
take on the disordered action, may produce it. The exciting cause may be a 
wound irritating a particular nerve; it may be exposure to cold, acting upon the 
extremities of various nerves that proceed from the surface : it may be a bundle 
of worms, irritating the nerves spread upon the mucous tissue of the alimentary 
canal; for I omitted to state before that some writers, especially MM. Laurent 
and Lombard, have maintained that tetanus is almost always, even when it super- 
venes after wounds, the .result of the presence of worms in the digestive organs. 
They have founded this opinion upon the fact, that worms have been very fre- 
quently indeed discovered in the stomach or intestines of persons dead of this 
disorder. I think this a point well worth attending to. It is objected that 
worms infest the human body without causing tetanus: but the very same thing 
may be said of the operation of cold; and of external injuries. Any of these 
may probably excite the disorder, when the body is preternaturally susceptible of 
it. The real mystery lies in this predisposition. We have reason to suppose 
that a high atmospheric temperature, continued for some time, is one predisposing 
cause ; but how it operates, or what is that state of system in which the increased 
susceptibility consists, these are points concerning which we are really in the 
dark. 

The disease is common enough in brutes : and it is frequently eccentric in them ; 
brought on by injuries, mostly of the extremities. Locked-jaw is well known in 
the nosology of farriers. It is not uncommon in the horse after castration. I 
remember a mare belonging to my father dying of that disease a few days after 
foaling. It often results, in these animals, from a prick in the foot by a nail in 
shoeing. Dr. Parry noticed eccentric tetanus in lambs. " I have often seen 
lambs," says he, " whose ears, for the purpose of marking them, have been bored 
with a red hot iron too near the root, so rigid ail over with tetanus, alternating 
with convulsions, that their bodies would project in a right line with their hind 
legs, when one held them out horizontally by the hind feet." Dr. Mason Good 
tell us that parrots also are frequently affected with trismus: a calamity which, 
supposing the bird to be within ear-shot, it would be difficult to commiserate. 

We are not advancing any wild theory, then, respecting the controverted patho- 
logy of this disease, when we lay down the following propositions: that it is 
essentially a disorder of the excito-motory apparatus ; that it results from irrita- 
tion of a peculiar kind, affecting that part of the nervous system ; that the irri- 
tating cause may be centric, — within the spinal canal itself; and that it may also 
be, and often is eccentric, — situated at the extremity, or somewhere in the course, 
of one or more of the afferent spinal nerves : and that a certain predisposition of 
the body is for the most part necessary, to render it susceptible of the disease 
under the operation of the exciting irritation. 



360 



TETANUS. 



At one time it was supposed that the physical cause of the disease was de- 
tected, in the presence of more or fewer thin scales of bony matter, lying in or 
upon the arachnoid of the cord. I have myself seen these after death preceded 
by tetanic symptoms. But tetanus often happens and proves fatal without them : 
and they are often met with when there has been no tetanus. If, therefore, there 
he any connection between these thin plates of ossification and the occurrence of 
tetanus (which may well be questioned), it must be of this kind ; that the scales 
of bony matter predispose the spinal cord, somehow, to be affected by the exciting 
causes of the disease. 

The doctrines recently propounded by Dr.' Marshall Hall, of which the im- 
portance becomes daily more apparent, and by which his name will be endur- 
ingly connected with the physiology of the nervous system, receive a strong 
confirmation from the phenomena of tetanus. They furnish a key to many 
problems which had previously perplexed the pathologist ; and they do this 
simply by distinguishing the proper functions of the two distinct nervous centres; 
the brain and the spinal cord. But the practical application of these new views 
is yet in its infancy. 

The treatment of tetanus is a mortifying subject. The disease is and has 
always been a lamentably fatal one. Hippocrates says, £ 7tt rp«/ia*t artasixos 
?jtiyevo[Asvos, Oavaaiixov, tetanus supervening on a wound, is mortal : and the 
aphorism holds true, with very few exceptions, in the present day. Almost all 
the acute and severe traumatic cases are fatal. Hennen declares that he never 
saw a case of "acute symptomatic tetanus" recover. Dr. Dickson found all 
curative measures followed by " unqualified disappointment." Mr. Morgan use3 
these words: "I have never yet seen or heard of an instance of recovery from 
acute tetanus." Another of Hippocrates' aphorisms is oxoaot vrto tetavov a%t<sxovtai, 
ix *£68apaiv Yi^woiv attoTdJovtau, they who are. seized with tetanus, die within four 
days: but he adds, riv 8e ?avta$ Sia<prycotftj/ vyisss yivovt at ; if they get over this 
period they recover. And to this we can only add now, that those who survive 
the first few days, and ultimately get well, recover in a variety of different ways, 
and under various modes of treatment. But as to the mode of treatment which is 
to be preferred, or even as to the real efficacy of any mode, there is much room 
for doubt. Under every plan of management a vast majority die. 

Let us brieily pass in review the principal remedies that have been tried, and 
inquire what degree of success has followed their employment. 

One drug from which much benefit has been hoped for, is opium. In some 
spasmodic disorders it is of unquestionable service. Very large doses of it have 
been given and borne in tetanus; and some have recovered under its use, and 
more have died. 

It is well known that pain fortifies the nervous system against the peculiar 
influence of narcotic substances. We need not, therefore, be surprised that 
opium, administered in enormous quantities, in this painful disease, has had but 
little effect. I was assured by a physician, with whom I formed an acquaintance 
in Edinburgh some years ago, and who is known, I find, to a student now pre- 
sent, that his own wife, while labouring under a tetanic affection, swallowed, in 
twenty successive days, upwards of 40,000 drops of laudanum, which is at the 
rate of more than four ounces a day; in all, more than two imperial quarts. The 
lady recovered. A ease is recorded in the second volume of the Medko-ChU 
rurglcal T^ratisactions, in which an ounce of solid opium was taken, in divided 
doses, every day, for twenty-two days. This appears a more astounding instance 
than the former; but I am not sure that it was so; for, in this complaint, solid 
opium does not always dissolve in the stomach. I have heard the late Mr, Aber- 
nethy say that he had found enough undissolved pills of opium in the stomach 
after death, to poison a dozen healthy persons. This fact should teach you, if 
you resolve on trying opium at all, to exhibit it in a liquid form ; laudanum, or a 
solution of the acetate or of the muriate of morphia. And with the internal ad- 



TETANUS. 



361 



ministration of opium, it would be well, perhaps, to combine its external use ; to 
apply a broad strip of opiate plaster along the whole length of the spinal column. 

It is sometimes a difficult matter to introduce medicine by the mouth, so strong 
is the spasmodic contraction of the muscles that close the jaws. You cannot get 
the mouth open. Some persons set to work to heave it open, by levers ; and it 
has been proposed, and I believe practised, to break off or extract a tooth or two, 
to make a passage for the introduction of medicine and of nourishment; but I 
hope you will never be guilty of such clumsy barbarity as this. Food, and phy- 
sic, may be carried into the fauces and into the stomach by means of a flexible 
tube : and this may be inserted through the nostril ; or through the mouth, by 
passing it between the jaws, behind the back teeth, where there is always an 
aperture that will admit a tube sufficiently large. 

After all, in respect to the cures that have been ascribed to the opiate treat- 
ment, they have all (so far as I know) occurred in cases of the milder or more 
chronic tetanus ; and mostly in the idiopathic form of the disease ; and this cir- 
cumstance makes it a question whether they were cures at all : whether they 
were not simply recoveries. 

Dr. William Budd (in the paper already referred to) challenges the propriety, 
on physiological principles, of giving any opium in this disease. He says, " It 
has been ascertained that the effect of that drug is to excite, and not to quiet, the 
motor function of the spinal cord : indeed, it is well known that the motor acts of 
the cord may be rendered much more active and powerful, by giving, before 
decapitation, opium to animals that are to be subjects of experiment." He con- 
siders "these objections, furnished by theory, to be motives sufficient for the 
future exclusion of opium from the treatment of tetanus." 

I had long been aware that the effect of opium upon frogs was to produce tetanic 
spasms. But in no case of poisoning by opium in the human subject (and I have 
seen a great many) have I ever witnessed any approach to tetanus: and I much 
question the safety of arguing, in such matters, from what we know to happen in 
the inferior animals, to what we suppose would happen in man. 

The failure, however, of opium in the severer forms of the malady, and its 
equivocal utility in any, taken together with these theoretical objections, prevent 
my recommending opium as a remedy for tetanus. 

What is the result of experience in regard to blood-letting in tetanus ? I am 
afraid that, as a curative agent, it has very little power over the disease. Yet it 
may be, and probably is, of considerable use, as an auxiliary to other measures. 
When the disorder bears any aspect of inflammation — when, for instance, fever 
is lighted up, and pain is felt along the course of the spine, or when the approach 
of the spasm is marked by the supervention or the increase of pain in the wound 
— then our chance of doing good by venesection is the greatest. Some of the 
cases that happened in the peninsular war, were decidedly benefited by blood-letting 
practised under such circumstances. I need scarcely say that though the bleed- 
ing, when adopted, should be early, free, and full, so as to produce some sensible 
impression upon the system, yet we must always use this remedy with caution. 
The tendency of the disease is to exhaust the power of the heart ; and if by one 
over-bleeding we bring that organ to a stand-stili, it may refuse to begin again. 

In a complaint which depends so much on irritation, and so often on manifest 
irritation of external parts, we look naturally to the warm bath for help. And it 
has been fairly tried: and some persons have found it useful; and others have 
found it useless, doing neither good nor harm: and some have condemned it as 
actually hurtful. 

The coldbath has been extolled as a much more powerful agent than the warm; 
and so, doubtless, it is. But it is more potent for harm as well as for good. For 
example: a tetanic patient, in St. Thomas's Hospital, was plunged into a cold 
bath, at his own request. "All the symptoms disappeared (says Mr. Morgan) 
in a moment; and he was almost immediately taken out of the bath: but he was 
taken out lifeless." Sir James M'Grigor says that, during the campaign of Spain, 



362 



TETANUS. 



" the warm bath gave only momentary relief; and the cold bath was worse than 
useless." 

However, the application of cold water to the surface has, in many recorded 
instances, been of at least temporary benefit and comfort : and, in the West Indies, 
where the disease is common, the cold effusion still continues, I believe, to be the 
most favourite expedient. After it, the patient is rubbed dry, put to bed, and has 
laudanum administered. I have again to observe, of this remedy also, that it is 
chiefly serviceable in the idiopathic form of tetanus. It has been tried upon ani- 
mals. Dr. Parry says that it was quite unavailing in the case of certain lambs 
that had the disease. In a note, which I made at the time, of Mr. Abernethy's 
lecture on tetanus, I find the following statement. " The effect of cold in dimi- 
nishing excessive muscular action was strikingly shown in the case of a horse 
belonging to Professor Coleman, which had tetanus. The animal was slung, and 
carried out of the stable, and laid on the snow, which was then on the ground: 
and he was covered over with snow also. A horse affected with tetanus is a 
curious sight. His legs straddle, and become stiff; his ears are pricked up ; and 
his tail sticks out. In this case, on the application of the snow, his ears sunk, 
his tail became pliant, and the rigidity of his muscles was removed. He was 
again taken into the stable, and the spasms returned." Mr. Abernethy said, that 
were he himself the subject of tetanus, he would desire to have the cold affusion 
tried. If you are willing to assay the same remedy, do not plunge your patient 
into a cold bath, but take him out of his bed on an extended sheet, pour cold 
water over his body, wipe him dry, and place him in another dry bed. This will 
often, for a time at least, diminish the spasmodic action ; and the patient will 
sometimes sleep comfortably after it. 

Dr. Todd has suggested to me the application of ice to the spine ; a measure 
which he has found eminently beneficial in convulsions. This mode of employ- 
ing cold as a remedy in tetanus seems well worthy of trial. It would have the 
advantage of not inflicting any shock which might excite or disturb the reflex 
function of the cord, through its incident nerves. 



LECTURE XXXIII. 

Treatment of Tetanus, continued. Wine ; Mercury ; Purgatives ; Digitalis ; 
Tobacco; Musk; Prussic Acid; Belladonna ; Carbonate of Iron; Oil of 
Turpentine; Strychnia; Surgical Expedients ; General Rules. Hydro- 
plwbia. 

In the last lecture we considered the symptoms, the nature, the causes, and to 
a certain extent the treatment, of that terrible malady, tetanus. There is good 
reason for believing that it is essentially a disorder of the excilo-motory apparatus ; 
that it is caused by irritation of a peculiar kind, affecting that part of the nervous 
system, and producing tonic spasm of the voluntary muscles ; that the irritating 
cause may be centric, situated within the spinal canal, and applied directly to the 
cord ; or eccentric, situated out of the spinal canal, applied to some part of one or 
more of its afferent nerves directly, and thus influencing indirectly the cord itself, 
and through it the reflex motor nerves : and that a certain ill-understood state of 
the system is necessary, a certain aptitude to take on the disease, before the ex- 
citing cause can be efficient; and that one circumstance which has been ascer- 
tained to tend to the production of such an aptitude, is a long-continued high 
temperature of the atmosphere. 

I mentioned several remedies and plans of treatment which have been fairly 
tried, and mostly tried in vain, for the removal of this disease. The severe cases, 
and especially the severe traumatic cases, almost all prove fatal; the less severe 



TETANUS. 



363 



cases, those in which the paroxysms are less violent and less frequent, and which 
run on for several clays, sometimes terminate in health : whether in consequence 
of the measures employed, or whether in spite of them, it is not easy to say. 
The idiopathic cases, as they are called, those which appear to be produced by- 
exposure to cold and wet, are usually the least severe, and the more hopeful. 
The remedies that have been tried, and which were mentioned in the last lecture, 
are opium; blood-letting; the warm-bath; the cold-bath. I showed you that, 
under each of these remedies, a great number of patients died, and some reco- 
vered ; and that the recoveries had been almost exclusively among those patients 
in whom the disease appeared originally in its milder form. So that whether the 
complaint was actually cured in any of these cases, whether, i. <?., any single patient 
recovered, or recovered sooner, from using any of these remedies, who would 
have died, or in whom the disease would have been protracted, if he had not used 
them, is a matter of uncertainty. 

The celebrated American physician, Dr. Rush, regarding the disease as essen- 
tially a disease of debility, and looking probably at its common tendency to death 
by asthenia, wrote a paper to recommend the employment of bark, and wine, and 
spirits, in full doses. It is curious enough, but quite in agreement with what has 
been already stated of opium, that how much wine soever may be swallowed by 
the patient, nothing like intoxication is produced by it. The system resists the 
ordinary influence of the alcohol. In one instance related by Dr. Currie, the 
disease lasted six weeks, and in that space of time the patient drank 110 bottles 
of port wine. The same author mentions a remarkable case, in which a horse, 
which was attacked by tetanus, and happened to be a great favourite with its 
master, was treated with wine, and got well, after swallowing more port wine 
than he was worth. Whenever this plan has appeared to do good, it has been in 
the more chronic variety of the complaint. 

Mercury, you may be sure, has not been left untried. It is said that the system 
is slow in submitting to its influence, in this malady. The specific effect of 
mercury upon the gums is not, however, so strongly resisted as that of wine or 
opium upon the nerves. Nor can we be surprised at this, when we consider that 
in tetanus the functions of organic life are, comparatively, but little involved. It 
is clear that there is not time for any effectual exhibition of mercury in those 
severe cases that are early fatal. In its more chronic form the disorder has been 
known to yield upon the mouth becoming affected. This happened, if I mistake 
not, in Mr. Mayo's patient, mentioned in the last lecture. Tetanus has some- 
times, however, commenced while the patient was in a state of salivation. Dr. 
Wells has recorded three instances of that kind. The experience of the military 
surgeons who were in Spain, is, upon the whole, against the reputed efficacy of 
mercury. We must take care not to conclude too hastily, that because a patient 
uses a certain remedy and recovers, he recovers through the operation of that 
remedy : any more than we should conclude, if he recovered during a general 
election, that the election had cured him. Yet this absurd and unsafe mode of 
reasoning is for ever employed in respect to disease, by the public ; and too often, 
I fear, by ourselves. 

Purgatives have been much given in tetanus ; and often with manifest advantage : 
I mean in the less severe cases. But very large doses are commonly required to 
procure evacuations from the bowels. Whether the torpor of the intestines be 
always the effect of the disease, or whether it may not sometimes he, in part at 
least, a consequence of the opium that is given, I am not sure. When they do 
act, very unnatural motions are frequently produced. Mr. Abernethy tells us of 
a hospital patient of his who recovered under the use of purgatives; they were 
long" before they had any effect, and when they did at last operate, such foetid 
stuff came from him that no one who could crawl out of the ward would remain 
in it. He says also that the nurses, in other cases, have reported the stools to be 
more like sloughs than feces. Enormous quantities of drastic purgatives have 
been given. You may read an instance of this in the second volume of the Medico- 



364 



TETANUS. 



Chirurgical Transactions. It is related by Mr. Harkness. There is a still more 
extraordinary case detailed by Dr. Briggs, in the fifth volume of the Edinburgh 
Medical and Surgical Journal. In little more than 48 hours, the patient in that 
case took 210 grains of scammony, 89 of gamboge, 80 of calomel, an ounce and 
four scruples of jalap, and 2| pints of what we call black dose, the infusion and 
tincture of senna: and all this without either sickness or griping; but, on the 
contrary, with the most decided benefit. In the first week of his disease, the 
patient swallowed — of calomel, 280 grains; scammony, 260; gamboge, 110; 
jalap, 3 ounces and 10 grains; infusion of senna, 5f pints. And altogether in 
the first 25 days — of calomel, 320 grains; scammony, 340; gamboge, 126; 
jalap, 5 ounces and 1\ drachms ; infusion of senna, 10| pints ; besides an ounce 
and a half and .35 grains of the colocynth pill. I mention all this to show what 
the system will bear, under the bondage of the disease ; not as an encouragement 
to you to prescribe such doses. 

It is certainly proper and necessary to clear out the bowels, and to endeavour to 
correct unhealthy secretions; yet numerous evacuations, the act of going to stool 
often repeated, should be avoided. Under such obstinacy of the bowels, the 
croton oil would perhaps be the most eligible purgative. 

Foxglove and tobacco are two medicines, or rather poisons, which have been 
used ; both, probably, upon the same principle. Their effects, when full doses 
have been given, are much alike: sickness, faintness, feebleness and fluttering of 
the pulse, coldness of the surface, with that slack and passive state of the muscles 
which belongs to syncope. But if we consider that the influence of these sub- 
stances upon the involuntary muscles, especially upon the heart, is more certain 
and decided than upon the muscles of voluntary motion, which are the muscles 
involved in the tetanic spasm, and if we take also into account the strong disposi- 
tion observable in tetanus towards death by asthenia, we shall scarcely be prepared 
to expect any good, but the contrary, from digitalis, or tobacco; especially in the 
latter periods, when, so far from obviating the tendency to death, they would seem 
to co-operate with the disease in extinguishing life. However, if the result of 
experience were clearly in their favour, we should not be warranted, by mere 
theoretical view's, in withholding these drugs. The army surgeons, some of 
them, have fancied digitalis useful. Sir James M'Grigor mentions a case in 
which it caused a relaxation of the spasms; but the man died afterwards, appa- 
rently from the effects of the remedy. And this is just what I find with digitalis. 
When given in large doses (and small ones here must be useless) it becomes 
unmanageable. Certainly we have no such accounts of its salutary power as 
would induce me to give it with much expectation of success, or to give it at all. 

The tobacco is not given by the mouih, but thrown up into the rectum : either 
the smoke of its burning leaves, or (what is probably as efficacious, and I should 
think more uniform and less unsafe) an infusion of them in water. Mr. Curling, 
after analyzing a large number of cases of tetanus, thinks tobacco the best remedy 
we at present possess. Mr. Travers is of the same opinion. However, I should 
recommend great caution in the use of this ticklish remedy. You ought to know 
that, when injected in other emergencies, in strangulated hernia, for example, mortal 
syncope has followed such enemata. 

Musk, in large doses, has been strongly recommended by a Frenchman, Four- 
nier-Pescay, who has written on this disease. He gave ten or twenty grains, at 
intervals ; so that a drachm, or even two drachms, were taken in the cour-e of the 
day ; and he declares that he found it more efficacious than any thing else that he 
had tried. 

Prussic acid and belladonna are said, by Dr. Eiliotson, to have been freely pre- 
scribed, and to have failed ; whether in his own hands, or in those of others, I do 
not know. 

There is another remedy which the same physician has employed : and em- 
ployed not without success : the carbonate of iron. Reflecting, he tells us, upon 
the good effect of this medicine in another complaint which has some points of 



TETANUS. 



365 



analogy with tetanus, viz., chorea, of which I shall soon speak, and considering 
how miserably narcotics had failed, he determined to give the carbonate of iron a 
fair trial upon the first opportunity. He has published some account of its effects 
in tetanus, in the Medico- Chirurgical Transactions. In the first case in which 
he used it, the tetanus supervened upon a compound dislocation of the great toe. 
The method in which the remedy was administered was this. The carbonate was 
made into an electuary by mixing it with twice its weight of treacle. The elect- 
uary thus made was well stirred in beef-tea just as the patient was about to drink 
it. He took this every two hours, as much as he could swallow : and he got well. 
The next case is described as being a very severe one ; it resulted from a contu- 
sion of the thumb. Dr. Elliotson says that he never saw a case, which did well, 
that was more severe. This patient also took the carbonate of waft, as much as 
could be got down ; and that was about two pounds a day. He had injections 
twice daily, to keep the bowels unloaded ; and the iron is described as having 
come away in large red lumps, in shape like horse dung. This man recovered. 
In a third case, where a chilblain above the heel was the exciting cause, the boy 
died within twenty-four hours of the time when the remedy was first prescribed. 
To produce its effects upon the system (Dr. Elliotson observes, very truly), iron 
must be given for a few days: nay, he holds that months sometimes elapse before 
it has any effect. So that if it really be useful in tetanus, we cannot expect much 
good from it in the more acute cases : and these are the cases for which we want 
a remedy. 

Oil of turpentine is one of the many substances that have been praised as useful 
in tetanus. Now, bearing in mind its power (which I shall hereafter describe, 
but which you must at present take for granted) as a worm-killer, and also the 
frequency with which worms are met with in the stomach and bowels after death 
by tetanus, this is one of the drugs which I should employ as a purgative, taking 
my chance of whatever good might possibly arise from its specific or anthelmintic 
qualities. It may be given in such cases either by the mouth, or in an enema, or 
at both ends together: but it must be given in large doses, not less than an ounce 
at a time; and it may be mixed with an equal quantity of castor oil. The one oil 
dissolves or becomes incorporated in the other. 

Strychnia has been suggested as a remedy for severe tetanus ; not in infinitesi- 
mal doses, as Hahnemann would, I suppose, prescribe it, but in sufficient quantity 
to produce a sensible effect. The principle upon which this has been recom- 
mended is the same with that on which the nitrate of silver ointment is applied to 
the inflamed conjunctiva in purulent ophthalmia. We know that strychnia acts 
upon the spinal cord, affecting apparently those parts and those functions of the 
cord which are affected in tetanus: and in so fatal a malady, it would be justi- 
fiable, I conceive, to give the strychnia, in the hope that it might occasion a mor- 
bid action which would supercede the morbid action of the disease, and yet be less 
perilous and more manageable than it. But it would be right to try such a remedy 
as this in the first instance, in corpore vili; upon one of the lower animals. This, 
were it successful, would be a cure, according to the Hahnemannic doctrine — • 
similia similibus curantur — a doctrine much older, however, than Hahnemann. 
But the opposite maxim, contraria confrariis, has been suggested. Mr. Morgan 
proposes to give such poisons as are known to cause paralysis, with the view of 
countervailing the undue action of the muscles in tetanus. He produces artificial 
tetanus by inserting a poison brought from Java, called " chatic," into a wound, 
and then relieves the tetanic symptoms by a'North American poison, the ticunas. 
Professor Sewell, of the Veterinary College, has tried this principle in one case 
at least, where the tetanus was the result, not of any poison, but of disease. Not 
having had an opportunity of getting the particulars of this case from Mr. Sewell 
himself, I give you Mr. Mayo's account of it. " A horse, suffering from a severe 
attack of tetanus and locked-jaw, the mouth being too firmly closed to admit the 
introduction of either food or medicine, was inoculated on the fleshy part of the 
shoulder with an arrow point coated with the wourali poison. In ten minutes 



366 



TETANUS. 



apparent death was produced. Artificial respiration was immediately commenced, 
and kept up about four hours, when reanimation took place. The animal rose up, 
apparently perfectly recovered, and eagerly partook of corn and hay. He was 
unluckily too abundantly supplied with food during the night. The consequence 
was over-distension of the stomach, of which the animal died the following day, 
without, however, having the slightest recurrence of tetanic symptoms." I had 
fancied that the death had resulted from some injurious effect upon the lungs, pro- 
duced by the artificial breathing. But I have little doubt that Mr. Mayo derived 
his statement from Mr. Sewell himself. The experiment deserves to be carefully 
repeated. 

I have but little to say concerning what may be called the surgical treatment of 
traumatic tetanus. It was a natural thing, the source of the irritation being sup- 
posed to be the wound, to expect relief from amputation of the limb. But that 
will not arrest the morbid action after it has once been fairly established. Dr. 
Elliotson says he has searched scores of books, and found only one case in which 
the limb and the disease were lopped away together. However, Mr. Blizard 
Curling, in his Essay on Tetanus, refers to seven instances of recovery, after the 
injured part had been amputated. Yet he states that " it is almost impossible to 
ascertain with certainty how far the amputation, in these cases, was of service." 
I believe I cannot offer you better advice on this subject than may be gathered 
from the concluding remarks of a very distinguished and philosophical surgeon, 
in his lectures on this disease. I allude to the late Mr. Abernethy, whose pupil 
I had the good fortune to be. He said, " The state of the part injured is not the 
sole cause of tetanus. In cases of tetanus I have often amputated injured fingers ; 
and though I did not thereby save my patients, yet I think that the symptoms 
were mitigated after such amputations. In such cases, then, I would not ampu- 
tate any considerable member; nor even a small one, unless I thought that, from 
the injury sustained, it would prove useless to its possessor, even though the case 
should terminate favourably." 

The tourniquet has been applied to the hurt limb ; but not, so far as I know, with 
any good effect. The most promising expedient which surgery offers is the 
division of the principal nerve proceeding to, or rather from, the seat of the injury. 
This, supposing the nerve to be known and accessible, is less formidable, less 
severe, less hazardous, less maiming, and, if we may judge from past experience, 
more effectual, too, than amputation of the part. Dr. Murray has recorded (in 
the eleventh volume of the Medical Gazette), a very interesting case, in which the 
operation was followed by most decided and instant relief. The patient was a 
young midshipman who, having trodden on a rusty nail, which pierced the sole 
of his left foot, had kept watch the same night upon deck, the weather being very 
cold. The disease began the next day, and the symptoms ran high. It was a 
case, therefore, of severe or acute tetanus. Wihout loss of time, the posterior 
tibial nerve was divided. The limb was previously cold, and, as the patient 
said, dead, and he had little power of moving it. He could not articulate dis- 
tinctly, on account of the closed state of his jaws. The nerve was cut through 
by one stroke of the scalpel: and " immediately (says Dr. Murray) he opened 
his mouth with an exclamation; and on looking at his countenance I was asto- 
nished at the striking improvement in it. I asked him how he felt, and he said 
he was already much better, and that his leg had come to life again." Some stiff- 
ness of the jaws and neck remained for a day or two ; but he soon recovered. 
Dr. Murray refers to another case, mentioned by Baron Larrey, in which division 
of the nerve had a similar result. 

Probably, to be successful, the operation must be early ; before the morbid 
condition peculiar to the disorder has had time to root itself in the nervous 
system. 

Although, in the present state of our knowledge, there is no one remedy or 
plan on which we can rely for the cure of this fearful malady, we may with 



HYDROPHOBIA. 



367 



much confidence lay down certain general rules, the observance of which will 
secure to the patient the best chance of a favourable result. 

Since any, the smallest movement, or impression made upon the surface, or 
upon the senses, will bring on the severer degrees of spasm, it is of primary im- 
portance to protect the patient against these sources of trouble, so sure to aggra- 
vate his sufferings, and so likely to augment his danger. Hence if blood-letting 
should be thought advisable, it should be done early, sufficiently, and once for all. 
There should be no repetition of venesection, or of cupping, or of leeches, unless 
the circumstances and progress of the case plainly demand them. The same 
remark applies to the frequent use of purgatives. The bowels should be well 
cleared in the outset, and then let alone. The patient should lie in a darkened 
room ; from which noise also should, as much as possible, be excluded. He 
should not be surrounded by a multitude of friends or attendants. He should be 
enjoined to speak, to move, to swallow as seldom as he can. In the severe trau- 
matic cases, the nerve, in my judgment, should be promptly divided. And in all 
cases, there being no special indications to the contrary, I should be more in- 
clined to administer wine in large doses, and nutriment, than any particular drug. 
If the tendency to mortal asthenia can be staved off, the disturbance of the excito- 
motory apparatus may, perchance, subside or pass away. 

There is a form of this complaint called trismus nascentium. As the name 
implies, it occurs in newly-born children. It is very frequent and very fatal in 
the West Indies ; coming on usually in the second week after birth. Hence it 
has been called " the ninth-day disease." Another of its names in the British 
settlements there, is " the jaw-fall ;" from the circumstance that shortly before 
death the lower jaw, which had previously been firmly pressed against the upper, 
drops on the breast. It has been said that a fourth of the infant negroes in Ja- 
maica used to die of this disorder. Some persons refer it to the irritation pro- 
duced by the retention of the meconium in the intestines ; others to irritation from 
the wound made by dividing the navel string. A dose of purgative medicine 
appears to be the most hopeful remedy. The complaint is common, I am told, 
in ill-ventilated lying-in hospitals. Pure air must, therefore, be desirable *as an 
adjuvant. 

Tetanic symptoms sometimes occur (but I should think very rarely) in ague. 
Or paroxysms of tetanus return at regular intervals, and terminate by profuse 
perspiration : the patient being well during the intermissions. When such phe- 
nomena arise, the treatment proper in severe forms of ague must be adopted : 
what that treatment is, I shall in no long time be able, I hope, to lay before you. 

Again, tetanus is occasionally a symptom in hysteria ; and then the treatment 
applicable to hysteria must be had recourse to ; especially enemata of oil of tur- 
pentine, or the same medicine given by the mouth ; and the cold affusion. 

If the disease of which I have been speaking be dangerous, and very often fatal, 
in spite of all remedial measures, that which I propose to bring next under your 
attention is still more appalling; for I believe that hitherto it has been uniformly 
mortal. I know not that any one has ever been rescued by art, or saved by the 
efforts of nature, from Hydrophobia, after that frightful disease has once declared 
itself by its characteristic symptoms. The nature of those symptoms, and the 
absence of all definite or constant traces of organic change in the dead body, suffi- 
ciently mark the disease as belonging essentially to the nervous system, and as 
being essentially a spasmodic disease also. 

What are the symptoms stated in broad outline? These. Excessive nervous 
irritability and apprehension ; spasmodic contractions of the muscles of the fauces, 
excited by various external influences, and especially by the sight or sound of 
liquids, and by attempts to swallow them; and extreme difficulty, amounting 
sometimes to impossibility, of drinking. 

This is one of the diseases which are produced by animal poisons ; and its 
course will be most conveniently traced if we include in our description of it the 



368 



HYDROPHOBIA. 



very first step towards its production, — the application of the specific poison to 
the body. A man is bitten by a dog. After a time the symptoms proper to 
hydrophobia come on. After another interval the man is dead. Before we 
advert to the many very interesting points of inquiry which arise out of the con- 
templation of this malady, let us follow the tragedy from its commencement to its 
closing scene. 

A person is bitten, then, by a mad dog. Does the existence of rabies in the 
animal modify in any way the injury thus inflicted? No; the wound that is 
made behaves just the same, to all appearance, as it would have behaved if the 
dog had not been rabid ; and it gradually heals. After an uncertain interval — 
which lies, for the most part, between six weeks and eighteen months, and which 
has been called the period of incubation — the following symptoms begin to be 
noticeable. The patient experiences pain, or some uneasy or unnatural sensa- 
tion, in the situation of the bite. If it has healed up, the cicatrix tingles, or 
aches, or feels cold, or stiff", or numb ; sometimes it becomes visibly red, swelled, 
or livid ; on one occasion a papular eruption took place around it ; sometimes it 
opens afresh, and discharges a peculiar ichor. The pain or uneasiness extends 
from the sore or scar towards the central parts of the body: L e., if the bite has 
been inflicted on a limb, the morbid sensations extend towards the trunk. All 
this gives fearful notice of what is about to happen. This period is called the 
period of recrudescence. I believe it seldom fails to occur, although it sometimes 
is not noticed; the attention of the patient, and of his medical advisers, being 
absorbed by the horrible sequel. Very soon after this renewal of local irritation 
— within a few hours, perhaps, but certainly within a very few days, during which 
the patient feels uncomfortable and ill — the specific constitutional symptoms begin : 
he is hurried and irritable ; speaks of pain and stiffness, perhaps, about his neck 
and throat: unexpectedly he finds himself unable to swallow fluids, and every 
attempt to do so brings on a paroxysm of choking and sobbing, of a very dis- 
tressful kind to behold ; and this continues for two or three days, till the patient 
dies exhausted, in the way of asthenia. 

I have seen only two examples of this terrific malady; one in St. Bartholo- 
mew's Hospital, in the year 1826; one much more recently in the Middlesex 
Hospital. As they constitute the whole of my personal experience in the matter, 
I shall relate these cases. 

The first occurred in a coachman, the back of whose right hand had been 
struck, ten weeks previously, by the teeth of a terrier dog; but, as both the pa- 
tient and his fellow-servants declared, there was no wound made, no blood drawn, 
no breach or lifting of the skin ; but merely an indentation, showing where the 
animal's teeth had pressed. He was brought to the hospital on a Tuesday. On 
the preceding Thursday his hand had become painful, and swelled a little. On 
Friday the pain extended into the arm, and became more severe. His wife stated 
.that he had been in the habit of sponging his head and body every morning with 
cold water, but that, on this morning, he refrained from doing so, on account of 
some feeling of spasm about the throat. His own remark on this was, that " he 
could not think how he could be so silly." 

On Saturday the extent and the severity of the pain had still further increased. 
On this and the preceding night he got no sleep. He felt ill and drowsy on the 
Sunday, but drove the carriage to Kensington Gardens: he was, however, obliged 
to hold both whip and reins in his left hand. The pain extended to the shoulder. 
He was then bled. A slop-basin full of blood was taken, with much relief to the 
pain ; and purgative medicine was given, which operated well. 

The next day he complained of "feeling very ill all over," and he told his 
medical attendant that, he could not take his draughts, because of the spasm in his 
throat. That gentleman (Mr. Macdonald), concealing his own suspicions as to 
the true nature of the disease, said, V Oh, you don't like the taste of your physic ! 
drink some water." But he declared he had the same difficulty with water. 
The next day he came to the hospital. When there, water was brought and 



HYDROPHOBIA. 



369 



placed before him in a basin, for the alleged purpose of allowing- him to wash his 
hands. It did not seem to disturb him, nor to excite any particular attention. 
Water was then offered him to drink, which he took, and carried to his mouth, 
but drew his head from it with a convulsive shudder. After this, on the same 
morning, he was much questioned by several persons about the supposed cause 
of his illness; and water was again brought him, which agitated him, and he 
became exceedingly distressed and unquiet, complaining of the air which blew 
upon him. 

I first saw him myself soon after this. He was then, to all outward appear- 
ance, well ; lying on his back, without spasm, without anxiety ; his face some- 
what flushed. He said he had a little headache, but no pain in the arm. His 
pulse was 132, full, and strong; his tongue moist, and slightly furred. He ap- 
peared to be a very quiet, good-tempered man ; and smiled generally when he 
was spoken to. 

I was naturally much interested by this case, and at nine in the evening I visited 
the patient again. He was composed and tranquil. Gruel was mentioned, and 
then he sighed two or three times deeply ; then sat up, and, afier a moment's look 
of serious terror, took half a spoonful of the gruel in a hurried gasping manner; 
and said he would not take more at a time, lest the sensation should come on. 
He was desired to drmk the last portion of the gruel from the basin. He accord- 
ingly seized it with hurry, carried it to his mouth with an air of determination, 
and then a violent choking spasm of the muscles about the throat ensued, the 
sterno-mastoidei starting strongly forwards. Most of the gruel was spilled over 
his chin ; and he observed that he had been too much in a hurry, or he should 
have managed it. 

The treatment consisted in full doses of opium, repeated at frequent intervals. 
On this visit to him I noticed, that while attempting to take some of the gruel 
with a spoon, he seemed inclined to doze as he sat. Otherwise there were no 
signs of his being overwhelmed, or even sensibly affected by the opium, unless 
indeed his general quietness was the consequence of it. He was quite rational 
and calm, except when attempting to take fluids. 

On the Wednesday, at noon, he was in nearly the same state, but said he was 
better. In the course of the night some morsels of ice had been given him: with 
considerable effort he swallowed two or three of these ; the third or fourth caused 
so much spasm, however, that he was obliged to throw it out of his mouth: but 
so great was his resolution that he seized it again, and, by a strong exertion, suc- 
ceeded in swallowing it. He complained now that his mouth was and had been 
clammy; and he champed much, and spat out a good deal of tough mucus. At 
his own request, and (as he said) that he might injure no one, a straight-waistcoat 
was brought, which he assisted in putting on. But he was perfectly tranquil 
then. 

I now had an opportunity of seeing him take some arrow-root. He sat up in 
bed to eat it; and before attempting to do so, he made hurried inspirations, and 
sobbings precisely resembling those which occur when one wades gradually into 
cold water. He swallowed small quantities of arrow-root eight or nine times, 
with hurry and difficulty, and with sighs that succeeded each other rapidly. He 
said that he felt the upper part of his throat narrower than it should be. He con- 
tinued to take laudanum mixed with sugar and bread into a kind of pulp. 

By the evening of that day the disease had not made much further progress. 
He again sat up and tried to eat some thinnish gruel. While taking the basin 
into his hand, he drew back his head to a distance from it, apparently involun- 
tarily. He took one half-spoonful with effort and distress, then sighed deeply 
and rapidly, or rather his breathing consisted of a succession of sighs at short 
intervals: he gave up the basin, and sank back on his pillow still sighing. In the 
course of that night he ceased to take the laudanum ; he could no longer attempt 
it. The next day he was still composed, though more easily irritated ; and it was 
found that he had lost the power of moving the left arm. His pulse was 140, and 



370 



HYDROPHOBIA. 



much weaker than before, and his mental powers were failing. He gradually 
sank, and died in the evening, having repeated the Lord's Prayer an hour previ- 
ously. During the last hours of life he had been moaning, and tossing from side 
to side: his bowels were purged; fluid stools ran from him, and distressed him 
greatly. His lower extremities first became cold, and the coldness extended by 
degrees up to his chest. He hawked up in the course of the day a considerable 
quantity of ropy mucus, and much frothy saliva came from his mouth towards 
the close. As his wife was wiping this away, his teeth, whether by convulsive 
accident or otherwise, came in contact with her finger, and drew blood. The 
part was cut out ; and no bad consequence followed that I know of. 

The examination of his body threw no satisfactory light upon the essential 
nature of the disease. Blood and serous fluid escaped on the removal of the cal- 
varium. The vessels of the membranes were full, and the brain itself was mottled 
somewhat by its vascularity. There were a few spots of ecchymosis on the 
heart. The back part of the tongue was very vascular. The stomach presented 
the most notable appearance. There was a quantity of brownish-coloured mucus 
on its inner surface, and the mucous membrane had disappeared from a space 
about four inches in diameter at its left and larger end. That space alone was 
diaphanous; its edges sloped inwards; and a segment of this thin place looked 
exactly like a piece of china. On a white ground, there were inosculating ves- 
sels, some of them blue, and some of them of a coffee-coloured brown. I con- 
clude that this appearance was produced by the action of the gastric juice after 
death. 

This was in some respects a remarkable case. It was remarkable for its dura- 
tion. Dr. Bardsley, in the article on Hydrophobia in the Cyclopsedia of Practical 
Medicine, states that the patients " invariably go on from bad to worse, and finally 
die before the sixth day." Now if we reckon that stage of the complaint here 
referred to by Dr. Bardsley to have begun on the morning of Friday, when he 
was obliged to omit his sponging because of the spasm about his throat, this 
patient did not die till the middle of the seventh day. In fact it was a very pro- 
tracted case; and the symptoms were less violent than usual. Whether this was 
owing to the opium he took or not, it would be difficult to determine. 

In the second of the two cases which it has been my lot to witness, the charac- 
teristic symptoms of hydrophobia were more faintly pronounced than is usual. 

On my arrival at the Middlesex Hospital, on Thursday, the 5th of October, 
1837, I was told that a patient had been admitted (under one of my colleagues) 
labouring probably under hydrophobia. He had applied at the hospital in the 
middle of the night; but was then sent away, after receiving some aperient pills, 
with assurances that he was only feverish and nervous. On his reapplication in 
the morning he had been admitted. 

I found him in the ward: a man twenty-five years old, of dark complexion and 
hair. He expressed his conviction that he was afflicted with hydrophobia; and 
said he was prepared for his fate. I observed that every now and then he sud- 
denly sighed in a very peculiar manner; just as I had seen the former patient 
sigh. This would happen sometimes in the middle of a sentence, while he was 
speaking. He told us that he had been bitten by a dog in the latter end of July ; 
the dog was swimming, and like to drown, in a canal, and upon his reaching over 
to lift him out of the water, the animal seized upon his hand. After dragging the 
dog out, he beat him for his ingratitude ; and then the dog ran off, and was pursued 
by a mob of boys, who had previously been pelting him as a mad dog. There 
was a scar on the middle finger of the right hand ; the nail of that finger had (he 
said) been torn through, and each of the two adjacent fingers had been more 
slightly bitten. His pulse was 84; but varied in frequency at short intervals. 

He acknowledged that after receiving the bite he was uneasy as to its possible 
effects, and read books about hydrophobia at the time: but he affirmed that he 
had afterwards ceased entirely to think about it. He had persuaded himself that 
the dog could not be mad, from its being in the water. On Tuesday, if not earlier, 



HYDROPHOBIA. 



371 



he had been uncomfortable and restless; and on Wednesday he found he could 
not swallow liquids. On one of these days he experienced a slight pricking 
sensation, without any redness or tenderness, in the site of the scar; his right 
arm and leg seemed to himself hotter than the opposite limbs ; and the arm, 
though not tender, felt raw, and he could not bear the light contact of his clothes 
upon it. He became feverish also. From time to time a slight expression of 
terror passed across his features, and then he made a sudden, deep, sighing inspi- 
ration : at other times his breathing and appearance were perfectly natural. It 
was said that when some water was brought him he drew himself back from it 
with horror. He talked a good deal. 

I saw him eat rice, made pulpy with milk. He took it without looking at the 
spoon, from which he averted his eyes, and ate several mouthfuls, in a gulping 
manner, and with evident effort. His bowels had been purged by the pills, and 
he declared that the noise of the water in the water-closet had distressed him. 
The sound of some water poured from one vessel into another by the patient in 
the next bed, had also agitated him. So did the contact of my cold hand on his 
arm ; and currents of air, even the breath of any one speaking to him ; so that he 
insisted on conversing with the apothecary in such a position that the chin of each 
was upon the other's shoulder. But there was no actual or apparent spasm. 

At this time he affirmed ihat the presence of company cheered him, and did 
him good ; and begged that he might not be removed into a separate room. And 
he wished for some amusing book that he might read. 

In the evening I again went to see him. He did not seem worse, though he 
said "his symptoms were increasing." He had taken a dose of musk and some 
morphia. 

The next day I found the hospital in some confusion. Between eleven and 
twelve o'clock in the preceding night some of the officers of the hospital had gone 
to his bed, while he was apparently asleep, and certainly very quiet. They 
asked him if he would like some water. This seems to have greatly excited him ; 
and immediately after their departure he rushed out of bed, (terrified he said,) 
became furious and unmanageable, and was never again tranquil till he died, about 
the same time next night. He was now put into a room by himself; and, taking 
advantage of the momentary absence of the nurse, he bolted himself in alone ; 
and declared he would admit no person but her. The door was at length forced, 
and a straight-waistcoat was put upon him. He then became quieter in his man- 
ner; begged that no unnecessary violence might be used ; asked to be poisoned ; 
spat at some of the bystanders, and reproached them, talking rapidly and wildly 
like an insane person ; yet loudly and angrily imposing silence on every one who 
addressed him. He said he could not bear to hear any one speak ; that he did 
not like my bass voice. Then he would sneer at the students, and say they 
showed bravery enough now he was confined : " Was it right for young gen- 
tlemen of education to stand there gazing with curiosity on a dying man?" 
asked for bread soaked in water, and when it was held towards him, snatched it 
in his mouth in a savage manner; spoke of his "poisoned tooth," and talked 
perpetually. He took a fancy to one of the students, and begged that he might 
remain with him. 

About this time he vomited some yellow fluid, and thought he felt the better 
for it, and asked for an emetic; and some tartarized antimony was exhibited. He 
was now pale, and his lips were livid; but none of the distinctive spasmodic 
attacks occurred : indeed water was not at this time suffered to be N brought near 
him. This circumstance it was, this absence of the peculiar spasmodic paroxysms 
which characterize hydrophobia, that induced several medical men of much saga- 
city and experience to doubt, and even with some positiveness to deny, that the 
patient was suffering under that disease at all. They supposed him to be hysteri- 
cal, half-crazy, or on the brink of delirium tremens. But though slightly ex- 
pressed, the symptoms were unlike any thing I had ever witnessed, except in the 
previous instance. And the closing scene was quite distinctive. 



372 



HYDROPHOBIA. 



It appeared, and he spoke of it as a thing which distressed him, that when he 
was most excited, his urine passed involuntarily. 

In the evening I found his father with him. He had recognized him, and kissed 
his mother-in-law ; but soon began to rave, and to be apparently occupied with 
absent persons. He was pale and weak, and lay with his head over the side of 
the bed, spitting continually upon the floor, which was thus made quite wet. He 
wished to have his hands at liberty that he ntight M clear his mouth." He was 
soliloquizing when I went inio the room in this way : " Monsters — monsters- 
see that monster, Susan — take her away." (It appeared that he was now speak- 
ing of a young woman who had had a child by him.) " I thought they would 
do much for science, but never supposed they would inflict such agony as this ;" 
and so on. 

A little later Mr. Arnott visited him. He had then no pulse at the wrist. The 
waistcoat was removed. He sat up, and used some water, brought to wash his 
hands, without apparent distress. Soon after he sank back exhausted ; and ex- 
pired. 

His father corroborated what the patient had said of the dog ; and told us his 
son was clever, and better educated than many of his rank (he was a tailor), but 
always exceedingly nervous. 

The body was examined the next day. Its posterior and undermost surface 
was very livid. The blood everywhere quite fluid. The veins of the spinal 
cord, on its posterior part, were turgid ; not at all so on the anterior. The substance 
of the cord was quite natural. There was some fluid in the theca. The brain 
appeared to me, in every part, quite sound and healthy. 

The head and face, which had been hanging over the table while the spinal 
canal was opened from behind, were deeply purple as though universally bruised. 
This colour diminished rapidly after the corpse was placed supine, and the head 
raised somewhat above the level of the body. The papillae at the^back part of the 
tongue were greatly exaggerated, and looked like large vesicles. The cartilage of 
the epiglottis, at its lower part, was red. At about the middle portion of the 
oesophagus there was an appearance as if the cuticle was abraded. The mucous 
membrane of the stomach was soft, and red here and there, with a dotted injec- 
tion resembling ecchymosis, especially on its rugae. The air-passages were ap- 
parently healthy. 

Generally, the disease, when it has once set in, and shown the peculiar hydro- 
phobic symptoms, runs a short and fierce course. The nervous irritability be- 
comes extreme. The peculiar paroxysms of choking spasm, and sobbing, are 
excited, not only by attempts to swallow liquids, but by the very sight or sound 
of them. Dr. Elliotson mentions a boy who was thrown into a state of violent 
agitation by hearing a dresser who sat up with him make water. The passage 
of a gust of wind across his face, the waving of a polished surface, as of a mirror, 
before his eyes, the crawling of an insect over his skin, is often sufficient to excite 
great irritation, and the peculiar strangling sensation about the fauces, in a hydro- 
phobic patient. These circumstances were but little observable in the men whose 
cases I have related. The first of them indeed was remarkably calm and tranquil 
under the disease. In general the patient is dreadfully irritable, and apprehensive 
and suspicious ; and in most cases there is a degree of mania or delirium mixed 
up with the irritability ; the sufferer is very garrulous and excited. In this 
respect there is a marked difference between hydrophobia and tetanus. In the 
latter disorder the mental faculties are clear, and the patients serene, and what is 
called heart-whole, to the last. The two diseases differ in another striking par- 
ticular : the spasm in the one case is tonic, in the other clonic. In tetanus, again, 
there is no thirst, and seldom any accumulation of tough and stringy mucus in the 
fauces and about the angles of the mouth; in hydrophobia both these symptoms 
are always, I believe, present. So probably is vomiting ; but vomiting in tetanus 
is rare. The nervous irritability in hydrophobia is doubtless a part of the disease, 



HYDROPHOBIA. 



373 



and is very seldom absent even now-a-days. Sometime ago it might perhaps have 
been plausibly attributed to the treatment adopted. I allude to that period in 
which it was believed that these miserable persons had both the power, and the 
inclination, to impart the disease to others by biting them; and when, under pre- 
tence of shortening his sufferings, but really, I am afraid, with the cowardly view 
of protecting themselves, his friends were accustomed to smother the unhappy 
patient between two feather-beds, or to open a vein, and to leave him to bleed to 
death. Any person suspecting what was the matter, and foreseeing such a ter- 
mination to his disease, might well be nervous and irritable. But now that this 
barbarous practice has been exploded, and the dread of being smothered does not 
occur to the mind of the patient, he is still found to be exquisitely irritable and 
timorous. The foam and sticky mucus that gather in the throat and mouth, these 
patients make great efforts, by spitting and blowing, to get rid of; and the sounds 
they thus produce have been exaggerated by ignorance and credulity into the 
barking and foaming of a dog. In the same way the paraplegia which sometimes 
takes place, rendering the patient unable to stand upright, has been misconstrued 
into a desire on his part to go on all fours like a dog. The pulse, though it may 
be strong and hard at the outset, becomes, in a short time, frequent and feeble, and 
the general strength declines with great rapidity. Death occasionally takes place 
within twenty-fours after the commencement of the specific symptoms. Most 
commonly of all it happens on the second or third day ; now and then it is post- 
poned to the fifth day ; and in still rarer instances, of which my first case was 
one, death does not occur till the seventh, or eighth, or ninth day. In most cases 
the paroxysms becoming more violent and frequent, exhaust the patient; hut in a 
few instances the symptoms undergo a marked alteration before death. The 
paroxysms cease, the nervous irritability disappears, the patient is able to eat and 
drink, and converse with ease; those sights and. sounds which so annoyed and 
distressed him before, no longer cause him any disquiet. In this state he often 
sinks into a sleep, and suddenly wakes from it to die : sometimes his existence is 
put an end to by a sudden and violent convulsion. 

It is needless for me to go into a minute account of the morbid appearances 
that have been met with in persons dead of hydrophobia. They are various, 
uncertain, unsatisfactory. In some bodies the most careful examination has dis- 
covered nothing amiss. In others, vascularity of the brain, or of the spinal cord, 
has been noticed. And in not a few instances the mucous membrane of the fauces, 
oesophagus, and stomach — or of the larynx and trachea — or of both these tracts — 
has been found red, and covered with adhesive mucus. But w r e must take care 
not to attribute undue importance to these last appearances — not to conclude that 
they have been the cause of the symptoms, when, in truth, they may have been 
the effect of the disease. That we should find the parts in the throat red and 
congested is what we might naturally expect, when we consider the violent strain- 
ing spasmodic action of these parts for some time before deatii. The morbid 
anatomy of this disease throws but little light upon its nature, or upon its proper 
treatment. 

There are many very interesting questions connected with hydrophobia. I 
will state the principal of these as shortly as I can. 

1. You will be surprised when I tell you that some persons have made it a 
question whether there is any such disease at all. I have known such. The 
late Sir Isaac Pennington, who was Regius Professor of Physic at Cambridge, 
had never seen a case of hydrophobia, and nothing could persuade him that any 
one else had seen any thing more than a nervous complaint produced by the 
alarmed imagination of the patient, who, having been bitten by a dog reputed to 
be mad, and having, the fear of feather beds before his eyes, was frightened into 
a belief that he had hydrophobia, and ultimately scared out of his very existence. 
Now if you meet with such incredulous persons, and think it worth your while to 
argue the point with them, you may object to their unbelief, the improbability that 
so many persons who have been bitten by mad dogs should have suffered so pre- 



374 



HYDROPHOBIA. 



cisely the same train of symptoms, and at last have died, from the mere force of a 
morbid imagination. You may urge them with the fact that many of these per- 
sons have been under no apprehension at all until the disease has seized upon 
them ; that many also have been men of naturally strong and firm minds, not at 
all likely to be frightened into believing that they were seriously ill unless they 
really were so, and still less likely to be terrified into their graves. And if this 
has no weight with such reasoners, you may bring forward the conclusive facts 
that the disease has befallen infants and idiots, who had never heard or understood 
a word about mad dogs or hydrophobia, and in whom the imagination could have 
had no power in calling forth the complaint. And if they are proof against this, 
you must give them up: I can suggest nothing more. 

2. Allowing that the disease exists as a real, and not merely imaginary disease, 
and also that it is caused by the bite of a rabid animal : this important question 
arises — has it any other cause ? 

Setting aside that quibbling application of the term hydrophobia, which some 
writers have chosen to make, to diseases in which, from some painful affection of 
the throat, the patients have been unwilling to attempt to swallow fluids, there are 
cases recorded, exactly resembling hydrophobia in their symptoms, and occurring 
in persons who were never known to have been bitten by, or even to have been 
in the presence of, a rabid animal. The celebrated and accurate Pinel has given 
the history of such a case. There is another by Savirotte, in the Journal des 
Savans (August, 1757). Now it is just possible that this disease may sometimes 
develop itself in the human body without any contagion having been applied: and 
it is also possible, and much more probable, in my judgment, that the poison may 
have been applied without the person's being aware of it. We shall see, by and 
by, some very possible ways in which that might happen. All that we need 
concern ourselves with practically, is this — that in 999 cases out of 1000 the dis- 
ease in the human body is derived from a rabid animal. If it ever be spontaneous, 
we cannot reckon upon meeting with such a case : indeed, many medical men 
pass through life without witnessing the disorder at all. 

3. Granting, then, that the disease in man is the result of an animal poison, 
the next question is, from what animals may he receive the infection 1 

We are sure that the disease, by the inoculation of which hydrophobia may be 
produced in man, is common in the dog, and that it has been communicated to 
the human animal by the fox also, the wolf, the jackal, and the cat. Mr. Youatt 
says that the saliva of the badger, the horse, the human being, has undoubtedly 
produced rabies, .and some affirm that it has been propagated even by the hen and 
the duck. The same author mentions a case in which a groom became affected 
with hydrophobia through a scratch which he received from the tooth of a horse 
that was labouring under the disease. All animals, even fowls, are susceptible of 
the disorder when bitten by the rabid dog. Of course it is an important question 
to have resolved, whether the saliva of all these is capable of conveying the malady. 
The case just now mentioned on Mr. Youatt's authority would seem to settle the 
question as respects the horse ; but as horses, cows, turkeys, &c, do not generally 
bite, we have not many opportunities of supplying a positive answer to the gene- 
ral question : there can be no doubt about the cat, the fox, the ivolf, and the 
jackal. 

The late Duke of Richmond died abroad of hydrophobia, communicated, it was 
thought, by a tame fox. In the 13th volume of the Medico- Chirurgical Trans- 
actions, an account is given by Mr. Hewitt, of several cases of fatal hydrophobia 
from the bite of a wild and rabid jackal. Many examples are on record of the 
production of the disease by the bites of mad cats and wolves. 

The first case which I have spoken of, as having been seen by myself, would 
seem to prove, if all the facts were correctly stated at the time, that the saliva of 
the dog may be sufficient to produce the disease, when it is merely applied to the 
unbroken skin. It was affirmed by various persons that the teeth of the terrier 
did not break the cuticle. But we must take care not to draw a hasty general 



HYDROPHOBIA. 



375 



inference from a single case. Mr. Youatt, who has seen more of the disease 
probably both in man and in other animals, than any person alive, does not think 
that the saliva of a rabid animal can communicate the disorder through the un- 
broken cuticle: he believes that there must be some abrasion or breach of surface. 
He holds, however, that it may be communicated by mere contact with the 
mucous membranes. 

Of its harmlessness on the sound integument he offers this presumption — that 
his own hands have many times, with perfect impunity, been covered with the 
saliva of the mad dog. He mentions some singular instances in which the disease 
has been transmitted by contact of the saliva with the mucous membranes. " A 
man endeavoured to untie with his teeth a knot that had been firmly drawn in a 
cord. Eight weeks afterwards he perished, undeniably rabid. It was then recol- 
lected that with this cord a mad dog had been confined. A woman was attacked 
by a rabid dog, and escaped with the laceration of her gown. In the act of mend- 
ing it she thoughtlessly pressed down the seam with her teeth. She died." If 
these cases be authentic, they are conclusive of this question; unless, indeed, the 
lips of those who perished happened to have been chapped or abraded. But Mr. 
Youatt's own opinion is, that the virus cannot be received on a mucous surface 
without imminent danger. 

The disease is said to have been caused by the scratch of a cat. But as we 
know that cats as well as dogs frequently apply their paws to their mouths, espe- 
cially when the latter part is uneasy, (as it clearly is in mad dogs,) this fact, of 
the production of the disease by a scratch, if thoroughly made out, would not 
prove that the disease can be introduced into the system in any other way than 
by means of the slaver. 



LECTURE XXXIV. 

Hydrophobia, concluded. Various Questions considered respecting the Disease 
as it appears in the Human Subject, and respecting Babies in the Hog. Pa- 
thology of the Disorder. Treatment. Preventive Measures. 

After giving you some account of the phenomena of hydrophobia, or rabies 
canina, I began to notice, in the last lecture, the chief of the interesting questions 
which naturally present themselves to the minds of most men, and especially of 
medical men, in respect to that shocking disorder. 

In the first place, there is such a disorder. It appears, too, secondly, from 
statements made upon credible authority, that the same group and succession of 
symptoms as characterize the disease when it is produced by the bite of a rabid 
animal, have been observed to occur in persons who were never known to have 
been bitten. In my own opinion it is more probable that these persons had been 
exposed to the virus without being aware of it, than that the disease was sponta- 
neously engendered in their bodies. I would make the same remark with regard 
to an instance which is said to have happened of hydrophobia in a lad who had 
been bitten five weeks before by a healthy dog: the dog remaining well at the 
time of his seizure and death. Mr. Youatt holds, indeed, that however the disease 
originated, it never occurs now, not even in the dog, except as a consequence of 
the application of the specific contagion. It is certain, in the third place, that 
(besides the dog) the wolf, the fox, the jackal, and the cat, have communicated 
the disorder to the human animal. Mr. Youatt affirms, that the saliva of the 
badger, of the horse, and of the human being, has caused rabies ; and I mentioned, 
on his authority, a case in which a groom contracted the disease through a scratch 
which he received while administering a ball to a rabid horse. But I feel much 
less certain about these latter animals. Respecting the dog, the fox, the wolf, 



376 



HYDROPHOBIA. 



the jackal, the cat, there can be no question. The result of certain experiments 
made at the Veterinary School, at Alfort, is opposed to Mr. Youatt's statement. 
Professor Dupuy made wounds in cows and sheep, and rubbed upon these wounds 
sponges which had been chewed by rabid animals of the same species : yet he 
never succeeded in communicating the disorder in this way; but when he used a 
sponge that had been mumbled by a mad dog, then the disease occurred in the 
sheep and cows. 

It is still more interesting to inquire, whether the saliva of a human being, 
labouring under hydrophobia, is capable of inoculating another human being with 
the same complaint? Mr. Youatt says yes: that the disease has undoubtedly 
been so produced. If this be so, the fact will teach us— not to desert or neglect 
these unhappy patients, still less to murder them by smothering — but to minister 
to their wants with certain precautions : so as not to suffer their saliva to come in 
contact with any sore or abraded surface ; nor, if it can be avoided, with any 
mucous surface. On the other hand, all carefulness of that kind will be unneces- 
sary, if the disease cannot be propagated by the human saliva. Certainly many 
experimenters have tried in vain to inoculate dogs with the spittle of a hydrophobic 
man ; but there is one authentic experiment on record, which makes it too proba- 
ble that the disease, though it may not be communicant/ often, or easily, is yet 
communicable. The experiment is said to have been made by MM. Magendie 
and Breschet, at the Hoiel-Dieu, and to have been witnessed by a great number 
of medical men and students. Two healthy dogs were inoculated, on the 18th of 
June, 1813, with the saliva of a patient, named Surlu, who died of hydrophobia 
the same day in that hospital. One of these dogs became mad on the 27th of the 
following month. They caused this dog to bite others, which, in their turn, 
became rabid also : and in this way they propagated the malady, among dogs, 
during the whole summer. Now this is a very striking fact, yet it ought not to 
be considered conclusive : for it is possible that the dog might have gone mad at 
that time, whether he had been so inoculated, or not. It may have been a mere 
coincidence. We want repetitions of such experiments to settle the point: never- 
theless, we have enough in this one experiment to make us use all necessary 
caution when engaged in attending upon a hydrophobic patient. 

I just touched upon the question, whether the saliva of a rabid dog could pro- 
duce the disease if it fell upon the sound skin ? The first of the two cases which 
I related as having been witnessed by myself, would appear to give an affirmative 
answer to this question. Mr. Youatt thinks the disease would not follow such an 
application of the virus; but that it cannot be received upon even the unbroken 
surface of a mucous membrane without the greatest danger. Horses are said to 
have died mad after eating straw upon which rabid pigs had died. Portal was 
assured that two dogs, which had licked the mouth of another dog 1 that was rabid, 
were attacked with rabies seven or eight days afterwards. Mr. Oilman, of High- 
gate, in a little pamphlet on Hydrophobia, quotes an instance from Dr. Perceval, 
in which a mad dog licked the face of a sleeping man, near his mouth, and the 
man died of hydrophobia, although the strictest search failed to discover the 
smallest scratch or abrasion on any part of his skin. 

At the very close of the lecture I observed, that even should it be clearly proved 
that hydrophobia has ever resulted from the scratch of a rabid animal's c/a?#s— 
the claws of a cat, for example — we are not to set it down as a sure thing that 
the disease can be introduced into the system independently of the saliva of the 
diseased animal. As we know that dogs and cats are in the habit of putting their 
paws to their mouths when they feel uneasy there, we may readily understand how 
the poisonous saliva may be introduced by a mere scratch with the creature's nails. 
Mr. Youatt believes that the saliva only is capable of conveying the disease. 

4. Supposing the virus to have been inserted into the part bitten, what becomes 
of it? Is it immediately taken into the system, and does it, like the poison of 
small-pox, in some mysterious way, multiply and diffuse itself in the body, until 
the disease explodes? Or does it remain imprisoned in the wound, or in the 



HYDROPHOBIA. 



377 



cicatrix, for a time? This is an important practical question. For if the poison 
lurks for some weeks in the place where it was originally deposited, we might 
successfully remove it at any time between the infliction of the bite and the period 
of recrudescence. Now, the facts that at this period of recrudescence the wound 
or scar is re-inflamed often, and almost always becomes the seat of some fresli 
morbid phenomena, pain, swelling, numbness and the like, spreading towards the 
trunk — and that, sooji after this, the peculiar paroxysmal symptoms begin — these 
facts are strong in favour of the belief that the poison does lie inert in the place 
of the original hurt, for some lime. Dr. Bardsley states that the recrudescent 
pains seem always to follow the course of the nerves, and do certainly never in- 
flame or irritate the lymphatic glands in the vicinity, though passing in a parallel 
course towards the trunk. He affirms the entire absence of any fact contrary to 
this observation in the works of the numerous authors who have written on the 
subject. I mention this statement because it certainly is not correct. Mr. Mayo 
says, " in one case which I witnessed and examined after death, the inner part of 
the cicatrix was bloodshot ; and a gland in the axilla had swelled at the coming 
on of the hydrophobic symptoms." And I find among my notes of Mr. Aber- 
nethy's lectures, another striking case, still more to the point. " A very intelligent 
boy had been bitten by a dog in the finger: he was brought into St. Bartholo- 
mew's Hospital. Caustic had been liberally used, affecting the sinewy parts, and 
producing a terrible sore: yet the boy was recovering himself, and the sore was 
healing. One day as Mr. Abernethy was going round the hospital, he saw and 
spoke to the boy, who said he thought himself getting well, but that he had that 
day an odd sensation in his fingers, stretching upwards into his hand and arm. 
Going up the arm, Mr. Abernethy saw two red lines, like inflamed absorbents: 
they doubtless were so. He affected to make light of the matter, ordered a poul- 
tice, and recommended the boy to take some medicine. Early the next morning 
Mr. Abernethy visited the ward, pretending he had some other patient there whom 
he wished particularly to see : and when going out again, he asked the boy, in a 
careless tone, how he was. He said that he had lost the pain, but that he was 
very unwell, and had not slept all night. Mr. Abernethy felt his pulse, told him 
he was a little feverish, as might be expected, and asked him if he were not 
thirsty, and would like some toast and water. The boy said he was thirsty, and 
that he should like some drink; when, however, the cup was brought, he pushed 
it from him ; he could not drink. In forty-eight hours he was dead." 

Facts, such as these, would lead to the conclusion that, in cases in which ex- 
cision had not been performed in the first instance, the scar or the sore might be 
cut out with propriety at any time before the period of recrudescence: and if the 
case happened to be my own, I would have this done even at that period, the mo- 
ment any new sensation manifested itself in the seat of the injury. Mr. Mayo, 
on the same grounds, advocates the removal of the cicatrix, even although the 
hydrophobic symptoms may have appeared. I do not mean to say that the facts 
now referred to, show with any certainty that the poison remains in the place 
where it was first deposited, until the phenomena of recrudescence take place: 
but they afford some presumption in favour of that notion ; and in such a disease 
as hydrophobia, we are bound to act upon the very lowest presumption that affords 
a chance for our patient's life. The poison may be absorbed into the general sys- 
tem at the period of recrudescence, although no affection of the absorbing vessels 
or glands should be manifest : through the veins, namely. 

Considering the matter philosophically, we might be inclined to suppose that 
the poison was silently maturing its force in the general system during the period 
of incubation, just as the poisons of small-pox and of measles are presumed to 
do. But looking at it practically, I should recommend, under the circumstances 
already stated, the excision of the cicatrix. 

5. Another important question is this. Is a man who has been bitten by a 
mad dog, and in whose case no precautions have been taken, a doomed man? 
will he be sure to have the disease, and therefore to die of it? By no means. 



378 



HYDROPHOBIA. 



But few, upon the whole, of those who are so bitten, become affected with 
hydrophobia. 

It is curious that different species of animals appear to be susceptible of hydro- 
phobia in different degrees. Thus, according to Mr. Youatt, two dogs out of 
three, bitten by one that is rabid, become rabid. The majority of horses inocu- 
lated with the virus, perish. Cattle have a better chance : perhaps because in 
them the skin is looser and less easily penetrated. A full half (he thinks) of 
those that were seized by a mad dog, would escape. With sheep the bite is still 
less dangerous. He reckons that not more than one in three would be affected. 
The tooth, perhaps, has been wiped clean in its passage through the wool. The 
human being is least of all in danger. John Hunter states that he knew an in- 
stance in which, of twenty-one persons bitten, one alone fell a victim to hydro- 
phobia. Dr. Hamilton estimates the proportion to be one in twenty-five. But I 
fear these computations are much too low. In 1780, a mad dog, in the neigh- 
bourhood of Senlis, took his course within a small circle, and bit fifteen persons 
before he was killed : three of these died of hydrophobia. The slaver of a rabid 
wolf would seem to be highly virulent and effective. These beasts fly always, I 
believe, at a naked part. Hence, probably, the fatality of their bites. The fol- 
lowing statement applies exclusively to the wolf. In December, 1774, twenty 
persons were bitten in the neighbourhood of Troyes ; nine of them died. Of 
seventeen persons similarly bitten in 1784, near Brive, ten died rabid. In May, 
1817, twenty-three persons were bitten and fourteen perished. Four died out of 
eleven that were bitten near Dijon : and eighteen of twenty-four bitten near Ro- 
chelle. At Bar-sur-Ornain, nineteen were bitten, of whom twelve died of hydro- 
phobia within two months. Here we have one hundred and fourteen persons 
bitten by rabid wolves, and among them no less than sixty-seven victims ; con- 
siderably more than one-half. There is no doubt, however, that the majority of 
persons who are bitten by a mad dog escape the disease. This may partly be 
owing to an inherent inaptitude for accepting it. We see some persons who, 
though often in the way of it, do not contract syphilis ; there are others upon 
whom the contagion of small-pox has no influence. This difference exists, appa- 
rently, efen among dogs. There was once a dog, at Charenton, that did not 
become rabid after being bitten by a rabid dog ; and it was so managed that, at 
different times, he was bitten by thirty different mad dogs ; but he outlived it all. 
Much will depend also upon the circumstances and manner in which the bite is 
inflicted. If it be made through clothes, and especially through thick woolen 
garments, or through leather, the saliva may be wiped clean away from the tooth 
before it reaches the flesh. In the fifth volume of the Edinburgh Medical and 
Surgical Journal, there is a case described by Mr. Oldknow, of Nottingham, in 
which a man was bitten in three different places by the same dog; viz., in the 
scrotum, the thigh, and the left hand ; the bite on the hand was the last. Now it 
seems not improbable that but for this last bite, on a naked part, he might have 
escaped. At least it was a remarkable circumstance that the phenomena of re- 
crudescence occurred only in the hand and arm. The dog is supposed to have 
closed his mouth after inflicting the first two bites ; and thus to have charged his 
teeth afresh with the poisonous saliva. 

It is this frequent immunity from the disease in persons who have been bitten, 
that has tended to confer reputation upon so many vaunted methods of preven- 
tion. Ignorant persons, and knavish persons, have not failed to take advantage 
of this. They announce that they are in possession of some secret remedy which 
will prevent the virus from operating: they persuade the friends of those who die 
that the remedy was not rightly employed, or not resorted to sufficiently early : 
and they persuade those who escape that they escape by virtue of the preventive 
remedy. If the plunder they reap from the foolish and the frightened was all, 
this would be of less consequence: but unfortunately the hope of security with- 
out undergoing a painful operation, leads many to neglect the only sure mode of 
obtaining safety. 



HYDROPHOBIA. 



379 



Mr. Youatt is of opinion that the power of the virus ceases with the life of the 
animal. He states, that in many dissections of the dog, the saliva, in spite of all 
care, must have come in abundant contact with his hands, and they were not 
always sound. I should strongly recommend you not to act upon this opinion : 
but to use the same precautions, in dissecting a rabid animal, as you would use if 
you were persuaded that the disease might be communicated with equal certainty 
before and after the death of the animal. 

6. A still more anxious inquiry next arises. Whoever has been bitten by a 
rabid or a suspected animal, must be considered, and will generally consider him- 
self as being in more or less danger of hydrophobia. This dread is not entirely 
removed, even by the adoption of the best means of prevention. Now, how long 
does this state of hazard continue? When is the peril fairly over? After what 
period may the person who has received the injury lay aside all apprehension of 
the disease ? To this inquiry no satisfactory reply can be given. In a vast majo- 
rity of instances, indeed, the disorder has broken out within two months from the 
infliction of the bite. But the exceptions to this rule are too numerous to permit 
us to put firm trust in the immunity afforded by that interval. Cases are recorded 
in which five, six, eleven, nineteen months have intervened, between the insertion 
of the poison and the eruption of the consequent malady. Nay, in one instance, 
three years are said to have elapsed, and in another the enormous period of twelve 
years. In these cases one cannot help supposing that some unsuspected re-inocu- 
lation, some fresh application of the peculiar virus, must have taken place. If 
not, then we must conclude that the poison really lies imprisoned in the part; and 
only becomes destructive when, under certain obscure conditions, and at indefi- 
nite periods, it is set afloat in the circulating blood. 

It is interesting to know that the same uncertainty of access has been noticed 
among infected dogs. On the night of the 8th of June, 1791, the man in charge 
of Lord Fitzwilliam's kennel was much disturbed by the hounds fighting; and 
got up several times to quiet them. On each occasion he found the same dog 
quarreling; at last, therefore, he shut that dog up by himself, and then there was 
no further disturbance. On the third day afterwards, the quarrelsome hound be- 
came unequivocally rabid ; and on the fifth day he died. The whole pack were 
thereupon separately confined and watched. Six of the dogs became subsequently 
mad ; and at the following widely different intervals from the 8th of June, viz., 
23 days, 56, 67, 83, 155, and 183 days. 

There are some considerations respecting this disease which relate both to the 
biter and the bitten ; the canine and the human being. And there are some which 
relate exclusively to the dog, yet concerning which, we, as medical philosophers, 
ought not to be ignorant. I shall advert to a few of these. 

One question I have already glanced at, viz., whether the disease may be pro- 
duced by a healthy, though angry dog or cat. I referred to one instance in which 
this was supposed to have been the case ; and I repeat that I should be more in- 
clined to think, unless we had other examples of the same kind, that the person 
had been inoculated in some way that he was not aware of. But I have heard 
Mr. Youatt describe cases in which there had been no symptoms of rabies ob- 
served in the dog at the time the injury was inflicted, though soon afterwards the 
animal became decidedly rabid. It is much to be regretted that the dog is so often 
destroyed. When a person has been bitten by a dog or cat suspected to be rabid, 
the beast ought by no means to be killed, but to be secured and kept under sur- 
veillance, and suffered, if it shall so happen, to die of the disease. If he does 
not die, in other words, if he is really not rabid, that will soon appear ; and the 
mind of the patient will then be relieved from a very painful state of suspense 
and uncertainty, which might otherwise have haunted him for months or years. 
If the dog dies mad, the injured person will be no worse off than if the animal 
had been killed in the first instance: nay, in one respect, he will be better off, 
inasmuch as certainty of evil is preferable to perpetual and uneasy doubt. " Give a 
dog a bad name (says the proverb), and hang him :" and it is literally so with the 



380 



HYDROPHOBIA. 



imputation of madness. A poor wretch of a dog is perhaps ill, or weary, or cross, 
or he may have been worried already by mischievous boys: the cry of mad dog 
is raised ; and then he can expect no mercy. There are gross errors prevalent 
with regard to the signs of madness in the dog. If a dog be seen in a lit in the 
street, some person charitably offers a conjecture that perhaps he may be mad ; 
the next person has no doubt of it ; and then, woe to that dog ! But Mr. Youatt 
assures us that the rabid dog never has fits: that the existence of epilepsy is a 
clear proof that there is no rabies. Again, it is a very common belief that a rabid 
dog, like a hydrophobic man, will shun water; and if he lakes to a river, that is 
thought to be conclusive evidence that he is not mad. But the truth is, that the 
disease, in the quadruped, cannot be called hydrophobia: there is no dread of 
water, but an unquenchable thirst ; no spasm attending the effort to swallow, but 
sometimes in dogs an inability to swallow, from paralysis of the muscles about 
the jaws and throat. They will stand and lap, lapping, without getting any of the 
liquid down. They fly eagerly to the water; and Mr. Youatt states that all other 
quadrupeds, with, perhaps, an occasional exception in the horse, drink with ease, 
and with increased avidity. This erroneous impression is not confined to the 
vulgar. In the case which I have more than once alluded to, and which is 
mentioned in Hufeland's Journal, of a lad who died of hydrophobia after having 
been bitten by a dog that had not been, and was not then, mad, one circumstance 
stated in evidence of the animal's freedom from rabies is, that he drank without 
difficulty a large quantity of water. 

There is another superstitious opinion not at all uncommon, viz., that healthy 
dogs recognize one that is mad, and fear him, and run away from his presence, 
in consequence of some mysterious and wonderful instinct, warning them of 
danger. This is quite unfounded. Equally mistaken are the notions that the 
mad dog exhales a peculiar and offensive smell, and that he may be known by 
his running with his tail between his legs ; except, as Mr. Youatt says, when, 
weary and exhausted, he is seeking his home. 

It will not be out of place to state what are the symptoms of rabies as observed 
in the dog, and as described by Mr. Youatt. 

The earliest symptoms of madness in the dog (he says), are sullenness, fidgeti- 
ness, continual shifting of posture, a steadfast gaze expressive of suspicion, an 
earnest licking of some part, on which a scar may generally be found. If the ear 
be the affected part, the dog is incessantly and violently scratching it. If it be 
the foot, he gnaws it till the integuments are destroyed. 

Occasional vomiting and a depraved appetite are very early noticeable. The 
dog will pick up and swallow bits of thread or silk from the carpet, hair, straw, 
even dung : and frequently he will lap his own urine, and devour his own excre- 
ment. Then the animal becomes irascible ; flies fiercely at strangers ; is impa- 
tient of correction ; seizes the whip or stick ; quarrels with his own companions ; 
eagerly hunts and worries the cats ; demolishes his bed ; and if chained up, 
makes violent efforts to escape, tearing his kennel to pieces with his teeth. If he 
be at large he usually attacks only those dogs that come in his way ; but if he be 
naturally, ferocious he will diligently and perseveringly seek his enemy. Accord- 
ing to Mr. Youatt, the disease is principally propagated by the fighting dog in 
towns ; and by the cur or lurcher in the country : by those dogs, therefore, which 
minister to the vices of the lower classes in town and country respectively. He 
maintains that if a well-enforced quarantine could be established, and every dog 
in the kingdom confined separately for seven months, the disease might be extir- 
pated. This opinion is founded of course upon the belief that rabies never origi- 
nates at present, any more than small-pox does, spontaneously ; but is always 
propagated by the specific virus. And it' is corroborated by the fact that rabies 
and hydrophobia are unknown in some countries. I fancy that South America 
is, or was, a stranger to it. It appears to have been imported into Jamaica, after 
that island had enjoyed an immunity from the disease for at least fifty years pre- 
viously ; and Dr. Heineken, states that curs of the most wretched description 



HYDROPHOBIA. 



381 



abound in the island of Madeira; that they are afflicted with almost every dis- 
ease, tormented by flies, and heat, and thirst, and famine, yet no rabid dog was 
ever seen there. On the contrary, 1666 deaths from hydrophobia in the human 
subject, are slated to have occurred in Prussia in the space of ten years. 

Very early in the disease, as it appears in the dog, the expression of counte- 
nance is remarkably changed ; the eyes glisten, and there is slight strabismus. 
Twitchings of the face come on. About the second day a considerable discharge 
of saliva commences; but this does not continue more than ten or twelve hours, 
and is succeeded by insatiable thirst : the. dog is incessantly drinking, or attempt- 
ing tp drink : he plunges his muzzle into the water. When the flow of saliva 
has ceased he appears to be annoyed by some viscid matter in his fauces ; and in 
the most eager and extraordinary manner he works with his paws at the corners 
of his mouth to get rid of it: and while thus employed he frequently loses his 
balance and rolls over. 

A loss of power over the voluntary muscles is next observed. It begins with 
the lower jaw, which hangs down, and the mouth is partially open ; but by a 
sudden effort the dog can sometimes close it, though occasionally the paralysis is 
complete. The tongue is affected in a less degree. The dog is able to use it in 
the act of lapping : but the mouth is not sufficiently closed to retain the water. 
Therefore, while he hangs over the fluid, eagerly lapping for several minutes, it 
is very little or not at all diminished. The paralysis often attacks the loins and 
extremities also. The animal staggers about, and frequently falls. Previously 
to this he is in almost incessant action. Mr. Youatt fancies that the dog is sub- 
ject to what we call spectral illusions. He says he starts up and gazes eagerly 
at some real or imaginary object. He appears to be tracing the path of some- 
thing floating around him, or he fixes his eye intently upon some spot in the wall, 
and suddenly plunges at it; then his eyes close, and his head droops. 

Frequently, with his head erect, the dog utters a short and very peculiar howl ; 
or if he barks, it is in a hoarse inward sound, altogether dissimilar from his usual 
tone, and generally terminating with this characteristic howl. Respiration is 
always affected : often the breathing is very laborious ; and the inspiration is 
attended with a very singular grating, choking noise. On the fourth, fifth, or 
sixth day of the disease, he dies : occasionally in slight convulsions : but oftener 
without a struggle. 

Mr. Youatt gives a detailed account of the appearances met with after death in 
the carcases of these rabid dogs. They are not very constant or distinctive. The 
most curious and uniform consist in the presence of unnatural ingesta in the 
stomach: straw, hay, hair, horse-dung, earth. Sometimes the stomach is per- 
fectly distended with these substances ; and when it contains none of them, there 
is a fluid of the deepest chocolate colour mixed with olive; or still darker like 
coffee: and when neither the unnatural ingesta nor the dark fluid appear, it will 
be found, Mr. Youatt says, upon careful inquiry, that the dog has vomited much 
hair, hay, straw, or the like. 

In 1837, a few days after the case of hydrophobia occurred in the Middlesex 
Hospital, I saw the carcass of a dog, that had died rabid, examined by Mr. Ain- 
slie at his and Mr. Yonatt's Infirmary. The most remarkable morbid appearances 
were in the stomach, which contained some bits of straw and stick, and a con- 
siderable quantity of a dark fluid like thin treacle. In various parts of the stomach 
there were spots almost black, of a considerable size ; apparently produced by 
dark blood partly extravasated beneath, and partly incorporated with, the mucous 
membrane. 

I believe that Mr. Youatt's opinion, already mentioned, of the cause of rabies 
in dogs, and in all creatures — viz., that it always results from the introduction of 
a specific virus into the system— I believe this opinion is not commonly enter- 
tained. Most people think that the disease is generated, de novo, in the dog at 
least ; and causes have been assigned for it which certainly are not the true or the 
sole causes. Thus hydrophobia in the dog has been ascribed to extreme heat of 



382 



HYDROPHOBIA, 



the weather. It is thought by many to be particularly likely to occur in the dog- 
days ; and to be, as Mr. Mayo observes, " a sort of dog-lunacy, having the same 
relation to Sirius that insanity has to the moon : which, indeed, in another sense, 
is probably true." Many cautions are annually put forth, about that period, for 
muzzling dogs, and so on : very good and proper advice, but, if those who have 
noted^the statistics of the disease may be depended upon, it would be as appropriate 
at one period of the year as at another. Rabies occurs nearly as often in the 
spring, in the autumn, and even in winter, as it does in summer. M. Trolliet, 
who has written an interesting essay on rabies, states that January, which is the 
coldest, and August, which is the hottest month in the year, are the very months 
which furnish the fewest examples of the disease. The disorder has often been 
ascribed to want of water in hot weather, and sometimes to want of food. But 
MM. Dupuytren, Breschet, and Magendie, have caused both dogs and cats to 
perish with hunger and thirst, without producing the smallest approach to a state 
of rabies. At the Veterinary School at Alfort, three dogs were subjected to some 
very cruel but decisive experiments. It was during the heat of summer, and they 
were all chained in the full blaze of the sun. To one salted meat was given ; to 
the second water only; and to .the third neither food nor drink. They all died ; 
but none of them became rabid. Nor does the supposition that the disorder has 
some connection with the period of sexual heat in these animals appear to have 
any better foundation. 

If you are desirous of knowing what my own opinion on this matter is, I must say 
that I think Mr. Youatt's doctrine by far the most probable one ; that rabies never 
occurs except from inoculation of the specific virus. It has never been proved, 
and indeed it would scarcely be susceptible of proof, that the disease ever breaks 
out spontaneously ; large tracts of country are totally free from it; and in nineteen 
cases out of twenty, perhaps, we trace the bite or the fray in which the inocula- 
tion has been effected. 

If I were asked to define the seat of this terrible disease, I should place it, 
without hesitation, in that division of the nervous system which comprises the 
excito-motory apparatus; the true spinal marrow, with its appendages of afferent 
and efferent nerves. Nay, I should go further, and say that it is the upper part of 
this apparatus, of which the functions are primarily and chiefly deranged : that the 
poison acts mainly upon the nervous arcs which pertain to the throat, and with 
which the eighth pair of nerves in particular is connected. There is nothing sin- 
gular in this localization of the influence of a specific poison. The ergot of rye 
affects principally those arcs which belong to the uterus ; cantharides, those which 
govern the muscular fibres of the bladder. It is true that the mental functions are 
remarkably modified, and that paralysis of the lower extremities occurs, in most 
instances of the disease. But neither of these phenomena is constant; and they 
simply illustrate, when they do happen, the facility with which any morbid state 
of the spinal cord may propagate its influence in either direction. Whether, in hy- 
drophobia, the essential change be centric or eccentric, cannot be determined with 
any thing like certainty: but it seems to me to be most probable that the sensi- 
bility of the afferent nerves of the fauces, of the skin, and of the air-passages, is 
altered or morbidiy exalted; whence, upon the application of the exciting stimu- 
lus, the peculiar sighing dyspnoea, and the strangling dysphagia, are produced by 
a reflected influence through the central axis upon the muscles concerned in these 
actions. But, as I said before, the pathology of the excito-motory apparatus is as 
yet in its new birth. 

What can I say of the treatment in hydrophobia, or in rabies? There is no 
well-authenticated case on record, that I am aware of, in which a hydrophobic 
person has recovered. As it has been, so it is still, Iatpo$ IcLtai 6avato$. The 
physician that cures is death. There can be no ground therefore for the recom- 
mendation of any especial drug, or form of medicine, nor even for any general 
plan of treatment, after the peculiar symptoms of the disease have once set in. 

Of course those powerful remedial agencies that are in common use among 



HYDROPHOBIA. 



383 



medical men, have been fairly tried ; copious blood-letting, mercury, opium, 
arsenic, sugar of lead, oil of turpentine, the cold affusion even : and not only 
those, but the strong poisons that are sometimes, but not so generally, employed 
for other diseases : belladonna, stramonium, prussic acid, white hellebore, strych- 
nia, cantharides, the nitrous oxide gas : and no end of less gigantic remedies ; 
such as alkalies, and especially ammonia, carbonate of iron, electricity and gal- 
vanism, tobacco-juice and the guaco (which was introduced into this country a 
few years ago with high encomiums for its power over the disease), the mineral 
acids, violent exercise : and if we take into account the substances administered 
to the brute also, we may increase this list by the alisma plantago, Scutellaria, 
box, and rue, all of which at one time or another, have been vaunted as success- 
ful remedies, veratrum sabadilla, and licunas poison. 

The difficulty of swallowing fluids, and in some cases of swallowing at all, is 
a serious obstacle to the fair trial of almost every form of internal remedy. It 
has been proposed to introduce powerful medicines into the rectum, in clysters ; 
but to this also the patients have been found to make great resistance. The in- 
jection of medicines into the veins has been tried. Magendie hoped that he had 
discovered a cure, in first largely bleeding the patient, and then injecting his veins 
with a corresponding quantity of warm water: but it has always happened with 
this, and with other promising experiments, that just as the patient seemed to be 
about to recover, he has died. The nervous irritability has in one instance or 
two been much calmed by the injection of a solution of a salt of morphia into the 
veins. In a case treated by Professor Todd the symptoms appeared to be greatly 
mitigated for a time, by applying ice to the cervical portion of the spine, and to 
the fauces. 

Mr. Mayo has suggested bronchotomy : upon this ground (to use his own 
words), "that the principal character of the disease, and the rapid exhaustion 
which attends it, appear to depend in great part upon the fits of spasm and closure 
of the glottis, brought on, not merely by the attempt, or the idea of drinking, but 
by any sudden impression upon the senses. Now it is clear (he adds) that as far 
as the distressing feelings in the throat consist in a sense of suffocation, they 
would be put an end to or relieved by the establishment of a free opening in the 
windpipe." Dr. Marshall Hall would use, in combination with tracheotomy, 
the hydrocyanic acid. Now I should be sorry to say any thing to damp your 
reasonable hope of benefit from any experiment; but I am bound to confess to 
you that I should not expect the smallest advantage from tracheotomy in this dis- 
ease. The mode of death offers no encouragement to its use. There may be 
spasm of the glottis, but I doubt it. At any rate the patients do not die of suffo- 
cation. The death is not death by apnoea, but by asthenia. We see persons 
labouring grievously for their breath for hours together, who yet survive, and are 
presently themselves again ; persons, for instance, who are affected with severe 
spasmodic asthma. I have seen a man sitting up in a bed a whole night long, 
inspiring with such difficulty that, if I had not been aware of his having, scores 
of times, been as bad before, I should not have thought he could exist five 
minutes longer. Now we have nothing of this dyspnoea in hydrophobia : and, 
as I said already, I am sorry, and diffident too, when I differ from great authori- 
ties on practical points, but I see no hope of cure, nor even of sufficient benefit 
to counterbalance the inconvenience and hazard of the operation from the perform- 
ance of bronchotomy. The principle is that of suffering the parts gradually to 
recover themselves, and of allowing the patient in the meanwhile to breathe 
through another channel. The principle is excellent (as I shall show you by and 
by), where there is a permanent obstacle to the admission of air to the luno-s 
through the larynx ; but in hydrophobia there is no such permanent obsta- 
cle to surmount. Though your patient in laryngitis should be at the point of 
death, yet open his wind- pipe, and he breathes again and is safe; but it is not at 
all uncommon for a hydrophobic patient to lose his spasms, to swallow well, and 
to breathe easily, yet he does not recover. This amendment is the prelude of 



384 



HYDROPHOBIA. 



death, the last flicker of the expiring lamp. Since I lectured upon this subject 
last year, Dr. Latham has told me the following circumstance respecting a patient 
whom he treated for hydrophobia, in the Middlesex Hospital. He went one day 
to the ward, fully expecting to hear that the patient was dead. But he found him 
sitting up in his bed, quite calm, and free from spasm : and he had just drank a 
large jug of porter. " Lawk, sir (said a nurse who sat by), what a wonderful 
cure !" The man himself seemed surprised at the change. But lie had no pulse; 
his surface was cold as marble. In half an hour, he sank back, and expired, 
Farthermore the experiment in question has been tried, and it has been tried by 
its proposer, Mr. Mayo, upon the dog, without affording, as Mr. Youatt assures 
us, the slightest relief. In the matter of cure, surgery, I fear, is as impotent as 
physic. 

Not so, however, in the matter of prevention : this is the most important part 
of the practice. The early and complete excision of the bitten part is the only 
measure in which we can put any confidence : and even here we are met with a 
source of fallacy. In the majority of cases, no hydrophobia would ensue, though 
nothing at all were done to the wound. How can we know, then, that the disease 
is ever prevented by its excision ? No doubt many persons go through the pain 
of the operation needlessly. But in no given case can we be sure of this. They 
get at any rate relief from the most harassing suspense, with which they would 
probably have been tortured for months. And if a large number of bitten persons, 
who had suffered the wound to heal as it would, could be compared with an equal 
number who had had the bitten part cut out, hydrophobia would be found a fre- 
quent consequence of the bite in the first class — a very rare consequence of it in 
the second. Mr. Youatt, who trusts to caustic, and who has himself been bitten 
seven times, and is yet alive and well, tells us that he has operated, with the 
caustic, on more than four hundred persons, all bitten by dogs, respecting the 
nature of whose disease there could be no question ; and that he has not lost a 
case. One man died of fright, but not one of hydrophobia. Moreover, a surgeon 
of St. George's Hospital told him that ten times that number had undergone the 
operation of excision there, after being bitten by dogs (all of which might not, 
however, have been rabid), and that it was not known that any one had been lost. 
Mr. Youatt, I say, trusts to caustic ; and the caustic he uses is the nitrate of silver. 
But I advise you to trust to nothing but the knife, if the situation of the bite will 
allow you to employ it effectually. If the injury be so deep or extensive, or so 
situated, that you cannot remove the whole surface of the wound, cut away what 
you can; then wash the wound thoroughly, and for some hours together, by 
means of a stream of warm water, which may be poured from a tea-ke*tle ; place 
an exhausted cupping-glass from time to time over the exposed wound ; and 
finally apply to every point of it a pencil of lunar caustic. If you cannot get the 
solid caustic in contact with every part, you had better make use of some liquid 
escharotic: the nitric acid, for example. In my own case — and what I should 
choose for myself I should advise for another — if I had received a bite from a 
decidedly rabid animal upon my arm or leg, and the bite was of such a kind that 
the whole wound could not be excised, my reason would teach me to desire, and 
I hope I should have fortitude enough to endure, amputation of the limb, above 
the place of the injury. 

But if the wound is of such a size, and in such a part, that it can be excised, 
what is the proper way of cutting it out? Were I to give you any opinion, as 
from myself, upon that point, you might think, perhaps, that I was stepping 
beyond my proper province. I shall, therefore, again retail to you the advice of 
my old master, Mr. Abernethy. " The cell (he says) into which a penetrating 
tooth has gone, must be cut out. Let a skewer be shaped, as nearly as may be, 
into the form of the tooth, and then be placed in the cavity formed by the tooth ; 
and next let the skewer, and the whole cell containing it, be removed together by 
an elliptical incision. We may examine the removed cell, to see if every portion 
with whichxthe tooth might have come in contact has been taken away : the cell 



HYDROPHOBIA. 



385 



may even be filled with quicksilver, to see if a globule will escape. The effi- 
cient performance of the excision does not depend upon the extent, but upon the 
accuracy, of the operation." Mr. Abernethy was of opinion that when once the 
poison had been imbibed into the system, nothing ever had done good, and nothing, 
probably, ever would. I should be sorry to be so absolutely despairing in respect 
to a disorder from which dissection after death discloses no reason why the patient 
might not recover. He used to add, that as bleeding had been much extolled, 
had he hydrophobia he would allow a surgeon to bleed him, even to death. Like 
Seneca he would be willing to have his veins opened, though his disease might 
not permit him to indulge at the same time, like Seneca, in the luxury of a warm- 
bath. 

I say early excision is the only sure preventive; but let me repeat that it will, 
in all suspicious cases, be advisable, if, for any reason, the operation has been 
omitted in the first instance, to cut out the wound, or the cicatrix, within the first 
two months, or at any time before the symptoms of recrudescence have appeared. 
One would do it, though with less hope, as soon as possible after they had ap- 
peared ; but I do not expect to hear of excision being successful then in stopping 
the disease. Dr. Bright has recorded a case in which the arm was amputated 
upon the supervention of tingling, and other symptoms, in the hand, in which the 
patient had been bitten some time before; but the amputation did not save him. 

It has been proposed to fill the wound with ink, and then to wash it until every 
trace of the ink is gone ; in this way, it is conceived, the complete ablution of the 
poison also will be ensured. With a timid or an obstinate patient, who would 
not submit to the knife or the caustic, some such expedient ought to be diligently 
tried ; but it would be better to try it after the excision, or after the application of 
the escharotic substance. It is impossible to take superfluous pains to obviate so 
fearful a disease as hydrophobia. 

It has been recommended, after the wound has been excised or cauterized, that 
it should be prevented from healing, and made to discharge for a long time, by 
means of irritating applications. This may be advisable when thorough excision, 
or complete cauterization, cannot be effected; but I should think it quite useless 
as auxiliary to those expedients, and only likely to keep up, or to produce, a hurt- 
ful irritability of the system. 

I should perhaps have mentioned before, a theory, and a plan of preventive 
treatment, which made a great figure in all the journals, foreign and domestic, a 
few years ago. It was pretended by a Russian physician, Dr. Marochetti, that 
some time between the third and the ninth day after a person has been inoculated 
with the hydrophobic poison, by the bite of a rabid dog, small pustules appear on 
or about the frasnum of the tongue, containing a small quantity of sanious fluid, of 
a yellow or greenish colour. Pustules of the same kind were declared to exist 
also under the tongues of the mad dogs themselves. Now Dr. Marochetti pre- 
tended further, that if, from the very time of the bite, you gave the patient large 
doses of the decoction of broom tops, and looked out for the eruption of these 
pustules, which seldom lasted more than twenty-four hours, you might infallibly 
prevent the disease by opening and emptying the pustules, and then cauterizing 
them with a red hot iron ; and afterwards causing the patient to gargle his mouth 
with that same decoction of broom. He held that the poison was deposited there 
for a short time, and then re-absorbed into the system ; and he proposed to prevent 
such re-absorption. This was a very pretty theory ; and took mightily in the 
medical world. But it has turned out a sort of hoax. I do not mean a wilful 
hoax on the part of Dr. Marochetti ; for I have no doubt that he contrived to hoax 
himself. These pustules have been looked for again and again ; but they have 
never been discovered in Englishmen affected with hydrophobia; nor in English 
mad dogs. The truth seems to be that the mucous follicles of the mouth, gene- 
rally, and those at the base of the tongue, and those beneath the tongue, in par- 
ticular, are commonly enlarged and exaggerated in the dog, and in the human 
animal, labouring under the disease; and these enlarged and altered follicles were 
25 



386 



HYDROPHOBIA. 



regarded by the Russian physician as a specific eruption, which furnished the 
virus and pabulum of the complaint. 

As almost every drug that has ever been included in any Pharmacopoeia has been 
administered with the hope of checking the disease, so a great number of medicines 
and measures have been praised as preventives. Some people have great faith in 
sea bathing ; and they go to the coast to be ducked and half drowned every day 
for six weeks: and if they escape- hydrophobia they conclude that the immersion 
in the salt water has saved them. Some of the specifics, as you may suppose, 
are great secrets; and they who possess them — whether they believe in them or 
not is another matter — sell them at no cheap rate to those who, having been bitten 
by the dog, are weak enough to be bitten again by the quack. The composition 
of several of them has transpired ; and they are found to consist either of ingredi- 
ents the most insignificant and worthless, or of poisons of which the inefficacy 
had already been ascertained. The celebrated pulvis antilyssus, which was intro- 
duced by no less a person than Dr. Mead, into the London Pharmacopoeia, was 
a mixture of ash-coloured liverwort and black pepper. The Ormskirk medicine, 
long famous, and scarcely obsolete yet in the north of England, was made up of 
bole arrneniac, alum, chalk, elecampane, and oil of aniseed. The Tonquin medi- 
cine was composed of cinnabar and musk : and the Tanj ore pills were a combina- 
tion of mercury and arsenic. Even now scarce a year elapses but some corre- 
spondent of the newspapers, whose philanthropy is more conspicuous than his 
judgment or his knowledge, recommends a new and infallible preventive. I 
confess to you that I have not the slightest faith in any one of them; but as I have 
a great respect for Mr. Youatt, and as he is not quite so sceptical as I am on this 
point, and as patients or their friends will insist upon the adoption of protective 
measures sometimes, when the local means of prevention have been omitted or 
imperfect, I will tell you what he (Mr. Youatt) has done in respect to these pro- 
phylactic drugs. 

In the first place he never succeeded in curing the disease in the dog with any 
thing that he had ever tried. 

In the way of prophylaxis, he experimented with a great number of substances. 
He thought that the box-wood, which is the basis of some celebrated preventive 
drinks in Hertfordshire and Kent, had some effect. He tried the'alisma plantago, 
the boasted efficacy of which had been strictly inquired into by the magistracy of 
Toula, and the receipt purchased by the Russian government at an immense price. 
But he had no success with it. He then put the belladonna to the test, beginning 
with two grains, and increasing the dose to a scruple twice every day, and con- 
tinuing this for six weeks: and he says he is confident that he saved several dogs; 
but he lost almost as many. They all became debilitated and most rapidly 
emaciated. 

Then, in the year 1820, his attention was directed to the Scutellaria lateriflora, 
which Dr. Spalding, an American physician, had found highly successful as a 
preventive of rabies : and upon trial of it, he soon was brought to regard it as really 
valuable: and (not to tire you with a detail of his proceedings in the interim) he 
at length combined it with belladonna: " and the result" (I here quote his own 
language) " has been a medicine which I cannot, dare not, call a specific; for it 
has failed: but the use of which, in the cases of doubt and fear to which I have 
alluded, I would most earnestly recommend." He relates two experiments, 
which seem to have made a great impression upon his mind. They are as 
follows : — 

" Three pieces of tape were thoroughly moistened with the saliva of a rabid 
dog, and inserted as rowels in the polls of three other dogs. To two the Scutel- 
laria and belladonna were given : the third, a fox-hound bitch, was abandoned to 
her fate. On the 29th day after the inoculation she became rabid." The others, 
at the time this was written, i. e., some months afterwards, were living and 
well. 

He afterwards took the same two dogs, and a third. He moistened two pieces 



EPILEPSY. 



387 



of tape with the saliva of a rabid dog, and inserted them in the polls of one of the 
old dogs, and of the third dog. Another piece of tape, dragged repeatedly through 
the mouth of the same rabid dog twenty-four hours after its death, was inserted 
in the poll of the second of the old dogs. This dog and the new one were suf- 
fered to take their chance. To the other old dog the medicine was given. In 
the fourth week the new dog died undeniably rabid. The other two survived. 

I repeat that I have no faith in these preventives. But sometimes some of them 
must be tried; and I would prefer those which are thus sanctioned by Mr. Youatt's 
good opinion to any others. 

And with respect to the established disease, I think that if I were the unhappy 
subject of it, I should wish to be put into a hot air bath, and thoroughly sweated, 
and to take opiates ; not so much in the hope of recovering as with a view to the 
euthanasia. But with all respect to those gentlemen who advocate that practice, 
no one, if I could help it, should make a hole in my wind-pipe. 



LECTURE XXXV. 

Epilepsy. Its symptoms and varieties ; duration and recurrence of the parox- 
ysms ; periods of life at ivhich they commence; warnings. Effects of the 
paroxysms, immediate and ultimate. Pathology. Anatomical, characters. 
Causes. 

The great functions of which the brain is the material instrument, are sensation, 
thought, and voluntary motion. The influence of the will is a cerebral influence: 
it reaches and acts upon the muscles through the interposition of the spinal cord. 
Motions that are involuntary belong more exclusively to the system of the true 
spinal marrow. Yet cerebral changes, morbid states of the brain, may excite 
them. 

I have shown you that all these functions are liable, under disease, to be sepa- 
rately affected, and each in various ways and degrees. The number of combina- 
tions capable of arising out of disordered conditions of two, or three, or all of 
these functions, is very great. Yet the symptoms proper to the nervous system 
do arrange themselves into groups sufficiently definite and constant to allow of 
our giving them distinctive names, and making them separate objects of inquiry. 

At the same time, as might indeed be expected, these several groups have strong 
resemblances to each other. They are obviously of the same family : " facies 
non omnibus una, nee diversa tamen ; qualis debet esse sororum.'" Occasionally 
the features are so nearly alike, that we find it somewhat puzzling to determine 
with which of the sisters we are conversing; but usually there is some mark or 
other by which the individual may be identified. 

Of these essentially nervous diseases, there are several in which the most 
prominent and obvious of the phenomena relate to the muscular system ; irregular, 
violent, and involuntary contractions occurring of muscles which, in the healthy 
state of the body, are subject to the control of the will. I have spoken of two very 
frightful disorders belonging to this head : — of tetanus , namely, in which the mus- 
cles of voluntary motion present the most striking changes, being affected with tonic 
spasm ; while the sensibility undergoes no other alteration than what is a conse- 
quence of that spasm, pain I mean in the muscles themselves ; and the intellectual 
functions continue undisturbed : — and of hydrophobia, in which the natural sensi- 
bility suffers much, and the mental functions some derangement; yet still the 
characteristic features of the malady depend upon the irregular and uncontrollable 
action of muscles usually obedient to volition. 

The disease which I am next to consider is scarcely less terrible to witness, 
when it occurs in its severer forms, than tetanus or hydrophobia ; but it is not 



388 



EPILEPSY. 



attended with the same urgent and immediate peril to life. Yet it is, upon the 
whole, productive of even more distress and misery ; and is liable to terminate in 
worse than death. You will understand that I am alluding to Epilepsy : a disease 
not painful probably in itself; seldom immediately fatal; often recovered from 
altogether: yet apt, in many cases, to end in fatuity or insanity; and carrying 
perpetual anxiety and dismay into those families which it has once visited. 

The leading symptoms of epilepsy are, a temporary suspension of conscious- 
ness, with clonic spasm ; recurring at intervals. 

It is impossible to frame a perfect definition of epilepsy : nay, so various are 
its forms, so numerous its modifications, that no general description even of it can 
be given. It will be necessary for me therefore here (as it has been stated before) 
to describe first the most ordinary type of the disease, as a standard ; and then 
to note the several variations from that standard which are known to occur in 
practice. 

A man, then, in the apparent enjoyment of perfect health, shall suddenly utter 
a loud cry, and fall instantly to the ground, senseless and convulsed. He strains 
and struggles violently. His breathing is embarrassed or suspended ; his face 
turgid and livid ; he foams at the mouth ; a choking sound is heard in his wind- 
pipe ; he appears to be at the point of death by apnoga. But presently, and by 
degrees, these alarming phenomena diminish, and at length cease ; the patient is 
left exhausted, heavy, stupid, comatose : but his life is no longer threatened. And 
in a short time he is once more, to all appearance, perfectly well. The same train 
of morbid phenomena recur, however, again and again, at different, and mostly 
at irregular intervals. — This is a brief description of the most ordinary form of 
epilepsy. 

The suddenness of the attack is remarkable: in an instant, when it is least 
expected by himself or by those around him, in the middle of a sentence, or of a 
gesture, the change takes place ; and the miserable sufferer is stretched foaming, 
struggling, and insensible upon the earth. This fearful suddenness is expressed 
in the name of the disease, Irttf.^ta, a seizure, an abrupt invasion. The ancients, 
among whom the complaint was well known, superstitiously ascribed it to the 
malice of demons, or to the anger of their offended deities. If a person was seized 
with epilepsy in the forum, it was considered an ill omen, and the meeting was 
at once dissolved, and all public business suspended for that day. Hence the 
disease was called morbus comitialis. Morbus qui sputatur was another of its 
names, because those present were accustomed to spit upon the epileptic man, or 
into their own bosoms ; either to express their abomination, or to avert the evil 
omen from themselves. In this country its common designation is the falling 
sickness: or, more vaguely, fits. The cry which is frequently, though by no 
means always, uttered, is generally a piercing and terrifying scream. Women 
have often been thrown into hysterics upon hearing it. It is said to have caused 
pregnant females to miscarry. Even the lower animals appear to be sometimes 
startled and alarmed by a note so harsh and unnatural. Dr. Cheyne informs us 
that, upon one occasion, " a parrot, himself no mean performer in discords, dropt 
from his perch seemingly frightened to death by the appalling sound." The 
muscular convulsions are strong, irregular, and often universal. In most of the 
fits of which I have happened to see the commencement, the first effect of the 
spasm has been a twisting of the neck, the chin being raised, and brought round 
by a succession of jerks, towards one shoulder: and one side of the body is, 
usually, more strongly agitated than the other. The features are always greatly 
distorted. The brows are knit; the eyes sometimes quiver and roll about, some- 
times are fixed and staring, sometimes are turned up beneath the lids, so that the 
cornea cannot be seen, and the white sclerotica alone is visible ; the mouth is 
twisted awry ; the tongue thrust between the teeth, and caught by the violent 
closure of the jaws, is bitten, often severely ; and the foam which issues from the 
mouth is reddened by blood. The hands are firmly clenched, and the thumbs 
bent inwards upon the palms : the arms are thrown about, striking the chest of 



EPILEPSY. 



389 



the patient with great force, or bruising themselves against surrounding objects, 
or inflicting hard knocks upon the friends and neighbours who have hastened to 
the patient's assistance. It frequently happens that the urine and excrement are 
expelled during the violence of the spasm : and seminal emission sometimes takes 
place. The spasmodic contraction of the muscles is occasionally so powerful as 
to dislocate the bones to which they are attached : the joints of the jaw, and of 
the shoulder, have been thus put out; and the teeth are sometimes fractured. 

When the convulsive paroxysm is over, the patient falls into a deep sleep. 
You might imagine that he slept from exhaustion, like a man worn out by great 
fatigue; but there is something more than this; the patient passes into a state of 
incomplete coma, or rather the insensibility continues after the convulsions have 
ceased. When he wakes he is often confused and incoherent for a time ; by de- 
grees, however, he resumes his ordinary appearance and condition : but he 
remembers nothing of what passed during the fit. 

You may suppose that so much irregular contraction of the muscles of volun- 
tary motion is not likely to occur without some derangement or modification of 
the functions of the circulation. The breathing is irregular, gasping, or arrested. 
The heart palpitates violently against the ribs during the paroxysm ; the pulse 
becomes frequent and feeble ; and sometimes it ceases to be tangible at the wrist 
during the height of the fit, and begins to be felt again as the spasms subside. 
The turgescence of the face indicates obstruction of the venous circulation ; the 
cheeks and lips become purplish and livid, and the veins of the neck and fore- 
head are visibly distended. 

This, then, is one form, the most severe and the most common as well as the 
best marked form, in which an epileptic attack occurs. 

But there is a large class of cases, in which the symptoms are much more 
mild. There is very slight and transient, or even no convulsion at all ; no tur- 
gescence of the face ; no foaming at the mouth ; no cry ; but a sudden suspen- 
sion of consciousness, a short period of insensibility, a fixed gaze, a totter per- 
haps, a look of confusion ; but the patient does not fall. This is momentary ; 
consciousness presently returns ; the patient resumes the action in which he had 
been previously engaged, and is not always aware that it has been interrupted. 
Sometimes, with this temporary abeyance of the mental functions, there is some 
slight evidence of convulsion or involuntary action ; the fingers of one hand, or 
less commonly of both, are moved irregularly, and without any object ; or the 
eyes roll or are turned upwards: or the muscles of the face are twitched. Some- 
times the patient is himself aware of what has been his condition, but shows some 
cunning in endeavouring to conceal it. 

This slighter attack is called by the French, petit mal; while the severer form 
is named grand mal. The former is spoken of also as epileptic vertigo, and dis- 
tinguished by that appellation from the epileptic fit. 

Of affections so different in degree, and in some respects so dissimilar in kind, 
you may be disposed to ask whether they really constitute the same disease. 
TJiat they are essentially of the same stamp, we have this evidence; that both 
forms of attack occur in the same individuals. Sometimes a patient will suffer 
many recurrences of the epileptic vertigo, and at length will become affected with 
violent epileptic fits. Or the two forms will intermingle, sometimes the milder 
happening, sometimes the severer. In such cases we cannot doubt that the 
attacks are the same in nature, though different in form and degree. And when 
(as sometimes happens) we meet with the slighter disease alone, we cannot refuse 
to assign to it the character and the name of epilepsy. 

Between the two extremes there are many links of gradation. Sometimes the 
sufferer sinks or slides down quietly, and without noise ; is pale, is not convulsed 
at all, but insensible; much like one in a state of syncope. After recovering, he 
remains sick, languid and confused, during the remainder of the day. 

You will perecive, from what I have now said, the difficulty of giving any 
single description of epilepsy, which will include all its varieties. It is of course 



390 



EPILEPSY. 



still more difficult to offer a strict definition of the disease. Cullen defines it to 
be " musculorum convulsio, cum sopore." Dr. Copland furnishes a larger and 
more comprehensive definition : " Sudden loss of sensation and consciousness, 
with spasmodic contraction of the voluntary muscles, quickly passing into violent 
convulsive distortions, attended and followed by sopor, recurring in paroxysms 
often more or less regular." 

But almost every one of these circumstances may, in its turn, be wanting. 
There may be no convulsion ; there may even be very slight and transient inter- 
ruption of consciousness ; there may be no subsequent coma or sopor; there may 
be no recurrence of the attack. 

Yet I trust that you now have obtained some general notion of what is meant 
by an epileptic seizure. And I go on to inquire into several most important points 
connected with the paroxysms. 

In the first place they vary considerably in duration. Sometimes, as I have 
already stated, the seizure is slight, and does not occupy more than a moment or 
two of time. But even the severer attacks are often over in a few minutes. 
They seldom continue longer than half an hour, and probably the average duration 
may safely be laid at between five and ten minutes. Attacks that are spread over 
three or four or more hours, generally consist of a succession of paroxysms, with 
indistinct intervals of comatose exhaustion. In the long-continued fits, or in the 
protracted succession of fits, the patient often dies. 

The periods at which the paroxysms return are also extremely variable. Occa- 
sionally the patient dies in the first paroxysm ; occasionally, though he recovers 
from it, he never has another. Both of these occurrences are rare. Rather more 
frequently the fits recur at very long intervals; at the distance, I mean, of many 
years. Most commonly of all, they revisit the sufferer at irregular periods of a 
few months or weeks : sometimes they are repeated at intervals of a few days : 
sometimes every day or every night: and not very unfrequently they take place 
many times in the twenty-four hours. This extreme frequency of repetition be- 
longs principally to the slighter imperfect seizure, the petit mal. Sometimes the 
fits observe a strictly regular period of return ; but, for the most part, they are 
quite uncertain and irregular. 

The time of life at which the fits commence, and the circumstances attending 
their commencement, are deserving of notice. They not uncommonly begin in 
infancy. Those fits of convulsion to which young children are subject during 
the first dentition, and which sometimes appear to depend upon the irritation of 
teething, and sometimes upon manifest disorder of stomach and bowels — these fits 
are not distinguishable in their phenomena from genuine epilepsy ; and we must 
reckon them as instances of epilepsy. It has been remarked by some one, that 
if you can trace the early history of an adult epileptic, you will almost always 
find that he or she suffered infantile convulsions.* To what extent this is true I 
do not know, but I recommend it to you as a point worth attending to in your 
future opportunities of observation. 

The epileptic attack may come on, for the first time, at any age. According; to 
Dr. Bright (whose account of the disease, though short, is particularly perspicu- 
ous), the most common periods are about the age of seven or eight years, proba- 
bly about the time of the second dentition ; and from fourteen to sixteen, shortly 
before the age of puberty. And the disease (he says) is very apt to occur for a 
few years subsequently to this. But sometimes the first fit has taken place be- 
tween the ages of thirty and forty ; in not a few cases after sixty ; and occasionally 
quite in the decline of life. 

Dr. Bright offers a little piece of theory in respect to the periods at which 
epilepsy is apt to begin. It is a reasonable piece of theory, and serves to tie the 

* [This is true. Epileptics it will, very generally, be found were affected with repeated 
attacks of convulsions during the period of infancy. In many subjects, however, we have 
known the disease to commence immediately subsequent to puberty or even late in life. 
In the majority of these latter cases the disease appeared to be the result of a life of intem- 
perance. — C] 



EPILEPSY. 



391 



alleged facts to one's memory, even if it be not yet proved to be true. Doubtless 
in many cases the circumstances that determine the first attack are quite accidental. 
But setting aside these casualties, lie says " there are leading periods in the evolu- 
tion of the frame, and peculiar circumstances connected with certain periods, which 
may well be considered as influential in the production of the disease. In infancy 
the nervous system is delicate, and easily acted upon by various causes of irri- 
tation. Then follows the trying period of teething. In a few years the second 
dentition occurs. In a few years later, all the great changes connected with the 
age of puberty. To this follow the excesses and exposures of manhood ; and 
after the lapse of years, the vigour of the system fails, and many causes act to 
derange the nice balance of the constitution ; the bowels often become sluggish ; 
changes more or less serious take place in the structure of the arterial and venous 
system ; and many causes, organic or functional, which had before been unable 
to exert an influence on the vigorous frame, acquire power from its relative weak- 
ness." 

The first accession of the disease takes place more commonly before than after 
puberty. Of sixty-six epileptic women, in whom the outset of that disease and 
the first period of menstruation were carefully noted, thirty-eight had epileptic 
fits before, and twenty-eight not till after that period. 

The attacks are very apt to come on during the night; in the commencement of 
the disease, they frequently are confined to the night. They are said chiefly to 
occur at the moment when the patient is sinking into sleep, or awaking from sleep. 
How far this is true I cannot tell. When the disease is yielding, the fits often 
happen in the night only ; so that after they have, for a certain period, taken place 
in the day-time, or during the day and night, indiscriminately, it is reckoned a 
good prognostic sign if they begin to restrict themselves to the night. Some 
patients, under these circumstances, suppose that the physician has particular 
remedies that will make the fits happen in the night rather than in the day; and 
they ask for these remedies. 

Sometimes each paroxysm arrives unannounced and unexpected; sometimes 
distinct warnings of its approach are given. The latter is less frequent than the 
former. Georget affirms that premonitory symptoms do. not occur more than 
four or five times in a hundred cases. I am sure that this is much understated. 
When warning symptoms do happen; they are sometimes spread over a con- 
siderable period; several hours, or a whole day; sometimes they last just long 
enough to enable the patient to remove from a situation in which a fall would be 
attended with unusual danger: to dismount from horseback, to lie down in a boat, 
to get away from the fireplace, from the edge of a precipice, from the vicinity of 
water, to assume the horizontal position of his own free will and in his own man- 
ner, or to give notice to those about him of what is going to befall him. In some 
cases the warning is too short and sudden even for this. The hind of notice that 
he receives is very variable indeed. Often it consists in some unnatural state of 
trie mind, the feelings, the temper ; the patient is fidgety, irritable, low-spirited, 
timid, sullen; or, on the other hand, he feels unusually strong, and hearty, and 
cheerful. Sometimes there is a notable change in some one or more of the natural 
functions, or of the bodily sensations; the patient loses his appetite, or his appe- 
tite becomes voracious ; a great flow of urine takes place ; he smells an ill smell, 
is aware of a strange taste, hears extraordinary noises, or sees spectral illusions ; 
not mere specks floating before him — muscae volitantes — but distinct forms of 
persons and things. This is not very common, but it certainly happens. The 
late Dr. Gregory, of Edinburgh, was assured by a patient of undoubted veracity, 
that always, when he had a fit of epilepsy approaching, he fancied that he saw a 
little old woman in a red cloak, who came up to him, and struck him a blow on 
the head, and then he immediately lost all recollection, and fell down. 

Headache, giddiness, dim or dazzled vision, are all of them common symptoms 
among those which have been observed to be precursory of epilepsy. Sometimes 
there are circumstances which are obvious to a bystander : a flushing of the face, 



392 



EPILEPSY. 



orlividity: difficult articulation; vomiting. Of twenty-one epileptics treated in 
the hospital at Wilna, by Joseph Frank, vomiting announced the paroxysm in 
seven. Some of the uneasy feelings are apt to come on and continue even for 
several days previously to the attack ; restlessness in particular, disturbed sleep, 
distressful dreams, a peculiar and sudden coldness of the extremities. An internal 
working is a phrase often used by such persons to express a sensation which is 
probably indescribable. 

But the most curious precursory symptom of all, if we except the spectral illu- 
sions, is what is called the epileptic aura. This is a sensation which is likened 
by different patients to different things ; to a stream of water or cold air, to the 
trickling of water, to the creeping of a spider. The sensation proceeds commonly 
from some distant part of the body, — from one of the extremities, from a thumb 
or finger, or toe, or from some spot on the trunk, — and runs along the skin 
towards the head : occasionally it gets no further than the pit of the stomach: as 
soon as it reaches the head, or stops at the epigastrium, or elsewhere, the patient's 
consciousness forsakes him, and the paroxysm declares itself. 

There seems to be some analogy between this epileptic aura and the well- 
known sensation, to be spoken of hereafter, of a ball rising from the stomach to 
the throat, and constituting the globus hystericus ; except that in cases of epilepsy 
the sensation commonly begins in an extremity, and not in the stomach : and the 
fit comes on when it reaches the head and not the throat. Sometimes, I think, 
these two sensations are blended. 

In some instances, spasms of the muscles of the part whence the aura proceeds 
are observed to take place prior to the more general state of spasm. 

This aura is certainly a very curious phenomenon. It has been thought to 
depend upon some change propagated along the nerve upwards to the brain, and 
to be sometimes connected with some injury done to, or some morbid impression 
made upon, an afferent nerve. I think that this explanation may apply to some 
cases. 

Dr. John Thomson, of Edinburgh, used to state in his lectures, that, he had 
known epilepsy to begin with an aura proceeding from an old cicatrix in the side. 
In a patient of my own, who was subject to epilepsy, the warning sensation com- 
menced in one of his thumbs, which presently after began to be twisted inwards ; 
hut by tying his handkerchief tightly round the thumb, he could prevent the fit 
Dr. Seymour mentions the case of an epileptic boy, who had learned to protect 
himself against a threatened paroxysm, by biting his tongue. 

In other cases the aura probably originates in some change within the head, 
and is analogous to the numbness or tingling that is often felt in some part of the 
body or extremities immediately before an attack of palsy or apoplexy. There 
is no real inconsistency in this twofold explanation : the source of the aura may 
be centric or eccentric ; so also may the exciting cause of the paroxysm ; as, in 
due time, I shall explain to you. 

A knowledge of these warning circumstances is clearly of importance, always 
as far as respects the comparative security of the patient during the attack ; some- 
limes as affording us the opportunity of staving off the fit altogether. And it is 
necessary to remark, that they sometimes give, as it were, a false alarm; they 
occur, and yet, although no measures of prevention are taken, no paroxysm 
follows. 

The phenomena that succeed the paroxysm are also of great interest and mo- 
ment. 

I have already apprised you that the convulsions generally terminate before the 
insensibility is over: the patient draws, perhaps, two or three deep sighs, and 
ceases to struggle. Some few persons are quite themselves again in a few mo- 
ments ; some appear to recover consciousness, and then fall into a deep and 
prolonged slumber; but many do not regain their consciousness at all upon the 
cessation of the convulsions, remaining in a state of profound stupor, from which, 
however, they can generally be roused for a time. This state of coma (for it is 



EPILEPSY. 



393 



nothing else) has been known to last a week. After the patient emerges from it, 
he is sometimes merely languid and inert : sometimes he is like a person stunned, 
or in a state approaching to idiocy, which gradually clears up ; sometimes he 
is furiously delirious for a short time : not unfrequently there is a degree of 
partial paralysis, which also usually soon goes off, though it occasionally is per- 
manent ; the eyes are fixed, or he squints, or the pupils are dilated, or he drags a 
leg, or he falters in speech. Most commonly he speaks of headache, or discom- 
fort of some kind. 

It is very seldom that the patients have any recollection whatever of what has 
passed during the fit. Many of them are not aware that they have had a fit: 
and those who do know it, discover the fact by finding themselves wet or dirty ; 
by the injuries they have received during the convulsions ; by the soreness of the 
bitten tongue; by the bruises of their limbs ; or by the confused or painful sen- 
sations which they subsequently experience, and which they have learned to 
associate with the conviction that a fit has happened, by having been informed on 
previous occasions, when they felt the same sensations, that they had suffered a 
paroxysm of insensibility and convulsions. 

Upon the whole, it is seldom that any permanent ill effect can be noticed as 
having been left behind it by any one single fit ; but, alas ! this cannot often be 
said of their repetition. 

Doubtless a single paroxysm does often leave the patient in a worse condition 
than that in which it found him ; but this does not become perceptible to an ordi- 
nary observer, until after the alteration has been rendered apparent by repeated 
fits, and repeated small additions to the permanent injury. The friends of the 
patient remark that his memory is enfeebled in proportion to the number of the 
attacks; that his mental power and intelligence decline. His features even 
assume, by degrees, a peculiar character; and too often he sinks into hopeless 
fatuity, or confirmed imbecility or insanity. It is this tendency which renders 
epilepsy so sad and fearful a disease. 

Foville affirms, that the intellectual degeneration is more constant, and comes 
on more early, in persons who are principally afflicted with the epileptic vertigo, 
the petit mat, the imperfect seizure, than in persons in whom the grand mal, the 
violent and decided paroxysm, takes place. Dr. Copland, on the other hand, is 
of opinion, that " the more severe the fits, the more is that result to be dreaded.' , 
This is a point which can only be settled by statistical facts. And as we all 
have the opportunity of collecting some such facts, and of adding them to the 
general stock, I mention this, and some other points that are still uncertain or dis- 
puted, as worth bearing in mind. More, probably, depends upon the repetition 
of the fits, than upon their precise nature or severity. Cases do occur in which 
epileptic persons preserve their faculties to a good old age; but those who are 
early epileptic do not often attain old age ; and whenever the disease comes on, if 
it repeats itself frequently, it is much more often than not followed by impair- 
ment of the mind, or by some apoplectic or paralytic affection, which implies and 
accompanies the mental change. You will sometimes hear the cases of Julius 
Caesar, of Mahomet, and of Bonaparte quoted, as examples of high intellectual 
power, existing and remaining in spite of epilepsy : — and it is allowable, perhaps, 
to make use of such cases for comforting the friends of epileptic persons ; or for 
giving the advantage of sustained hope to the patient himself. But, in truth, these 
cases are not worth much. Napoleon is said, I know not upon what authority 
however, to have suffered something like epilepsy during sexual intercourse. 
This is not very uncommon in persons subject to that disease. And, with respect 
to Julius Caesar, we learn from Suetonius, that it was only in the latter part of 
his life that he laboured under epilepsy ; and that he had two attacks while en- 
gaged in business. 

Having now described the phenomena of epilepsy ; the periods of life at which 
it is most apt to commence ; its varieties ; and its tendency and termination : let 



394 



EPILEPSY. 



us next inquire what is known respecting the real seat and nature of this strange 
and melancholy complaint. 

The functions that are affected are clearly the functions of the brain. Sensa- 
tion, thought, and motion regulated by the will, are the natural functions of that 
organ. The temporary abeyance of sensibility thought, and volition, and violent 
and irregular action of the muscles which are thus withdrawn from the empire of 
the will, constitute a paroxysm of epilepsy. We have, in this malady, another 
illustration of the fact, that when the controlling influence of the sensorium is 
suspended, *the peculiar functions of the spinal marrow are exercised, not only in 
a disorderly, but also in an unusually energetic manner. That the brain and the 
spinal marrow, though physiologically distinct, are yet intimately connected with, 
and dependent upon, each other, a thousand familiar facts assure us : and there 
are good reasons for believing that the change, whatever it is, which is the im- 
mediate precursor and cause of the epileptic fit, may sometimes originate in the 
spinal cord, and thence extend to the brain; and sometimes originate in the brain, 
and communicate itself to the spinal cord. Dr. Marshall Hall's doctrine, that all 
convulsive diseases are«diseases of the spinal marrow, cannot be properly applied to 
this convulsive disease of epilepsy. It is true that thespinal cord is concerned when- 
ever there is convulsion ; but it is concerned in every voluntary movement also, 
through the instrumentality of the brain itself ; and it may be, and often is, irregularly 
influenced by a disordered and unnatural state of the brain. Tetanus may fairly be 
regarded as a disease of the cord and its proper appendages. The spasms arise and 
reach their height, while the powers of thought and sensation are undisturbed, and 
while volition remains, although the morbid condition of the cord renders it inef- 
fectual. In epilepsy, these cerebral functions are always implicated. There is 
always a loss of consciousness : and in the epileptic vertigo, the petit mal, there is 
frequently a suspension of consciousness only, without any convulsion at all. 
The brain, therefore, we must consider to be essentially concerned in this disorder. 

What the precise state of the nervous matter may be, which determines the loss 
of consciousness and the spasms, we can only conjecture. A derangement in the 
relation between the arterial and venous circulation within the head ; a temporary 
pressure somehow arising ; a determination of blood towards the head ; a diminu- 
tion of the natural quantity of blood sent thither from the heart ; all these have 
been assigned as possible causes of the paroxysms. Plausible reasons might be 
given in favour of the operation of each of them ; but the speculation is more 
curious than useful. We have not yet penetrated the mystery of these remarkable 
phenomena, and it will be more profitable to turn to another question, which 
admits of a somewhat more definite answer, viz.: — what is the morbid anatomy 
of epilepsy ? 

Suppose that a person who has had epileptic fits, but in whom they have not 
been followed by any durable affection of the intellectual or locomotive functions, 
dies of some other malady ; and you may have the opportunity of minutely exa- 
mining the condition of the nervous system. Often you will find nothing at all 
which can throw any light upon the occurrence of the epileptic paroxysms ; no 
appreciable alteration whatever in any part either of the brain or of the spinal cord. 
In other cases you may discover some organic disease within the head : a scrofu- 
lous tubercle, a spiculum of bone projecting from the skull. Have you then 
detected the cause of the disease ? All that can be said is, that the piece of bone 
or the tubercle was probably a predisposing cause of that derangement of the 
nervous substance which determined the paroxysms; the derangement itself, if, 
indeed, it was of such a nature as to be cognizable by our senses, has gone, with 
the symptoms ; the tubercle or bone having in the meantime remained, without 
any sign which could betray its presence. 

M. Foville, whose testimony in this matter is entitled to much weight, affirms 
that in persons who have been subject to epilepsy, uncomplicated as yet with any 
permanent disorder of the intellect, or of the faculty of voluntary motion, and who 
have died in the Jit, constant alterations are observable within the head ; viz., a 



EPILEPSY. 



395 



strong injection of the vessels of the encephalon. The membranes, the brain, 
and the cerebellum, are gorged, he asserts, with livid blood. But he goes on to 
say that this is to be ascribed to the mode of death : that we see the same appear- 
ances in persons who have died by hanging, or any form of apnosa ; that they are 
not peculiar to epilepsy, and do not explain the attack, but only point out the way 
in which it has been fatal. 

It is, I fancy, a very common notion, both that such congestion does take place, 
and that it is the cause of the paroxysm: and it may be worth while shortly to 
state the reasons which are opposed to the conclusion, that the congestion (grant- 
ing for the moment that it does happen) is a sufficient explanation of the attack. 

In the first place it is not easy to conceive that the congestion could so sud- 
denly arise and subside again, as it must sometimes do, if it be the immediate 
determining cause of the fit: within the space of a single minute, for example. 

And in the second place, the signs of external congestion and plethora, by 
which signs we measure the amount of the internal, are most marked just when 
the symptoms of the paroxysm begin to subside and disappear. So that we 
cannot, I think, look upon the congestion as the cause of the convulsive symp- 
toms. 

Let us go a step further, and inquire into the state of the encephalon in those 
persons who, having suffered epilepsy, had, before death arrived, been affected 
with some permanent impairment of the mental functions, or (what often goes 
along with such impairment) with some degree or other of muscular paralysis or 
debility. 

The most common alterations met with in the brain in such cases are the fol- 
lowing. 

Induration of the white matter of the brain, which presents a dull appearance ; 
sometimes, besides the hardening, a general injection of the white matter ; and in 
the majority of cases a marked dilatation of the blood-vessels. In some instances 
the consistence of the white matter is diminished ; it is soft and flabby ; but there 
is the same dilatation of the blood-vessels. These changes pervade the whole of 
the white matter in every part of the brain. At the same time the gray matter is 
found irregular on its surface, marbled or of a rosy colour in its substance, and 
sometimes altered in consistence. And in many cases the membranes are found 
to be adherent in some parts to the convolutions with which they lie in contact. 

Such are the results of the experience of careful observers in respect to the 
morbid anatomy of epilepsy ; of Morgagni, of Foville, and of MM. Bouchet and 
Casauvielh. The changes last described are such as are produced by chronic 
inflammation of the brain and its membranes. They are the consequences (I 
imagine) of repeated paroxysms of epilepsy ; they are the very same as are fre- 
quently met with in cases of insanity complicated with paralysis, and they eluci- 
date, therefore, the connection of these affections ; but they certainly teach us little 
or nothing of that actual condition of the nervous mass upon which the epileptic 
paroxysms depend. And, in truth, to expect to find in the brain the traces of 
convulsions that have passed away, would be as unreasonable as to expect to find 
the traces of former voluntary movements. 

Of those organic changes which may be regarded as strong predisposing causes 
of the paroxysms, my own experience accords with that of Dr. Bright; who 
states, that they are more frequently such as affect the surface, than the deeper- 
seated parts of the brain : tumours external to the cerebral matter ; alterations in 
the bones of the skull ; or in the membranes that envelop the organ. Various 
altered states of the spinal marrow have also been recorded. 

But besides the morbid appearances that are sometimes only visible in the nerv- 
ous centres themselves, there are others, which it is of great importance to attend 
to, situated in other parts of the body, and at a distance from those centres : dis- 
eased states of the liver ; biliary concretion ; granular kidneys ; renal calculi ; 
stones in the bladder; worms in the alimentary canal ; diseases of the uterus ; and 
of various other parts. And these morbid conditions have often, no doubt, an 



396 



EPILEPSY. 



intimate connection with the epileptic paroxysms. Accordingly, some authors 
make almost as many varieties of epilepsy as there are organs of the body ; they 
specify the cerebral, the spinal, the cardiac, hepatic, gastric, intestinal, nephritic, 
genital, uterine, and so on. It will be sufficient, however, to consider two species 
only ; that, namely, in which the disease originates in the nervous centres them- 
selves, and especially in the brain ; and that in which it originates in some other 
part. Most persons who have written on epilepsy make this distinction, although 
they employ different terms to express it. Cerebral and occasional ; primary and 
secondary ; idiopathic and sympathetic ; centric and eccentric. The last two 
terms are the best. But let us clearly understand them. The disease may, in 
one sense, be considered eccentric, even when it is situated in the brain ; eccen- 
tric, i. e„ in respect to the true spinal marrow. But I apply the epithet centric to 
epilepsy when its cause lies in either of the two great nervous centres ; the brain, 
or the craniospinal axis. The distinction itself we shall find to be an important one, 
both as regards the prognosis and the treatment. But T must first say a few words 
respecting the causes, and the diagnosis of epilepsy. 

There is no doubt that a tendency to epileptic disease is frequently hereditary. 
It may be derived from parent to child; or it may skip over a generation or two, 
and appear in the grandchild or great-grandchild ; or it may be traceable only in 
the collateral branches of the ancestors. This is just what takes place in other 
hereditary maladies. You may often notice also that other forms of nervous dis- 
order prevail in the same families. 

MM. Bouchet and Casauvielh found that among 110 instances of epilepsy, 31 
were hereditary. Of 321 persons afflicted with epileptic insanity, and seen by 
Esquirol, 105 were descended from insane or epileptic parents. 

Again, a tendency to epilepsy is very often found to go along with an unnatural 
form of the head, which is pinched up like a sugar-loaf; or misshapen and un- 
sym metrical, one-half being unlike the other; or oddly configurated in some way 
or other. Epilepsy is no uncommon attendant of chronic hydrocephalus. 

And thirdly, the scrofulous diathesis is a strong predisposing cause of epilepsy. 
Dr. Cheyne even holds that epilepsy is as certain a manifestation of the strumous 
disposition, as tubercular consumption, or psoas abscess. Now of the two pre- 
disposing circumstances last mentioned, it may be observed, that they commonly 
merge in that which preceded them: the strumous diathesis, and a particular con- 
formation of the head, are both very likely to descend from parents to their 
progeny. 

Whether the sex has any influence in determining a predisposition to epilepsy, 
is a question that remains to be settled. Foville thinks it is most common in 
females ; Dr. Elliotson in males. I have certainly seen more epileptic boys and 
men, than girls and women. But the casual experience of a single observer is 
not enough to determine the point. We want numerical statements on a large 
scale. At the close of the year 1813 there were 162 male epileptics in the 
Bicetre; 289 female cases in the Salpetriere. Jos. Frank observed that of 75 
patients, 40 were females. 



LECTURE XXXVI. 

Epilepsy, continued. Recapitulation. Exciting causes. Simulated epilepsy. 
Diagnosis. Prognosis. Treatment : during the fit ; during the intervals : 
during the warnings. 

At our last meeting I began to speak of epilepsy. Let me rapidly retrace the 
ground we then passed over. 

An epileptic seizure may be very severe ; or very slight. The very severe 



EPILEPSY. 



397 



attacks are characterized by a sudden cry, immediate loss of consciousness, 
general and violent convulsions, and subsequent coma or heavy sleep. The very 
slight attacks consist in a momentary abeyance of the mental faculties, sometimes 
with and sometimes without slight and partial convulsion. The extreme forms 
of epilepsy we judge to differ only in degree, inasmuch as they both attack the 
same persons at different times ; or the one form conducts to the other. Between 
these the gradations are innumerable. We call the extremes the epileptic fit, and 
the epileptic vertigo; the French name them the grand mal and the petit mal. 

These Jits may last from a few seconds to half an hour. Paroxysms apparently 
longer than this commonly consist of a succession of fits. The average duration 
is from five to ten minutes. 

The fits recur at variable intervals; which are sometimes periodic, mostly 
irregular. There may be many in a single day : there may be only one for many 
years. They are commonly more severe in proportion as they are less frequent. 

The epileptic seizures sometimes begin in early infancy : another period at 
which they often commence is about the age of seven or eight: another about 
fourteen or sixteen, or for some few years after that age. They more frequently 
begin before puberty than after it. Sometimes the first fit takes place in the 
middle period of life: sometimes even in declining age. They often occur in 
the night, especially in the outset and the decline of the disease ; usually when 
the patient is between asleep and awake; i. e., at the commencement or the ter- 
mination of his slumber. 

In the majority, perhaps, of cases, the fit is unexpected, and preceded by no 
warning. But in other instances there is some alteration perceptible by the 
patient himself, or by his friends, giving notice of its approach ; some change in 
the temper, feelings, appearance ; some disturbance of the senses ; ocular spectra; 
or what is called the epileptic aura, a creeping sensation arising in some part of 
the surface, generally of the extremities, and gliding towards the head. Some 
of these warnings precede the paroxysm by a day or two, or by a few hours ; 
some by two or three seconds only. Sometimes the blow is threatened by their 
appearance, but it does not fall. 

The fit is almost always, in its severer forms, attended and followed by coma ; 
sometimes, after the coma, by temporary confusion of mind ; deafness ; slight 
paralysis; delirium; inarticulate>speech. There is seldom any appreciable per- 
manent damage effected by a single fit. 

A repetition of the fits leads, in a large majority of instances, first, to a defect 
of the memory, and of the general intelligence ; and at length to a peculiar 
expression of countenance, to decided imbecility of mind, to complete fatuity; 
and with this there is often associated some paralysis or muscular debility. 

The convulsions take place, necessarily, through the medium of the spinal cord 
and nerves — just as voluntary movements do ; but the suspension of sensation, 
thought, and volition (which suspension is seldom absent, while the irregular 
muscular action often is wanting) shows that the brain is essentially involved in 
the disease. 

Accidental organic lesions are sometimes (and sometimes only) found in the 
encephalon, or in the spinal cord, of persons who have suffered epilepsy uncom- 
plicated with any permanent mental or paralytic affection ; tubercles, for example, 
or bony growths from the interior of the skull : but as these are constant, while 
the paroxysms are occasional, and as in the intervals they give no signal of their 
presence, we can only regard them as being probably predisposing causes of the 
seizures. 

When the epilepsy has been complicated with permanent alienation of mind, 
or with some degree of paralysis, evidence of chronic inflammation of the brain 
and its membranes is generally discovered. This has been the consequence of 
the repetition of the paroxysms. This explains the frequent connection of fatuity 
and palsy with epilepsy of long standing. 

The diseased condition which excites the paroxysms may be situatad in the 



398 



EPILEPSY. 



nervous centres themselves, or in some other part of the body. In the one case 
we call the disorder centric, or idiopathic ; in the other, eccentric, or sympathetic. 
We cannot always be sure with which species of the disease, the centric, or the 
eccentric, we have to deal : but the distinction, when it can be made, is of consi- 
derable importance, in respect to the prognosis, and in respect to the management 
of the case. 

The predisposition to this fearful complaint is often hereditary. Malformation, 
or defect of symmetry in the two sides of the head, is a frequent predisposing 
cause. So, pre-eminently, is the scrofulous diathesis. And these two, viz., the 
scrofulous diathesis, and a peculiar conformation of the head, are both liable and 
likely to be propagated from parents to children. But the predisposition is found 
to be hereditary, even when the shape and structure of the body is, to all appear- 
ance, quite perfect and natural ; and when no outward indication of the strumous 
diathesis is perceptible.* 

At the very close of the lecture I informed you that it is an unsettled question 
— and it is not a question of very great importance — whether the disease is more 
common in females or males: whether the sex has any thing to do with the pre- 
disposition. 

There are certain vices which are justly considered as influential in aggravating 
and even in creating a disposition to epilepsy ; debauchery of all kinds ; the ha- 
bitual indulgence in intoxicating liquors; and, above all, the most powerful pre- 
disposing cause of any, not congenital, is masturbation — a vice which it is painful 
and difficult even to allude to in this manner, and still more difficult to make the 
subject of inquiry with a patient. But there is too much reason to be certain that 
many cases of epilepsy owe their origin to this wretched and degrading habit: 
and more than one or two patients have voluntarily confessed to me their convic- 
tion that they had thus brought upon themselves epileptic paroxysms for which 
they sought my advice. 

Among the exciting causes of epilepsy, fright is conspicuous. And any strong 
mental emotion is apt to produce the fit in a person who is already subject to the 
disease. This fact alone would be enough, I conceive, to forbid our ascribing the 
paroxysms exclusively to an affection of the spinal cord. Bodily pain ; manifest 
and great disturbance of almost any of the principal functions of the body,- may 
act also as exciting causes. Sometimes the cause is obvious ; sometimes it is 
quite inscrutable. If the attack occurs every night, Dr. Bright thinks it may be 
attributed to the " congestion " of sleep : if it takes place at monthly intervals in 
women, we may " often trace it to nervous irritation in sympathy with the uterus : 
and when long periods have intervened we may usually trace each distant parox- 
ysm to the repetition of some excess, or to a neglected state of the bowels." In 
these latter cases the epilepsy is of the sympathetic or eccentric kind ; the irri- 

* [The following statistics are presented by M. Leuret, in an interesting paper on Epilepsy 
in the Archives Generates for May, 1843. Among 106 epileptics, in 24, or nearly one-fourth, 
the disease commenced between the tenth and fourteenth years of their age; in 18, or nearly 
one-sixth, between the fifteenth and nineteenth years, and in 16, between the fourteenth and 
twenty-fourth years. Thus, 58 patients, or more than one-half, were first attacked between 
their fourteenth and twenty-fourth years. Of the whole number of cases, in six only was it 
ascertained that the disease existed in one or other parent, and in but eight was it found 
that one of the parents had died of any disease of the brain, namely, three of insanity, two 
of apoplexy, one of paralysis, one of suicide, and one of meningo-cephalitis. Of the 108 
patients, thirty had been drunkards, twenty-four masturbaters, and fifteen addicted to women. 
In fifteen cases, the actual or presumed cause of the first attack of epilepsy was ascribed to 
terror; in twelve to onanism; in six to drunkenness; in two to anger; in two to distress; 
in two to falls ; in one to Ubertinage, $c. Thirty of the patients had an attack very regularly 
once a fortnight; 17 suffered attacks once a month; 13 once a week; 9 every three or four 
days; 4 almost every day; 2 every day; 1 every two months; 3 every three months; and 
24 at very irregular intervals. In 35, the attacks took place in the night especially; in 29, 
they were as frequent in the day as in the night; in 12, they frequently occurred in the day; 
in 8, they occurred during the day only; in 8, during the night only; in 3, in the morning 
only ; in 3 others generally in the morning; and in 4, in the evening only. — C] 



EPILEPSY. 



399 



tation being seated in some part at a distance from the nervous masses in the 
stomach, or intestine?, or uterus.* Now I would suggest the expediency of ob- 
serving what muscles or sets of muscles are first affected by the spasm in such 
cases, and in what part the warning aura (if there be any) arises : because by 
accurately noting these particulars, we may, perhaps, be led to a knowledge of 
the part or organ in which the irritation operates: and if we know the seat of 
the irritation, we shall be more likely to know its nature and its cure. 

Among the exciting causes of epileptic fits are also enumerated — and I believe, 
from what I have myself noticed, with great justice — the repulsion of eruptions, 
and especially of eruptions about the head, when proper artificial evacuations are 
not obtained at the same time ; the cessation of habitual discharges ; and, on the 
other hand, profuse and unusual discharges. Hemorrhage certainly will often 
bring on convulsions and a state of insensibility exactly like certain forms of epi- 
lepsy. Persons who are bled till they actually faint, are often at the same time 
convulsed. And animals that are killed by loss of blood are always affected with 
convulsions before they expire. 

There is yet another very singular occasional cause of epilepsy that deserves 
to be mentioned, viz., the sight of a person in a fit of that disease. This has 
been noticed over and over again. Not only will a patient who has already suf- 
fered such attacks, often fall into one upon seeing another so affected ; but people 
will even sometimes do so who have never before shown any symptom of epilepsy. 
In this way the disease will now and then run through a boarding-school : or 
through a ward in an hospital. There is a very good example of this recorded 
in the 11th volume of the Medical Gazette, by Dr. Hardy, of Bath. A strong, 
healthy young man was hired to take care of an older patient, who suffered fre- 
quent and exceedingly violent paroxysms of epilepsy. He remained with the 
patient night and day; and at the end of seven weeks became himself epileptic in 
a very high degree. An acquaintance of his, of equally robust make, but some 
years older, occasionally visited the parties. In a fortnight from his first visit he 
also was seized with similarly violent attacks. Dr. Hardy quotes the following 
short case, also, from Baglivi : — "Vidimus, anno 1690, in Dalmatia juvenum 
gravissimis correptum convulsionibus, propterea quod inspexerat solummodo 
alium juvenem dum epilepsia humi contorquebatur."t 

Dr. Cullen, who, as well as many others, had noticed the same things, starts 
the question whether this mode of propagation of the disease be imputable to 
dread and horror ; or to the mere force of imitation, which is often so strong, in 
health as well as in disease : and he decides in favour of the force of imitation. In 
fact there are many other signs equally horrifying with that of a person in convul- 
sions ; yet there is no spectacle of horror so efficacious in producing a fit of epilepsy 
in others, as that of a person suffering under epilepsy. 

This principle of imitation holds good in many of the spasmodic diseases : and 
in some of them, especially in hysteria, its influence is more remarkably seen than 
in epilepsy : I shall therefore have to recur to it again. There is one very curi- 
ous fact, however, which relates to epilepsy in particular. You are aware that 

* [M. Lamothe relates, in the Jmirn. de Med. de Bourdeaux, a case in which the epilepsy 
was caused by a foreign body in the ear, and ceased upon its removal. The patient was 
a man thirty years of age, in whose external meatus a pebble had been accidentally intro- 
duced. He at first experienced only a slight diminution of hearing; afterwards suppura- 
tion occurred, and finally epileptic attacks supervened; from which he had suffered for 
two years before he consulted M. Lamothe. This gentleman, being informed of the proba- 
ble existence of a foreign body in the ear, made an examination, and detecting it, by proper 
means, succeeded in removing from the meatus a rough pebble of nearly a triangular shape, 
and from that period the patient had no more attacks of epilepsy. In the same Journal 
another case of the same kind is related by M. Roussilhe. — C.] 

j [M. Meyer has recently given an account of a number of the pupils in a female school 
that were attacked with epilepsy, in consequence of seeing one of their number under the 
influence of the disease. Most of the subjects were approaching the period of puberty; 
whilst they were all of a highly excitable temperament. — C] 



400 



EPILEPSY. 



this disease is often feigned, by impostors. Now I believe it is ascertained, be- 
yond the possibility of doubt, that fits and actions which were at first, in these 
pretenders, strictly voluntary, have at length become involuntary and uncontrol- 
lable, and have passed into paroxysms of real epilepsy. The rogue is caught in 
his own trap. 

And the mention of these impostors leads me to consider the diagnosis of epi- 
lepsy. First, how are we to distinguish the feigned disease from the true ? Se- 
condly, are there any other real diseases which may be mistaken for epilepsy, or 
for which epilepsy may be mistaken ? 

In the number of feigned diseases epilepsy is one of the most common. Sol- 
diers and sailors pretend to have epileptic fits, in the hope of obtaining their dis- 
charge from the service. Cases of simulated epilepsy occur also continually in 
our streets among mendicants and impostors, who think to excite the compassion 
and pecuniary charity of the credulous ; and are even sometimes actuated I believe 
by a desire to obtain admission into hospitals, where they live tolerably well, and 
quite idly. It is easy enough, they think, to throw their legs and arms about, 
and to grin ; and many of them get up a capital show of foaming at the mouth, by 
placing a bit of soap between the gums and cheek. The means of detecting these 
vagabonds are of some importance to us all ; and it is more particularly neces- 
sary that they should be well known to those who are likely to join the medical 
department of our fleets or armies. 

It is of course desirable, in questionable cases, to witness a fit. "But pretenders 
are not very willing to perform when they know that a medical man is looking 
on. You may sometimes convict them, in the absence of the fits, by cross- 
examination. A cheat will seldom be consistent in the account which he gives 
of his fits; as to whether they are regular or irregular; and as to the times and 
places in which he has suffered them. An impostor chooses such situations for 
his exhibition as are most suitable to his own purposes ; a crowded street, or a 
well-frequented public walk. True epileptics almost always select retired places 
to take exercise in ; especially if they have any warning or expectation of the 
approach of a paroxysm. You will find also that the impostor is not attacked at 
his own home ; but always fixes upon some spot in which he is not only sure to 
be seen by others, but in which he is not likely to sustain any injury by tumbling 
down. True epileptics are often seriously hurt by their falls; feigned ones gene- 
rally come off without much bodily damage. However, if the fits are alleged to 
be frequent, and if also they are regular, you may soon expect one, and must 
make a point of being present : and then you will seldom fail to remove or to 
verify your suspicions. In the first place the muscular power of epileptics is far 
beyond what is natural. It will sometimes take four or five stout men to hold a 
weak emaciated lad, in a fit of epilepsy. Of course no impostor can command 
more than his natural strength. In the second place a real epilectic fit, if it lasts 
long, is seldom violent; whereas impostors, for obvious reasons, make their fits 
both long and violent. You may often get much information from the state of the 
eyes, which usually in true epilepsy are partly open, with the eyeball visibly 
rolling and distorted. In feigned epilepsy the actor almost always prefers to shut 
his eyes completely. Sometimes, if he be closely watched, and no suspicion is 
expressed, he will be seen to open his eyes occasionally, to ascertain the effect of 
his exhibition upon the bystanders. In real epilepsy, too, the pupils are often 
considerably dilated, and do not contract when stimulated by light. This is a 
very sure criterion ; for no impostor can prevent his iris from acting on exposure 
to vivid light. The pulse, in true epilepsy, is not only frequent but often irre- 
gular also ; a circumstance which never can be imitated. The skin of an epilep- 
tic, during the fit, is commonly cokl ; but' that of an exhibitor is hot, and covered 
with sweat, obviously the consequence of his violent and voluntary exertions. In 
this respect, also, it is scarcely possible for him to deceive us. Again, an impos- 
tor will not bite his tongue, as epileptics often do ; nor very willingly void (like 
them) his excrements and urine during the fit ; indeed, it would not be very easy 



EPILEPSY. 



401 



for him to do so, and at the same time to carry on the necessary pretence of con- 
vulsions. Besides, epileptics, during a fit, are quite insensible to external im- 
pressions ; and hence the vulgar modes of detection, though harsh and not to be 
recommended, are often effectual ones ; such as dropping melted sealing-wax 
upon the patient ; putting some gin into his eyes ; burning him with a hot poker; 
or (what I believe is more fashionable among beadles and police constables, when 
they have to administer to such patients), the pressing your thumb-nail violently 
under that of the supposed impostor. This causes exquisite pain, yet inflicts no 
lasting or serious injury ; and I believe that few pretenders stand out against this 
expedient. It is astonishing, however, how much torture some of them will bear 
before they can be brought to confess their imposition. If we speak of having 
recourse to some of these painful tests in the hearing of the pretender, we shall 
find that the fit will soon come to an end. Dr. Cheyne mentions an instance in 
which one table was placed upon another, and a soldier, who was supposed to be 
shamming, was laid upon the upper one, while his paroxysm was on him ; and 
the fear of falling from such a height soon stopped the convulsions. Mr. Hutch- 
inson relates the case of a sailor who was suspected to be a cheat, in whom the 
convulsions were instantly removed by blowing some fine Scotch snuff up his 
nostrils through a quill. This brought on another kind of fit, viz. , a fit of sneez- 
ing, which lasted nearly half an hour ; and there was no return of the epilepsy 
so long as Mr. Hutchinson remained in that ship. He tried the same expedient, 
in cases of real epilepsy, but never could produce any similar effects, although 
the patients were not snuff-takers. There was a beggar in Paris, who often fell 
into epileptic fits in the streets; one day some compassionate spectators, fearing 
that he might injure himself in his struggles, got a truss of straw and placed him 
upon it; but when he was in the height of his paroxysm, and performing remark- 
ably well,, they sat fire to the straw ; and he presently took to his heels. 

There is another ingenious plan, very likely, I should think, to detect an im- 
postor, and yet not calculated, like the one last mentioned, to injure a real sufferer : 
which is to propose gravely, in his hearing, to pour boiling water upon his legs, 
and then to proceed actually to pour cold water upon them. 

Of the real diseases which are apt to be confounded with epilepsy, hysteria is 
the chief. The question whether a given case be one of epilepsy or of hysteria, 
very often arises. By a careful attention to several circumstances, the discrimi- 
nation is generally to be made. In the first place the total suspension of con- 
sciousness, which is so constant an accompaniment of the epileptic paroxysm, 
does not take place in the hysterical: in epilepsy there is no globus hystericus, no 
alternations of laughter and tears; the solitary cry which ushers in the epileptic 
attack so frequently, and which is sa characteristic, is not heard in hysteria; not 
that hysterical girls do not scream, for they often do ; but then it is repeatedly 
and continuously. The heavy comatose sleep that succeeds epilepsy is not com- 
mon in hysteria. Hysterical patients contrive also to avoid hurting themselves 
by their contortions : they do not bite their tongues, nor foam at the mouth. Dr. 
M. Hall tells us that, in epilepsy, there is a forcible closure of the larynx, and 
expiratory efforts which suffuse the countenance, and probably congest the brain 
with venous blood. In hysteria the respiration, on the contrary, is rapid and 
sobbing. 

Observe that I have been speaking, all along, of what has been sometimes called 
habitual epilepsy. It is not every attack of convulsions with insensibility which 
ought to be so named. Such attacks are apt to follow sudden injuries done to the 
brain; stunning blows on the head, fractures of the skull, the eruption of blood in 
sanguineous apoplexy, and even overwhelming emotions of the mind. The reten- 
tion of urea in the unpurified blood, occurring in connection with a peculiar renal 
disease to be hereafter described, appears to be a frequent cause of similar seizures. 
With these casual occurrences of epileptiform convulsion I do not here meddle. 

Epilepsy is one of those complaints concerning the probable issue of which the 
patient, and still more the patient's friends, are sure to make repeated and anxious 
26 



402 



EPILEPSY. 



inquiries. It is seldom that we can pronounce with any confidence a favourable 
prognosis ; but there are some cases in which the prospect is much worse than in 
others. 

If we have reason to believe that the disease is centric, and connected with any- 
organic derangement of the nervous centres themselves, the prognosis must be 
bad. Cseteris paribus it is rendered worse by the coexistence of any sign of 
scrofulous disease, or of the well-known bodily characteristics of the scrofulous 
diathesis ; it is rendered worse, also, when the disease has happened in the parents 
or among the more immediate ancestors of the patient; whenever, in short, there 
is reason to think the disposition to it is inherited. The prognosis is bad when 
the complaint occurs in persons who have slanting foreheads and misshapen 
skulls: and when the epileptic physiognomy has become established. The prog- 
nosis is always the more unfavourable the longer the disorder has lasted ; the 
oftener the fits have been repeated ; and the more habitual they have become. 
And when the memory is permanently enfeebled, or fatuity has come on, or the 
disease is complicated with any fyrm or degree of paralysis, the case is hopeless ; 
so far, at least, as a perfect cure is concerned. 

On the other hand, the prognosis is better when the disease is eccentric: i. e., 
when there is any obvious exciting cause of the paroxysms, manifest in structural 
or functional disorder of some part of the body other than the nervous matter. 
And when this eccentric cause is removable — a stone in the bladder, for instance, 
worms in the intestines-^-ihen the prognosis still further improves. On this 
account the prognosis is better in children than in older persons, for the exciting 
cause is often clearly eccentric, and likely to be transitory ; the irritation of teeth- 
ing, for example: and besides this, it is stated by many practical writers that even 
repeated and habitual attacks of epilepsy in children often go off as the patients 
grow older; and especially at the age of puberty. The experience of Heberden, 
however, was against this. He says that he had known several persons become 
epileptic at that time ; but that he had never met with one who had then got rid 
of the disease. He had seen a few who had recovered before, and some after, the 
age of puberty. Dr. Elliotson mentions a case in which a girl had epilepsy prior 
to the first period of menstruation: then the fits stopped; and she remained free 
from them until in advanced life the catamenia ceased to recur; and then the epi- 
lepsy returned. In all those cases in which we can assign some evident cause 
for the fit — such as the use of improper food,* uterine irritation, mental emotion, 
and so on — the prognosis is somewhat better than usual. " The eccentric epilepsy 
(says Dr. Hall) is to be viewed as curable, however difficult of cure. V And how- 
ever unfavourable the prognosis may be, there is nothing that can excuse any 
apathy or neglect on the part of the practitioner. Though few cases of habitual 
epilepsy admit of a cure under any treatment, yet there are few which may not 
be relieved by treatment, so far as regards the frequency or the violence of the fits, 
or both. 

The treatment of epilepsy resolves itself into the measures to be adopted during 
the fit; and the measures to be adopted during the intervals between the fits. 

In the paroxysm itself we have to provide against the risk of injury from the 
struggles and contortions of the patient ; and if possible, to mitigate the violence, 
and to shorten the duration of the fit. The patient should be placed in the centre 
of a large bed ; his neckcloth, and any ligatures about his person, should be 
loosened; his head should be somewhat elevated. When the risk of his hurting 
himself cannot be avoided in any other way, his limbs should be restrained by 
the bystanders, or secured in a waistcoat. ;Some persons have advised that a 
piece of cork or soft wood should be placed between his teeth, to prevent him 
from biting his tongue, or breaking his teeth. But it is not easy to manage this 

* [In the predisposed, one of the most frequent causes by which the paroxysm is brought 
on, is errors in diet, either in regard to the quality or quantity of the food taken. We have 
known cases in which the patients remained free from an attack so long as they abstained 
from a particular article of food, but invariably experienced one on partaking of it. — C] 



EPILEPSY. 



403 



expedient cleverly. If the head be visibly congested, and hot, cold wet cloths 
may be applied to it with propriety ; and if, at the same time, the extremities be 
cold, means of restoring warmth to them should be adopted. 

I do not know whether art can abbreviate the paroxysm. Some years ago the 
late Barry O'Meara sent a letter to one of the newspapers, saying that he fancied 
he had seen a popular remedy useful in such cases ; that, namely, of cramming 
salt into the patient's mouth: he thought he had succeeded in bringing the patient 
about by that expedient. In the epileptic patients that come into hospitals, tbe 
physician, not being always on the spot, does not see all, nor even many of the 
paroxysms ; but after reading that letter, I desired the nurses to treat all my 
patients who might be seized with epilepsy in the wards upon that plan : and on 
comparing the length of the paroxysms when the salt was used, with their ordinary 
duration as reported by the friends of the patient, or as previously observed in the 
hospital during some of the earlier fits, it certainly did seem to curtail the con- 
vulsions. Probably it is more calculated to relieve an hysterical than an epileptic 
fit. In the epileptic fits of children much benefit ofien results from immersing 
them in warm water: particularly if there be any coldness of the extremities. 

It is very much the fashion to bleed persons who are seen in a fit, of whatever 
kind; and to bleed them largely. I have already given you my opinion respect- 
ing the indiscriminate use of this decided measure in apoplectic attacks. If it be 
clear, from the phenomena, or from the known history of the patient, that the case 
is one of epilepsy, bleeding, during the Jit, will seldom be necessary or proper ; 
unless, indeed, the evidence of cerebral plethora is very strongly marked: and 
even then I would advise you not to do more than take a moderate quantity of 
blood, by cupping, from the neck or temples. The convulsions and the sopor 
may be expected soon to pass off; as soon, probably, and as completely without, 
as with, any abstraction of blood. Whereas the difference of the alternative is 
not trifling, in respect to the condition in which the patient will be left when the 
fit is over. The injurious effect of excessive blood-letting upon the system at 
large, is manifest, sometimes, for months afterwards. 

During the intervals between the attacks we seek to prevent their recurrence; 
and this end is to be attained, when it is attainable at all, by getting rid of the 
predisposition to the disease on the one hand, and by protecting the patient against 
its exciting causes on the other. Now there are certain kinds and causes of pre- 
disposition which we cannot get rid of; such are the tendency that is inherited; 
the strumous diathesis; malformation of the head ; the presence of some organic 
lesion in the brain or spinal cord. Vicious and dissolute habits are also difficult, 
but not impossible, to eradicate. It will be our duty when such are discovered, 
to set strongly before the unhappy patient the dreadful end towards which he is 
hastening; the certain loss of reason to which, when once the disease has shown 
itself, the continuance of his baneful indulgences will drive him ; and to urge 
upon him the necessity for a short and sudden turn on his part, if he would expect 
any aid from medicine. Where no physical cause of the proclivity exists, orcan 
be detected, it is of much importance to ascertain whether there be any deviation 
from the standard condition of health ; towards general plethora in the one direc- 
tion, or towards emptiness and asthenia in the other. The first of these unnatural 
states may be redressed by regimen and exercise, by abstinence from stimulating 
food and drink; by a slender diet also; and, if need be, by direct depletion. The 
second, which, perhaps, is the most common of the two, and which often leads 
(as I have explained before) to local plethora, may be removed or lessened by a 
tonic treatment. The object in both cases is to give stability and firmness to the 
nervous system; to diminish that mobility, or readiness to be impressed, which is 
so strong a characteristic of the class of patients affected with epilepsy, although 
it may not be very apparent in some few individuals among them. It is upon 
this principle, that mineral tonics sometimes do good in epilepsy, and not by any 
specific virtue which they possess in restraining the fits. 

It is owing, perhaps, to a neglect of these two somewhat opposite conditions 



404 



EPILEPSY. 



of general plethora and general debility, or to the difficulty which sometimes is met 
with in distinguishing them, that such a variety of opinions have been expressed 
concerning the proper treatment of habitual epilepsy. Plethora is to be reduced 
without causing hurtful debility: tone is to be given without inducing dangerous 
fullness. It requires some nicety to carry the balance even ; to attain the hoped- 
for good, and at the same time to avoid the evil that is apt to wait upon it. In 
very many cases the requisite extent and measure of the tonic plan on the one 
hand, or of the lowering system on the other, can only be learned by careful trials. 
But sometimes the indications of treatment are more plain. When the patient is 
young and strong, and full of blood, and not of a particularly movable tempera- 
ment ; when he has a hard pulse, or any degree of feverishness ; when the disorder 
has supervened upon the suspension of some customary discharge, so that there 
is an obvious cause of plethora; and when the disease is in its early stage, and 
the recurrence of the fits has not yet been established by habit; in any or all of 
these circumstances it will often be proper to abstract blood from the patient, and 
it will always be right to purge him actively, and to insist upon an abstinent regi- 
men. When former paroxysms have been preceded by signs of fullness of the 
vessels of the head — by headache, for instance, throbbing of the temporal arteries, 
distension of the superficial veins, a flushed or loaded countenance — you may 
sometimes, by a timely use of the lancet or the cupping-glass, avert an attack that 
was apparently impending. 

On the other hand, if the patient is pale and weak ; or unduly susceptible ; or 
if his malady has been fastened upon him through many repetitions of the fit; 
you will generally find that any form of active depletion is injurious, and learn to 
place your best hope in measures which are calculated to invigorate the frame. 

One of the most useful of the particular remedies employed for strengthening 
the body, is the cold shower-bath. This tends more, perhaps, than any single 
measure, to give permanent firmness and steadiness to the system. The best 
test, in all cases, of the tonic and bracing effect of this remedy is the occurrence 
of a pleasant and general glow after each application of it. It is the only safe 
mode in which the cold bath can be used by an epileptic person. 

You will find, in books, a great many tonic medicines recommended for this 
disease, which medicines you will have opportunity and ample time for trying. 
Of the mineral tonics, the salts of silver, zinc, copper, and iron, have been chiefly 
praised. The nitrate of silver used to be highly thought of; but there is one 
very serious objection to it which must never be forgotten: viz., that it is apt to 
produce a permanent discoloration of the skin, a frightful lead-colour. There is a 
footman in a house near Cavendish Square who has been thus blackened: and 
there is a gentleman of property resident at Brighton in the same predicament; 
his face looks as if it had been thoroughly and carefully penciled over with 
plumbago. A barrister, a friend of my own, had a narrow escape from a similar 
misfortune: in fact his skin has acquired a just perceptible tinge of gray. Now 
if the remedy were sure to cure the disease, I am not certain that every one would 
accept of a cure on such terms. It would be proper, even on that supposition, 
co tell the patient that though he (or, a fortiori, she) would get rid of the epilepsy, 
there was a likelihood that this unamiable complexion might ensue. But the truth 
is that in giving this nitrate of silver we run a great risk of obtaining its disfiguring 
effect, for the sake of a very small chance of curing the epilepsy. I have been 
assured, by one of his friends, that the Brighton gentleman has carried a dark 
outside for a quarter of a century at least; and that he is as subject to epileptic 
fits now as ever he was. If the lunar caustic is to do good, it must be given for 
some time together, and the probability is that it will not do good even then; 
and if it be given for some time together, there is great danger of its changing the 
colour of the skin. For these reasons I never give it myself, and therefore I 
cannot recommend it to you. If you wish to try it, or if you have a patient who 
insists on trying it, as some will, yon may begin with half a grain in a pill three 
times a day; and the dose has sometimes been carried as high as fifteen grains. 



EPILEPSY. 



405 



And it is worth observing that in the larger doses this drug proves purgative. It 
is possible that its good effect, when it has any, may be attributable to its operation 
in that way. 

There is no danger of spoiling the beauty of your patient by administering the 
oxide or the sulphate of zinc ; or the cuprum arnmoniatum. The liquor arseni- 
calis has been thought useful; but it requires to be exhibited with great caution. 
Of all the metallic remedies I should prefer some preparation of iron. I think I 
have seen much good done by the vinum ferri ; not by any specific agency, how- 
ever, but by its giving what is called tone to the nervous system, and rendering it 
less prone to be affected by the slighter exciting causes of the disease. I cannot 
pretend to weigh the merits of the long list of substances which have been lauded 
as efficacious in keeping off and curing the disease; and which, when they have 
been useful at all, have operated, I conclude, in diminishing the disposition to 
epilepsy by corroborating the nervous system. The most renowned of them are 
valerian, assafetida, wormwood, the misletoe of the oak, the cardamine pratensis, 
rue, the sedum acre, indigo ; narcotic vegetable preparations, stramonium, bella- 
donna, hemlock, lettuce ; animal substances, musk, castor, ox-gall ; and the num- 
ber might be many times multiplied: and this long array of drugs, all of which 
have been known, or supposed, to accomplish a cure, affords, in truth, one of the 
strongest evidences of the intractability of the disease under any plan of treat- 
ment. There is a shrewd remark of EsquiroPs, which I believe to be quite true, 
however difficult it may be to account for the fact, which is, that epileptics are 
apt to improve for a time under every new plan of treatment. 

Whatever drug you may see reason to prefer (and the patients will have drugs, 
and you must be prepared to ring the changes upon them), there are certain other 
points in the management of the disease which are of considerable importance. 
The patient who is subject to epilepsy should live by rule, and be temperate in 
all things. His diet should be simple, nutritious, but not stimulating : he should 
renounce all strong liquor, and become, in the new-fangled and vulgar phrase, a 
tee-totaller. He should rise early, and take regular exercise in the open air ; 
keeping his head cool, and his extremities warm. He should avoid all mental 
excitement, and the fatiguing pursuit of what is called pleasure : all probable 
sources of sudden anger, surprise, alarm, or deep emotion of any kind ; all striv- 
ing and contention of the intellect. The student, of whatever age and sort, in 
whom epilepsy has declared itself, should shut his books : the man of business 
abandon or abridge his professional toil: at least they must be instructed to 
abstain habitually in their respective callings, from such applications as would 
task and strain their powers, whether mental or bodily; and endeavours should 
be made to engage their thoughts and to interest their minds in less engrossing 
objects of attention. No minute rules can be laid down on these points, but, 
keeping the general indication in view, it will seldom be difficult to follow it up 
in practice. 

When the fits appear to have been brought on by a species of moral contagion, 
or by imitation of the same disease seen in others, care should be taken to ex- 
clude as much as possible those objects or trains of thought which produce the 
mental emotion or the morbid propensity. In these cases, and, indeed, I may say 
in almost all cases, it is more rational to expect benefit from such measures as lend 
to calm the mind and to fortify the nerves, than from this or that substance thrown 
at random into the stomach. 

There is cause for suspecting that epileptic fits sometimes depend upon a syphi- 
litic affection of the bones of the skull ; I am much mistaken if I have not seen 
such cases. When that suspicion arises, it will be proper to give mercury a full 
and fair trial. Such a plan has been followed by success. I should always pre- 
mise, however, in such cases, the iodide of potassium ; the efficacy of which in 
dispersing syphilitic nodes is no longer doubtful. I am accustomed to recommend 
a gentle and iong-continued course of mercury whenever organic disease of the 
brain is suspected ; the influence of that remedy being carefully watched. It will 



406 



EPILEPSY. 



be right and proper also to try the effect of counter-irritation ; of blisters, asetonin 
the neck, or the tartar-emetic ointment. But I must confess to you that, often as this 
expedient is employed, I have seldom witnessed any such result from it as would 
encourage me to expect benefit from repeating it in another case. There is one 
form of counter-irritation which I have never seen put to the test, but which has 
of late been strongly recommended by a very able and observing physician, Dr. 
Pritchard ; and of which I have heard very good accounts from a gentleman who 
had seen it extensively employed in Bristol; I mean the making a long issue in 
the head itself, dividing the integuments down to the bone by means of a scalpel 
in the direction of the sagittal suture, and keeping the incision open and dis- 
charging for some time, by means of issue peas. The formation of the issue is 
said to be not so painful as one might suppose. 

Dr. Quain, in his edition of Martinet's Pathology, relates the following case : 
" Some years ago I saw a boy who was epileptic from infancy, and who, in one 
of his usual fits, fell over a cliff by the sea-side, and received a very severe lace- 
rated wound of the scalp, which healed slowly and with a copious suppuration. 
While the discharge continued he was free from any epileptic attack ; but as soon 
as the wound healed, the fits returned as before." 

Twice I have seen similar good effects from the insertion of a setonin the neck. 
Twenty times that measure has disappointed my hopes. 

When the disease is ascertained or believed to be of the eccentric kind, we 
must search diligently to find the seat of the distant irritation, in some disturbance 
of function ; and apply our remedies accordingly. The irritation may be found, 
as T have already intimated, in almost any organ of the body. Painful or irregular 
dentition is perhaps one of the commonest of the eccentric sources of epilepsy. 
Sometimes the attacks are attended with symptoms of disease in the liver ; slight 
yellowness of the skin, uneasiness and tenderness of the right hypochondrium, 
and lowness of spirits. In such a case we must rectify that state of the liver, 
by such means as I shall have to specify hereafter. If the disorder depends 
on a stone in the bladder, the cure must be committed to the surgeon. I have a 
patient at present under my occasional inspection, who from time to time has 
slight fits of epilepsy ; on most occasions he passes about the same time a small 
calculus by the urethra. I make no doubt that in his case the exciting cause of 
the epilepsy lies in the kidney. 

You will find that most persons, in respect to such diseases as that which we 
are now considering, have some favourite or usual mode of treatment; and if I 
were called upon to name any single drug, from which, in ordinary cases of 
epilepsy, I should most hope for relief, I should say it was the oil of turpentine. 
And I find that other physicians have come to the same conclusion. Dr. Latham 
the elder was, I believe, the first person who made known its efficacy in this dis- 
order. Foville states that he has seen excellent effects from it. It is highly 
spoken of by Dr. Percival, in the Dublin Hospital Reports. It is not to be given 
in large doses, but in smaller ones, frequently repeated ; from half a drachm to a 
drachm every six hours. You are aware that it sometimes produces strangury, 
and therefore the patient must be forewarned of this, or carefully watched. Occa- 
sionally turpentine has done good in virtue of its anthelmintic properties. I know 
that a physician of my acquaintance cured a case of epilepsy in this way, some- 
what to his own surprise. Without having in his mind any notion of worms, he 
thought it might be well to purge his patient, who had laboured under epilepsy 
for some time, with the oleum terebinth in as. The patient, who is the brother of 
a person holding at present a high office in this country, was residing two or 
three miles out of town. In the middle of the night the doctor was summoned 
to him in a great hurry; the messenger said he was supposed to be dying. He 
was only intoxicated, however, by the free dose of turpentine he had swallowed : 
the next morning he voided into the close stool a large tape-worm ; and he has 
never had epilepsy since. A nobleman residing in Cambridgeshire was long 
epileptic ; and he too got rid of his epilepsy and of a worm at the same time. I 



EPILEPSY. 



407 



believe that the cure was effected by turpentine in his case also ; but I am not 
certain of that. Such cases are remarkably interesting : they show that irritation 
of the stomach or intestines may be sufficient to cause the fits; they illustrate ex- 
cellently well the eccentric form of the disease ; and they deserve to be always 
borne in mind when we are asked to prescribe for an epileptic patient. A cure 
from so dreadful a complaint, by such simple means — the cause of his malady, 
and the certainty of his having got rid of that cause, being both so obvious and in- 
telligible to the patient — may be enough, sometimes, to make a practitioner's for- 
tune. But I think you will sometimes find the oil of turpentine very useful, even 
though it expels no worm, and when there is no worm to expel. If the bowels 
should be costive, the oil of turpentine and castor oil, in equal proportions, go 
exceedingly well together. 

When the patient has a distinct warning of an approaching paroxysm, can any- 
thing be done to ward it off? Why, in some cases, by interrupting the precursory 
symptoms, it certainly may be prevented. A pupil of the class informs me that 
a brother of his, twelve or thirteen years old, has been subject to epileptic fits for 
two years. They occur in the night, especially if he is waked, even though the 
awakening cause has no tendency to startle him. He often is dull and drowsy 
the evening before, and if he is roused from this lethargic state by conversation or 
amusements, the attack expected that night sometimes does not happen. Another 
student knows a young girl, in whom the occurrence of very high spirits is always 
precursory of the paroxysm ; when this extreme vivacity is moderated by those 
about her, the threatened fit is sometimes averted. I mentioned before an instance 
in which the aura, proceeding from one of the thumbs, was frequently checked 
by a ligature tightly round the thumb. Other examples of exactly the same 

kind are on record. Mr. Wardrop cured a case beginning with an aura in one 
finger, by amputating a joint of the finger. Dr. M. Hall states that the immediate 
accession of the paroxysm may sometimes be prevented by dashing cold water on 
the face, or by exciting the nostrils by snuff. In this manner the disposition to 
closure of the larynx, and to expiratory efforts, is exchanged for sudden acts of 
inspiration. Another patient of my own, an old college friend, indeed, who is 
afflicted with epilepsy, feels convinced that he sometimes staves off a fit by 
applying smelling salts to his nose : and he always carries a bottle about with him 
for that purpose; but unfortunately the warning (which consists chiefly in giddi- 
ness) is generally so short that he has not time to have recourse to his preventive 
before he falls down. It is a question whether the fit may not be obviated by a 
strong mental effort in some cases. I make no doubt that it may, especially in 
the imitative form of the disease, which originates in and depends upon mental 
and moral causes. 

It is scarcely necessary that I should do more than advert generally to those 
precautions which every one who is subject to epilepsy ought to observe, and 
which it is the business of his medical adviser to enforce, both upon the patient 
himself, and upon his friends. His bed should be large; or if not large, it should 
be enclosed with some netting or other defence against his falling out of it. If he 
sleeps in a room by himself, care should be taken that in the winter a proper tem- 
perature is kept up, for if in his attacks he gets out of bed and on the floor he 
may be seriously injured by the cold. He should not, however, be left alone if 
it can be helped. Guards should be placed over every grate near which the patient 
may come. He should avoid ascending and descending stairs as much as he 
can. He should not ride on horseback; nor on the outside of a coach; nor even 
in a gig; nor go about, especially in solitary places, without an attendant. A 
patient of Dr. Cheyne's, a young man of twenty, was drowned in his own garden 
by failing into a little runnel of water, which was not four inches deep. Neither, 
on the other hand, will it be proper or safe for him to frequent crowded or hot 
rooms ; or the streets of a populous town, in which the multiplicity and distraction 
of objects are apt to produce, even in a healthy person who is not accustomed to 
them, a degree of vertigo and confusion. Dr. Cheyne advises that when the 



408 



CHOREA. 



patient's circumstances will admit of bis having a constant attendant with him, 
the latter should be provided with some diffusible stimulus ; a potion, for example, 
composed of camphor mixture and aether, by swallowing which the impending 
paroxysm may sometimes be repelled. 



LECTURE XXXVII. 

Chorea. Symptoms; Pathology; Complications; Causes; Treatment. 
Chronic Chorea. Other JS ! ervoas Disorders to which the same name has been 
applied. 

Another disease of a spasmodic kind, and essentially belonging to the nervous 
system, is Chorea — St. Vitus^s dance. This is far less serious than the com- 
plaints which we have recently been considering; but it is a very unpleasant 
disorder to suffer, and it has several points of analogy with the other nervous and 
spasmodic ailments. Its prominent symptom is an irregular and involuntary 
clonic contraction of some of the voluntary muscles, which, however, are not 
wholly or constantly withdrawn from the government of the will. In tetanus we 
had rigid spasm, while the mind w r as clear and free; volition was unaffected, but 
the muscles which should have obeyed the effort of the will, were seized upon 
by some stronger overruling power. In epilepsy, with convulsive spasm, there 
was suspension of the mental functions : a temporary interruption of conscious- 
ness, and therefore of volition. But in chorea we have a different state from 
either of these. There is no loss of consciousness ; no defect of volition. The 
ordinary movements of the body can be performed in some degree, or sometimes, 
under the direction of the will ; but it would seem as if some other power 
wantonly interfered to excite them when they are not needed, to render them 
unsteady and imperfect, to arrest the natural action, and give a new direction to 
the limbs, and to cause the patient to gesticulate and grimace like a Merry-Andrew. 
Moreover, these apparently absurd movements do not occur in paroxysms, but 
continue throughout the day, sometimes for weeks together; but they generally 
cease during sleep: for the most part, but not always, the agitated limbs are still, 
while the senses are shut up in slumber. The complaint is not attended with 
fever. 

This disorder was first distinctly described by Sydenham, whose account of it 
is very graphic and excellent, and has been copied by most subsequent writers. 
Without reference, however, to the portrait which he has left us, I will sketch the 
disease as it has occurred under my own observation. It usually begins with 
slight twiches of a few muscles in the face, or in one of the extremities ; and by 
degrees the spasmodic action becomes more decided and more general. All the 
voluntary muscles are liable to be affected by it. Those of the face seldom escape. 
The features are twisted into all sorts of ridiculous forms; you might suppose 
that the patient was what is called pulling a face, or making mouths at you: but 
there is neither mirth nor mockery in the contortion ; it is a convulsion. It is 
succeeded by a vacant look, and then it begins afresh. The disease occurs much 
oftener in young girls than in any other persons. If you ask the patient to put 
out her tongue, she makes sundry attempts to do so before she can accomplish it; 
and then the tongue is suddenly thrust out, and as suddenly withdrawn, and the 
jaws snap together as if she were resolved that you should have as short a glimpse 
of it as possible. She writhes and contorts her shoulders. She cannot keep her 
hand or arm half a minute in the same position. When, at meals, she desires to 
carry her hand to her mouth, it is arrested midway, and suddenly pulled back 
again, or pushed off in some other direction ; and it is only after many deviations 
and fruitless efforts that she succeeds. The lower extremities are equally affected. 



CHOREA. 



409 



When the patient intends to sit or stand still, her feet scrape and shuffle on the floor, 
or one is thrown over the other ; and if she endeavours to walk, her progress is 
most uncertain ; she halts and drags her leg rather than lifts it up, and advances 
in a jumping manner by fits and starts. In short, the voluntary muscles are 
moved in that capricious and fantastic way in which we might fancy they would 
be moved if some invisible mischievous being, some Puck or Robin Goodfellow, 
were behind the patient, and prompted the discordant gestures. With all this the 
articulation is impeded : there is the same perverse interference with some of the 
muscles concerned in the utterance of the voice. By a strong figure of speech, 
the disorder has been called "insanity of the muscles." 

Such is a picture of the main symptoms of this strange malady, as they have 
presented themselves to me ; and such, I venture to say, you will often see in your 
future practice. You will find, moreover, that the irregular jactitations are usually 
more marked and general on one side of the body than on the other: and some- 
times they are confined to the muscles of one side. Here, therefore, we have a 
trait of resemblance to epilepsy and to hemiplegia. If you take hold of the only 
limb which happens to be thus agitated, and keep it still by main force, some 
other limb or part will take on the convulsive action. The persons who are 
subject to chorea are always inordinately sensitive, and what is popularly called 
44 nervous." They are easily stirred up by new ideas and sudden feelings, and 
pass readily, and upon slight occasions, from one mood of mind to another. The 
mind is affected, as Dr. Cullen remarks, in the same way, and often shows the 
same varied, desultory, and causeless emotions, as in hysteria. You see the 
indication of this nervousness in the fact that the fidgety catching of the muscles 
increases when the patient is spoken to, especially by a stranger — by the physi- 
cian, for example. The nurses of the hospital constantly tell me that such or 
such a patient, who has chorea, is much more composed at other times than she 
is during my visit, when she is surrounded by students, and made the object of 
their attention. In most cases the jactitations are partly and in some degree under 
the influence of the will. Sometimes the patient seems to give way to them, 
indulges in or exaggerates them: at other times she can, by making an effort, 
control them. Many of the patients, especially such as are old and intelligent 
enough to understand the directions given them, and to make the trial fairly, can 
suspend for some seconds the convulsive movements, by taking a deep inspiration, 
and resting upon it, without expiring, for a little while. Like other spasmodic 
diseases occurring in movable constitutions, chorea is liable to be propagated also 
by a species of contagion, or rather of involuntary imitation. These diseases 
constantly approximate and touch each other in some of their characters. 

Chorea, in this its standard form, is essentially a disease of youth. Sydenham, 
and Cullen, who closely copies him, state that for the most part it attacks boys 
and girls, who have not reached the period of puberty; between the tenth and 
fourteenth years of their age. These limits are, however, too scanty. It is very 
common between the eighth and sixteenth years; it sometimes comes on as early 
as five or six; and now and then it begins in adult life, or in old age. I have 
already intimated that it is much more frequent in girls than in boys. Dr. Heber- 
den says the proportion is as 3 to 1. Dr. Elliotson, out of 30 patients, had 22 
females and 8 males. Of 84 cases reported by Dr. Reeves, of Norwich, 57 were 
females, and 27 males. Of 72 occurring in Dr. Manson's practice, at Notting- 
ham, 53 were females, 19 males. Of 18 cases in the Hampshire County Hos- 
pital, 12 were girls, and the rest boys. Now taking all these numbers together, 
we have 204 cases, of which there were 144 females and 60 males ; the propor- 
tion is as 12 : 5, or a little more than 2:1; and leaving out Dr. Reeves' list — 
which differs considerably from the others in containing a larger number of males 
—we have 120 cases, of which 87 were females, and 33 males; this ratio is as 
29 : 11 ; or nearly, but not quite, 3 : 1. [In 429 cases referred to by Dufossi 
and Rufz, 130 occurred in boys and 299 in girls.— C] I have also observed 



410 



CHOREA. 



that the disease occurs much more frequently in children having dark hair and 
eyes, than in those of a light complexion ; and I think I have seen the same remark 
in some book, but I forget where.* 

When the disease is strongly marked, or lasts long, there is usually some 
imbecility of mind manifested ; a slight degree of fatuity, and a foolish expression 
of the features. But this goes off with the other symptoms. The child gene- 
rally recovers, but the malady is apt to recur, and that more than once. In this 
respect we may trace a distant resemblance to epilepsy ; if we regard each attack 
as a long and mild paroxysm, then these paroxysms are liable to repetition. No 
doubt the duration of the disorder is often abbreviated by proper treatment; there 
are cures in this disease as well as recoveries. Tt is a very rare thing for chorea 
to prove fatal ; and the few fatal cases that have occurred have thrown no light on 
its pathology. Dr. Elliotson saw a strong girl affected with it die of apoplexy ; 
but perhaps she would have died of apoplexy whether she had had chorea or no. 
Chorea offers no protection against the invasion of other diseases. My colleague 
at the Middlesex Hospital, Dr. Hawkins, had a fatal case. He found great vas- 
cularity of the uterus, earthy concretions in the pancreas, omentum, and mesen- 
tery, and tubercles in the lungs. But these conditions had no connection pro- 
bably with the chorea. In an instance that proved fatal under Dr. Bright' s 
observation, there was considerable disease in the uterus and its appendages. I 
am afraid that we shall seek in vain in the dead body to discern the nature of 
chorea. When we find organic disease accompanying it, we must look upon 
such organic disease, if it have any connection with the chorea at all, as being a 
predisposing cause; as producing or increasing that irritability and mobility of 
the nervous system which fit it for submitting to the exciting causes of various 
nervous diseases. 

There is a speculation of some of the French writers respecting the seat and 
nature of chorea so ingenious, that I cannot refrain from mentioning it. 

It is affirmed by certain modern physiologists, as you may perhaps know, that 
one of the functions, the principal office indeed, of the cerebellum, is to preside 
over and regulate the faculty of locomotion ; to keep the muscles in due subordi- 
nation, as it were to the will. No voluntary movement, almost, can be executed 
without the combined and consenting action of many muscles ; it is the business 
of the cerebellum, they say, to maintain this consent and community of purpose; 
to prevent any mutiny of individual muscles, and to make them unanimously co- 
operate in producing a given movement. How far this doctrine is true I do not 
intend to inquire: but supposing it well founded, then they very ingeniously assign 
the cerebellum as the seat of that change, whatever it is, which gives rise to the 
phenomena of chorea. And it is most certain that the irregular movements by 
which chorea is characterized can neither be considered as the effects of imper- 
fect paralysis, as some have stated, nor of convulsion, in the proper sense of that 
word, as others have asserted; but rather as consequences of the want of due 
harmony and agreement between the various muscles, which should combine to 
produce the desired state either of rest or of motion. There is a defect of the 
requisite association in the actions of the different muscles ; and it is in this sense 
that chorea has been denominated insanity of the muscles. There is a certain 
portion of the brain which ministers to the intellectual functions ; there are certain 
altered states of that portion, which lead to mental aberration ; the persons so 
affected form false judgments ; cannot associate their ideas aright. So also there 
is a certain portion of the encephalon which presides over the locomotive func- 
tions ; and there are altered states of that portion, which lead to a loss of the 
due association of muscular contractions. That portion is the cerebellum. Such 
is their theory ; and it is a very plausible and pleasant, but withal an unsatisfying 
theory. The disorder really belongs, I apprehend, to the excito-motory depart- 

* [According to Mr. W. H. Bell — {Did. des Etudes Medicates) Dufosse (ibid.), and Rufz 
{Archives Generates de Med., iv. 239) — the subjects of chorea have chiefly light hair.— C] 



CHOREA. 



411 



ment of the nervous system. From some infirm or unnatural state, either of the 
cord or of the incident nerves that convey impressions to it, its reflex function is 
called into irregular play, and voluntary muscles contract independently of voli- 
tion. Sometimes, at the same instant, the patient wills certain definite move- 
ments through the instrumentality of the very same muscles. But the authority 
of the will is impaired, and the automatic motions are proportionally strong and 
unruly. The consequence is, that the same muscles, receiving at the same time 
contradictory orders from these two sources, obey neither mandate completely, 
but give rise, by their discordant action, to the grotesque and seemingly antic 
gestures which these patients exhibit. 

But to leave these seductive theories, and return to duller matters of fact. Cho- 
rea is a complaint that is seldom attended with any bodily pain. I have in seve- 
ral instances, however, known it to be accompanied by pain in the head ; and in 
some of them, with pain on that side only of the head which was opposite to the 
agitated limbs. I mention this as being of some practical importance ; for I have 
found the disease to become sensibly less severe, and very soon to cease, upon 
drawing blood by leeches, or cupping, from the painful side of the head. In a 
greater number of cases, however, no such pain is experienced. Sometimes you 
will find that in all respects, excepting the nervousness, and the irregular move- 
ments, the patient is in the enjoyment of perfect health. But neither is this very- 
common: generally there is something manifestly wrong in the state of the sto- 
mach and bowels, either before or during the complaint ; a capricious appetite, 
costiveness, a tumid abdomen, offensive breath, a foul tongue. 

Chorea is sometimes complicated with other disorders, and above all with hys- 
teria : and no wonder, since they both occur chiefly in persons of the same sex, 
of the same susceptible temperament, and at nearly the same period of life. It is 
said also to happen in conjunction with acute rheumatism and rheumatic pericar- 
ditis ; and with certain affections of the skin. Its coincidence with cutaneous 
complaints, if not merely accidental, may perhaps be owing to irritation of the' 
peripheral extremities of afferent nerves, by the eruption. Judging from my own 
experience alone, I should not say that the disease was often associated with 
acute rheumatism. Dr. Copland and Dr. Bright have both, however, noted that 
connection, and therefore I cannot doubt that it does sometimes exist. I certainly 
have seen jactitations like those of chorea in a few instances of rheumatic car- 
ditis. Very lately a boy, affected with chorea, became my patient in the hospital. 
We soon detected a strong bellows-sound of his heart; and tracing his history 
back a little, we found that he had suffered acute articular rheumatism. In a 
recent volume of the Medico- Chirurgical Transactions, there is a paper by Dr. 
Bright, detailing "cases of spasmodic disease, accompanying affections of the 
pericardium." Now we do not perceive any obvious or direct connection between 
the cardiac disorder and the nervous disorder. There are just two conjectures 
which occur to me upon the subject. Rheumatism (as we shall see by and by) 
is especially a disease of fibrous structures, and it usually affects various fibrous 
parts at the same time. It is not improbable, therefore, that, in the cases in ques- 
tion, some morbid condition of the membranes of the spinal canal may have 
arisen, simultaneously, with the inflammation of the pericardium. Or the car- 
diac disease may perhaps operate, by some ill-understood influence, upon afferent 
nerves of the cord, as an eccentric cause of the irregular movements. 

Probably any thing which makes a forcible impression upon the nervous sys- 
tem may act as an exciting cause of chorea. Strong mental emotion, or a sudden 
mental shock, is very likely to bring it on in those of a movable constitution who 
are predisposed to it. Of its ascertained or alleged exciting causes, fright is 
beyond all comparison the commonest. It has been known to follow a blow or 
Hill on the head ; but even in these cases the alarm may have had more to do with 
the disorder than the blow itself. It sometimes seems to depend upon irritation of 
the stomach or bowels, by improper diet, by accumulated feces, or by worms ; 
and it is found to be connected 3 in not a few cases, with difficult and painful men- 



412 CHOREA. 

struation. It frequently begins about the period of the second dentition : the late 
Dr. Gregory, of Edinburgh, was in the habit of relating instances of that kind. 
In one case, the old teeth were remaining while the new ones were appearing by 
their sides. The old teeth were drawn, and the removal of the chorea was com- 
plete. This Dr. M. Hall would justly call eccentric chorea. But even in such 
cases the state of the gums cannot be regarded as the sole cause of the chorea: 
there must be the predisposition, as well as the accidental exciting cause ; for the 
complaint is apt to recur under the agency of some new irritation, and may then 
be removed by other means.* 

Chorea, such as I have been describing it, may last from a week or two to some 
months. In those eighty-four cases which I have already mentioned as having 
been reported by Dr. Reeves, the shortest period of medical treatment was two 
weeks; the longest eight months ; and the common average seven weeks. This 
appears to me a long average. The disorder often terminates — at any rate much 
snore often than epilepsy does — at the period of puberty ; especially upon the first 
coming on of the menstrual discharge in the female.t 

I had occasion, in the last lecture, to remark, that when a vast number of differ- 
ent drugs are recommended as specifics in any given disease, we may sometimes 
infer from that very circumstance that the disease is difficult of cure, and generally 
intractable under all plans of management. But there is another class of diseases 
which a variety of drugs are supposed capable of curing, — those, namely, which 
tend to terminate in health. I believe that many cases of chorea — most cases — 
would at length get well without any aid from physic : I believe also that many 
of the boasted specifics have been quite innocent of any share in the recovery of 
the patients to whom they were administered; at the same time I am quite certain 
that treatment has a great influence over the disease. 

It was Sydenham's practice first to bleed and purge his patients, and then to 
administer bitters, aromatics, and antispasmodics, with the view of strengthening 
the nerves. After his time the blood-letting and purgatives fell into disuse, until 
the publication of Dr. Hamilton's well-known work again brought the latter 
deservedly into favour. 

The treatment of chorea embraces two definite objects. The first, and chief, 
is to give stability to the unduly movable nervous centres. The second is to 
remove or avert whatever may be likely to produce unnatural excitement of their 
incident nerves. 

Now the complaint is seldom (in its genuine form I may say it is never) 
dependent upon any organic" or inflammatory disease. The instrument is not 
broken anywhere, but it is slackened, jangling, and out of tune: and (to pursue 
the metaphor) we often can restore its harmony by bracing it up again. 

I can confidently recommend you to abstract blood locally in those cases in 
which there is a fixed pain in the head; but with this exception, blood-letting is 
neither useful, nor even (in my opinion) justifiable. There is oftener a deficiency 
than a redundance of red blood in the system. 

I shall not attempt to distract your attention by discussing the various remedies 
that have been vaunted against chorea; but shall take the liberty of referring you 
to books (to Dr. Copeland's Dictionary, for example) for further information on 
that subject, and content myself with telling you what modes of treatment I have 
been in the habit of employing, with very satisfactory results. I think, then, 
setting aside the complication with headache just mentioned, you will be able to 
deal successfully with most of the cases of chorea which you may have to treat, 

* [We have not found the disease to be much influenced by the season of the year or 
condition of the atmosphere. Duges, Rufz, Spangenberg, and Blache state that it occurs 
most frequently in summer. According to the statements of Rochoux, Chervin, and Danste 
it is a rare affection in the southern hemisphere. It is not a very frequent disease in 
Philadelphia.— C] 

t [Chorea, like epilepsy, may be excited by imitation (Andral) 5 the fact is, however, 
denied by Rufz and Blache.— C.J 



CHOREA. 



413 



if you have at your command purgative medicines, the shower-bath, preparations 
of iron and of arsenic, and the oil of turpentine. 

It will be right, in all cases, to begin by clearing out the bowels with calomel 
and jalap, or some active aperient ; and you should persist in the regulated use of 
purgative medicines, if they continue to bring away much fecal matter. You are 
to be guided less by the amount of the doses than by the effects they produce ; at 
any rate one full evacuation of the bowels should take place every day. But 
though purgatives are good auxiliaries, we cannot trust to them alone for the cure 
of the complaint. 

One of the most effectual of the tonic remedies is the cold shower bath. If the 
patient be of a feeble constitution, the water may at first be used tepid ; by degrees 
it should be used cold. This remedy should be employed every morning, or 
every other morning, early, as soon as the patient gets out of bed. Of the best 
indications of the propriety of its continuance I spoke in the last lecture only ; I 
need not tire you, therefore, by repeating the observations I then made. 

With this external tonic it will be right to combine some internal one ; and for 
the most part, the best for the purpose is some preparation of iron. The carbonate 
of iron is an exceedingly good form, and it may be given in the way recommended 
by Dr. Elliotson, one of whose pets it is,— namely, mixed with twice its weight 
of treacle, so as to form an electuary. You may begin with it in half-drachm 
doses, and presently increase the quantity to a drachm, or a drachm and a half, 
or two drachms. Much larger quantities indeed have been given, and that for a 
long time together; but I am not in the habit of so pushing this drug. Patients 
do not like to swallow from half an ounce to an ounce of the powder and twice 
as much treacle three or four times a day ; and some of them cannot get so much 
down. And I mentioned on a former occasion that the iron is apt to accumulate 
in the large intestines, and to be expelled at last, often with difficulty and pain, in 
large, hard, red masses, like what is called, I fancy, slag, or the dross of iron ore 
from a furnace. When one or at most two drachms given three or four times a 
day, make no impression on the disease, you had better (in my humble judgment) 
change the form of the medicine. Give two or three grains of the sulphate of 
iron for a dose, or frequent draughts of Griffith's mixture (mistura ferri composita), 
or twenty or thirty minims of the tinctura ferri muriatis. Dr. Bright says he has 
found the sulphate of zinc answer when the carbonate of iron had failed, and the 
iron succeed when the zinc had done no good. One most severe case, about 
which I was consulted, and which had resisted other remedies, got well under the 
use of the sulphate of zinc; the dose of which was gradually increased to ten 
grains, given three times a day. Whenever the medicine was pushed beyond this 
point it became emetic. Certainly the disease is often very obedient to arsenic; 
but, for plain reasons, it is better to effect a cure, when we can, by less hazardous 
substances. The gravest case I ever had to treat occurred, not long since, in one 
of my hospital patients. I tried the carbonate of iron in vain. The shower bath 
so terrified and agitated the girl that I could not persist with it. I then gave her 
arsenic, under which she improved at first, but it ultimately was very injurious ; 
her bowels were greatly irritated by it, she became paralytic in her lower extremi- 
ties, and sunk into a typhoid state; and 1 really was afraid that I should lose her. 
But she recovered from this condition, which [ could not but ascribe to the 
arsenic; and as soon as I dared venture, I began to give her the muriated tincture 
of iron, twenty drops at a time, every six hours. Under this treatment she 
steadily and rapidly improved, and was soon quite well. 

The oil of turpentine also is certainly a valuable medicine in this disease ; 
whether there be worms at the bottom of it or not. When the bowels are torpid, 
and the girl is of that age when menstruation may be conjectured to be at hand, 
its arrival seems sometimes to be accelerated, and great relief to be produced by 
the turpentine. The best way of exhibiting it in such cases is in combination 
with an equal quantity of castor oil; two drachms or half an ounce of the mixture 
may be given every morning, or every other morning, according to its effect upon 



414 



CHOREA. 



the bowels ; and when they are very sluggish, or the stools are unnatural, it will 
often be serviceable to give a couple of grains of calomel also, twice or thrice a 
week, at bed-time. 

It is scarcely necessary for me to say that due attention must be paid to the 
diet. This ought to be plain and simple, but at the same time nourishing, and 
even generous. Exercise, short of that which produces fatigue, in the open air, 
in fine and dry weather, will also conduce much to the patient's recovery. And 
all kinds of immoderate emotion should be guarded against: for the contest often 
seems to lie between the emotional and the voluntary impulses to action. The 
stillness of the muscles during sleep is in accordance with this belief.* 

There is an affection (it scarcely deserves to be spoken of as a disease") which 
is sometimes called chorea, of a chronic nature, and resembling the disorder I 
have just been speaking of, inasmuch as it commonly is met with in nervous per- 
sons, and consists in the irregular, unmeaning, and involuntary contraction of 
certain muscles, especially in the limbs, neck, or face: but differing from it in this, 
that the same muscles are always affected, and in the same way ; that it lasts long, 
almost always for life, and implies no accompanying derangement of the general 
health. In its slighter form the irregular movements are rather awkward tricks 
than spasms: a repeated shake of the head, or knitting of the eyebrows, or corruga- 
tion of the integuments of the nose, or shrugging of the shoulders — which the person 
seems hardly conscious of. At other times, however, the motions are more 
extensive ; a limb starts out, or the head is turned awry ; and the individual who 
performs these, evolutions is quite aware that he does so, and vexed and annoyed 
at the ridiculous figure he makes, but he cannot help performing them ; or if he 
can prevent it, the necessary effort is worse than the disease. One young man 
who was subject to this infirmity told a friend that he could stop the movement by 
a strong exertion of the will ; but that that exertion was extremely painful, and 
was followed by languor and much discomfort. In some instances I make no 
doubt that the continuance of the affection is the result of a long-established habit. 
It occurs more frequently in men than in women. I had for a long time, as an 
out-patient at the hospital, a girl about seventeen years old, in all other respects 
the picture of health, but who was annoyed by an involuntary shake of the head, 
which took place two or three times in a minute. She received no benefit from 
medicine. A lad in my own service was affected in a similar manner. He seemed 
to be giving me, and my friends, from time to time, a familiar nod; and I was 
obliged to part with him. Others are subject to twitchings of the face. I am 
acquainted with one gentleman who is perpetually wrinkling his nose : and he 
has assured me that he was subject, when young, to an involuntary shake of the 
head, like the two persons just mentioned ; but a blister having been once applied 
to his throat for some disorder in his air-passages, the shaking of the head was 
thereby rendered painful and difficult, and the movement there ceased : but (as he 
expressed it) it broke out in his nose, where it triumphs to this day. This chronic 
chorea, as it has been called, I merely mention to prevent your confounding 
together two affections which, though they have received the same name, and are 
in some respects analogous, yet differ in still more points, and those points of 
more importance. I believe that medicine has no power over any of these tricks. 
They are distressing and unsightly ; but in no way dangerous. 

The word chorea, which you know signifies a dance — and the trivial term of 
St. Vitus's dance — are not very appropriate to either of the modifications of the 
nervous affection which I have been noticing. In fact that term was originally 
applied, and much more suitably, to another set of symptoms of a most singular 
kind, concerning the real occurrence of which we might well be sceptical, if we 

* [ For further observations on the treatment of chorea the reader is referred to the 
Editor's Treatise on Diseases of Children, page 399 et seq. — C] 



CHOREA. 



415 



had not authentic narratives of many instances of such disorder from different 
persons of credit, as well in this country as in others. What has happened many 
times before, may happen again; and you ought not to be in ignorance of the his- 
tories to which I allude. They relate to an affection characterized by movements 
that cannot be called spasmodic, but are rather owing to an irresistible propensity 
to muscular action, increased sometimes to a sort of mania by the force of imitation, 
or by the sound of music. It is the volition that, in these cases, is morbid and 
perverse. You might fancy the patient to be possessed and coerced by an evil 
spirit, like the daifiovi^ofiavoi of the Gospel history. 

Some of the subjects of these extraordinary affections, impelled by a strange 
unintelligible necessity, execute measured and regular movements with surprising 
energy, rapidity, and perseverance. When music is performed in their hearing, 
the movements become an actual dance; and where crowds are collected together, 
the dancing mania is apt to spread from person to person by a sort of imitative 
infection ; realizing the fable of Orpheus, and giving origin (it may be presumed) 
to those romantic legends met with in the literature of most ages and countries, 
of universal, involuntary, and unceasing saltation, at the sound of a magic pipe. 
To these feats the term chorea is apposite enough. Indeed I have seen it some- 
where suggested that the phrase chorea Sancti Viti is but a vulgar corruption of 
chorea Sancti inviti; and took its rise in the misfortune of some holy person 
who chanced to be afflicted with one of these unwilling but invincible impulses 
to caper. The common explanation makes this holy person to have been a cer- 
tain German Saint Weit, to whom a chapel is said (I know not with how much 
truth) to be dedicated at Ulm, in Suabia. 

Sometimes, instead of dancing on their feet, these patients drum and beat with 
their hands, either upon their own knees, or upon the objects near them. This 
variety has received the bombastic title of " malleation." Sometimes they cir- 
cumvolve with great rapidity; or they turn their heads repeatedly from side to 
side with great velocity: this is " rotation." When they are irresistibly impelled 
to move in a given direction, the term " propulsion" is employed. The very 
invention of these names attests the reality of the disorder. 

You will find one of these singular cases related by Mr. Kinder Wood in the 
seventh volume of the MecUco-Chirurgical Transactions. 

The patient was a young married woman. After having suffered sovere pain 
in one side of her face, she began to be troubled with involuntary movements. 
They commenced in the eyelids, which were opened and shut with excessive 
rapidity. Then the muscles of the extremities became affected. The palms of 
the hands were beat rapidly upon the thighs, and the feet upon the floor. The 
motions soon extended to the trunk and pelvis. The patient was suddenly half 
raised from her chair, and instantly reseated. This was repeated as quickly a3 
one action could possibly succeed another. Sometimes she had a propensity to 
leap upwards, and strike the ceiling with the palm of her hand; or to touch little 
spots or holes in the furniture of the room. Or she would dance on one leg, 
holding the other in her hand. These attacks were accompanied by headache, 
sickness, and vomiting. At last she took to making steps about the room, regu- 
lated by an air, or by a series of strokes on the furniture as she passed, her lips 
moving as if words were articulated, but no sound escaping them. A person 
thinking he recognized the tune which she beat on the furniture, began to sing 
it; and she danced directly up to him, and continued dancing till he was out of 
breath. A drum and a fife were now procured and the same air played upon them. 
She immediately danced up to the drum, and as close to it as possible, till she 
missed the step, when the motions instantly ceased; and this was found always 
to be the case. The motions stopped also when the measure was changed ; or 
was increased in rapidity beyond her power to keep pace with it. A continued 
roll on the drum had also the effect of putting an end to her movements. This 
being discovered, their approach was watched; and by always rolling the drum 
as soon as they threatened to begin, the chain of association which seemed to 



416 



CHOREA. 



• constitute the disease was at length broken. The bowels were in an unnatural 
state during the complaint; and the menstrual discharge appeared on the evening 
of the day on which it ceased. One might conceive that the conduct here de- 
scribed was an indication of folly or of insanity ; but Mr. Wood declares that the 
patienfs spirits were good, and her perception and judgment accurate and just; 
that during the absence of the paroxysms she went about her household affairs as 
usual ; and that she had a correct knowledge of her situation, and of the advantage 
she derived from the drum, with an anxious desire to continue its use. She stated 
" that there always was a tune dwelling upon her mind, which at times becoming 
more pressing, irresistibly compelled her to commence the involutary motions. w 
In a lady, whom Dr. Abercrombie saw, the following symptoms, among others, 
occurred : — After she had been ill with various nervous affections for two years, 
she began to suffer convulsive action of the muscles of the back, and involuntary 
twitches of the legs and arms, producing a variety of movements of the whole 
body very difficult to describe. These were much increased by touching her, 
especially on any part of her back. This is a symptom quite in conformity with 
Dr. HalTs doctrine of eccentric irritation. At one time there was difficulty of 
deglutition, so that attempts to swallow produced spasms, resembling those of 
tetanus. At other times, after lying for a long while quiet, she would in an in- 
stant throw her whole body into a kind of convulsive spring, by which she was 
jerked entirely out of bed : and in the same manner, while sitting or lying on the 
floor, she would fling herself into bed, or would leap, as a fish might do, upon the 
top of a wardrobe fully five feet high. These are feats that surpass the powers 
of a person in health : and I say we should hesitate to believe them if they were 
not related by a physician of such sober judgment and unquestionable veracity as 
Dr. Abercrombie. He tells us that during the whole of these symptoms her mind 
continued entire : and the only account she could give of her extravagance was, a 
secret impulse which she could not resist. 

But after a time motions still more wonderful commenced, affecting the muscles 
of the upper part of the back and neck, and producing a constant semi-rotatory 
motion of the head. This sometimes continued without interruption night and 
day for several weeks together; and if the head or neck were touched, the motion 
was increased to a most extraordinary degree of rapidity. These paroxysms were 
relieved by nothing but cupping on the temples to the amount of ten or twelve 
ounces, when the affection suddenly ceased, with a general convulsive start of the 
whole body. She was then immediately well, got up, and was able to walk 
about in good health for several weeks; when the same symptoms returned, and 
required a repetition of the same treatment. All this went on, at intervals, for 
four years ; the menstruation during that time being irregular and scanty, and the 
bowels torpid. She was pale and bloodless from the frequent bleedings, but, not 
reduced in flesh. At last, in the spring of 1829, she had a severe paroxysm of 
the rotatory motion of the head ; and it was then determined to allow the attack 
to take its course, and to direct the treatment entirely to the menstruation. Sul- 
phate of iron, and Barbadoes aloes, were prescribed. She went on for three 
weeks, the convulsive motion of the head continuing without intermission night 
and day. At length, in the middle of the night, the paroxysm ceased in an instant, 
with the same kind of convulsive start of the whole body with which it used to 
cease after cupping. At the same instant menstruation took place in a more full 
and healthy manner than it had done for many years. From that time she re- 
mained well ; at least up to the period when .Dr. Abercrombie wrote the account. 

The alternating rotatory motion of the head is by no means an uncommon fea- 
ture of these singular cases. It occurred in a patient of Dr. Conolly's ; in whom 
the menstruation was irregular, and about to cease altogether. It came on in 
paroxysms which were repeated many times a day, and was attended with inordi- 
nate loquacity. The head was turned from side to side about eight times in a 
second, and each paroxysm lasted three or four minutes. The patient got well 
after being cupped and leeched, and thoroughly purged. I have seen precisely 



CHOREA. 



417 



the same thing in a hospital patient. Dr. Crawford met with an instance of in- 
voluntary rotation of the head, without pain, but attended with intolerance of light. 
And there is a striking example of it described in the twenty-third volume of the 
Edinburgh Medical and Surgical Journal, by Mr. Hunter, of Glasgow, who 
speaks of it under the name of " rotatio or chorea." The motions are said to 
have been furious and alarming: they were executed with such extreme rapidity, 
that it was difficult even for the eye to follow them. She appeared, Mr. Hunter 
says, absolutely to be looking backwards and forwards, and in every direction, at 
the same moment. This woman had sometimes fifty paroxysms of this kind in 
a day : they greatly exhausted her; but she was perfectly rational in the intervals. 
A modification of the same kind of affection took place in a most extraordinary 
case recorded by Dr. Watt, of Glasgow, in the fifth volume of the Medico-Chi- 
rurgical Transactions. His patient was a girl ten years old. First she had 
headache, accompanied by vomiting, and increased by the slightest deviation of 
the body from the erect posture, either backwards, or forwards, or to one side. 
These symptoms lasted about a month ; and during that time she lost the power 
of speech and of walking. At the end of that period she was seized with a pro- 
pensity to twirl round on her feet, like a top, with great velocity, always in one 
direction ; and was pleased when those about her assisted in increasing the rapidity 
of her movements. After continuing nearly a month, these motions ceased, the 
headache returned, and she became unable to move her neck, or support her head. 
Soon after, she was visited with a new kind of motion; she would lay herself 
across the bed, and turning over like a roller, more rapidly from one end of it to 
the other. At first the fits of this kind lasted two hours ; but they gradually ex- 
tended to six or seven hours every day. On being carried into the garden she 
rolled rapidly from one end of a gravel walk to the. other; and even when laid in 
the shallow part of a river, though apparently on the point of being drowned, she 
began to turn round as usual. The rotations were about sixty a minute. She 
made little or no use of her arms in revolving. In about another month or six 
weeks an entirely new set of movements began. She lay upon her back, and, by- 
drawing her head and heels together, bent herself like a bow, and then allowing 
her head and heels to separate, her buttocks fell with considerable force upon the 
bed. She repeated these movements ten or twelve times in a minute, first for six 
hours daily, and at length for fourteen. After another space of about five weeks 
had elapsed, the most singular freak of all ensued ; she became possessed with a 
propensity to stand upon her head with her feet perpendicularly upwards. As 
soon as the feet were elevated in this manner, all muscular exertion seemed to be 
withheld, and the body fell down as if dead ; her knees striking the bed first. — 
This was no sooner done than she instantly mounted up as before; and continued 
to do so from twelve to fifteen times in a minute, for fifteen hours a day. After a 
variety of fruitless treatment, a spontaneous diarrhoea came on, and she recovered. 

The spinning motions observed during a part of this case have been observed 
in other instances. 

In Magendie's Journal de Physiologic, the two following singular forms of 
disease are referred to. A man, after some other symptoms of cerebral disorder, 
was seized with an irresistible inclination to move forwards, stopping only when 
exhausted. He would sa!ly forth into the streets, and continue walking straight 
forward until he dropped down from fatigue, and was obliged to be brought home in 
some conveyance. This man at length died, and several tubercles were found in 
the anterior hemispheres of his brain. Dr. Laurent, of Versailles, exhibited to' the 
Academy of Medicine a young girl, labouring under the exactly opposite neces- 
sity. In the attacks of a nervous disease she was irresistibly propelled backwards, 
and with some rapidity: being unable to avoid obstacles or hollows, she received 
many falls and bruises in her course. 

I say that histories such as I have been giving you some samples of, and those 
mostly in an abridged form, would sound very like romances, if they were met 
with in the old authors alone, or if they were not attested by unimpeachable au- 
27 



418 CHOREA. 

thority. They resemble chorea in this respect, that they are examples of muscular 
actions performed by persons in possession of consciousness, and performed in 
spite of themselves. But in most other respects they differ from what we now-a- 
days mean when we speak of chorea. Perhaps they may rank among hysterical 
vagaries. It is remarkable that the majority of them occur in young women, in 
whom the menstrual function is suspended or irregularly performed. Some per- 
sons may consider them as varieties of insanity. The patients certainly did not 
feign to be ill, for the feats of strength and agility which many of them enacted 
were much beyond their neural power and endurance. The truth seems to be, 
that there are innumerable modifications of the nervous functions, and that some 
of them are more common and more capable of being arranged into groups than 
others ; but that they all offer points of resemblance, like (as I observed before) 
the different members of a large family, in which the individuals have the same 
general cast of features, and yet preserve each his particular identity. 

I advert to these odd forms of disease with a view of directing your attention 
to such of them as may come in your way. We are yet terribly in the dark 
about morbid affections of the nerves, both organic and functional. Hereafter 
some medical Newton will arise, and reduce all these apparently complicated 
phenomena under one simpler law. At present all that we can do is to collect 
and, as far as we may, to arrange facts, in the hope that at length some better 
light will be shed upon the subject. And it must be observed that some of the 
modern researches into physiology do throw a little glimmering of illumination 
into these dark corners of pathology. In certain of M. Magendie's experiments 
on animals the following curious facts were ascertained : — When a vertical section 
of the cerebellum of a rabbit was made, leaving one-fourth of the whole adhering 
10 the cms of the right side, and three-fourths to the left, the animal rolled over 
and over incessantly, turning itself towards the injured side. The same phenome- 
non occurred upon the division of the crus cerebelli. The animal lived for eight 
days, and continued during the whole of that time to revolve upon its long axis, 
unless stopped by coming in contact with some obstacle. How like is this to 
the symptoms exhibited at one period in the girl whose case is related by Dr. 
Watt ! Nor is Dr. Watt's case a singular one; M. Serres has described another 
much resembling it. A shoemaker, sixty-eight years old, of intemperate habits, 
after one of his debauches, exhibited a kind of drunkenness which surprised his 
friends. Instead of seeing objects turn round him, as a drunken person is apt to 
do, he thought he was himself turning, and soon began to revolve ; and this lasted 
till he died: and when his head was examined, extensive mischief was found in 
one of the peduncles of his cerebellum. 

Again, M. Magendie noticed that when the upper part of the cerebrum is 
gently removed in birds and mammalia, they become blind ; but no affection of 
the locomotive powers is produced. No further result is occasioned by the 
removal of a portion of the gray matter of the corpus striatum: but when the 
striated part is cut away, the animal immediately darts forward with rapidity, and 
continues to advance as if impelled by some irresistible force, until stopped by an 
obstacle ; and even then it retains the attitude of one advancing. The experiment 
was tried with the same result upon various species of animals — dogs, cats, hedge- 
hogs, rabbits, Guinea-pigs, and squirrels. It seems that there are horses that 
cannot back; although they make good progress enough in a straightforward 
direction. Now Magendie says that he has opened the heads of such horses; 
and* has always found, in the lateral ventricles of their brains, a collection of 
water, which must have compressed and even disorganized the corpora striata. 
It has further been ascertained, by the same experimenter and by others, that 
certain injuries of the cerebellum cause animals to move backwards contrarily to 
their will. If the tail of the animal so mutilated be pinched, he still persists in 
his retrograde course. Injuries of the medulla oblongata had the same effect. 
Pigeons into which he forced a pin through that part, constantly receded for more 
than a month, and even flew backwards. A section of the medulla oblongata, 



CHOREA. 



419 



where it approaches the anterior pyramid, gives rise to a movement in a circle, 
like that of a horse in a mill: the animal, in its walk or its flight, bearing round 
continually to the injured side. Surely we have, in these facts, supplied by 
experiments on living animals, and by observation of the phenomena of disease in 
the living human body, some of the materials for a more exact knowledge, both 
of the physiology and of the pathology of the nervous system, than we have yet 
reached. M. Magendie supposes that different portions of the encephalon are 
endowed with energies which tend to cause motion in various directions ; that in 
the healthy state these balance each other, and that a preponderating impulse can 
be given to any one of these forces by the will; but that when the equilibrium is 
destroyed by disease, the will is not sufficient to counteract the tendencies which 
are then brought into play. Mr. Mayo offers a different explanation of the phe- 
nomena. He supposes that the injuries inflicted on the nervous matter produce 
a sensation analogous to vertigo; and that the animal conceives itself either to be 
hurried forward, and makes an exertion to repel the imaginary force ; or to be 
moving backward, or turning round in one direction, and endeavours to correct 
this by moving the corresponding muscles. Whatever may be the true explana- 
tion, the facts themselves are abundantly curious and interesting, and I recommend 
them to your attention. 

Some of the affections that I have been describing, fall, perhaps, under the 
category of those to which the appellation of the leaping ague has been given in 
some parts of Scotland. There is a class also of convulsive spasmodic affections 
which resemble epilepsy on the one hand, and chorea on the other, or rather form 
a link of alliance between the two, and which are especially remarkable for this, 
that they are capable of being propagated by that kind of imitative contagion of 
which I have several times spoken. This point might be well illustrated by the 
history of various sects of religious enthusiasts. One or two of those enthusiasts 
have apparently at first worked themselves up into a state approaching to epilepsy, 
accompanied even by insensibility sometimes ; and then this state has been com- 
municated by sympathy to the more susceptible of their auditors. I must not, 
however, go into any further details on this subject ; and perhaps I have prose- 
cuted it too far already. Those among you who are inclined to pursue it further 
may find some curious accounts of an epidemic which occurred in Lanarkshire, 
in Sir John Sinclair's Statistical Account of Scotland, under the head of the 
" Conversions of Cambuslang;" and in one of the early volumes of the Edin- 
burgh Medical and Surgical Journal. Dr. Robertson has described, in an inau- 
gural dissertation Be Chorxa Sancti Viti, a similar epidemic, which occurred in 
the states of Tennessee and Kentucky, in the western districts of America. This 
is also referred to in the same volume of the journal. Among other things, Dr. 
Robertson says, that while extravagant sounds, and actions, and gesticulations, 
were in the first instance wilful, the actors M at length to their own astonishment, 
and the diversion of many of the spectators, continued to act from necessity the 
curious character which they had commenced from choice.^ 1 will only remark 
further of such forms of nervous disease, that as they spring often from moral 
causes, so they admit, in a great degree, of moral remedies. The pranks played 
by the Scotch enthusiasts were brought to an end by threatening to duck every 
one who should thereafter be attacked ; and, I believe, a few of them were horse- 
ponded, by way of example. With respect to the solitary instances of perverted 
locomotion, our business must be to correct whatever is wrong in the state of the 
bowels : in women, to amend the disordered uterine functions ; to strengthen and 
confirm the system generally; and, in addition to the measures proper to effect 
these objects, I suspect that the cold sousing would in many cases be found o£ 
most material service. 



420 



PARALYSIS AGITANS. 



LECTURE XXXVIII. 

Paralysis Agitans. Mercurial Tremor. Hysteria : Two forms of Hysteric 
Paroxysm; Diagnosis from Epilepsy ; Class of Persons most liable to 
Hysteria; Diseases apt to be simulated by Hysteria; Treatment ; Pre- 
vention. 

In the last lecture I spoke of chorea, and of some singular forms of disorder 
that have sometimes been included under the same appellation ; and I shall begin 
the present with a few observations concerning a disease very closely allied to 
some of those which we were then considering, and yet distinct enough to deserve 
and require a separate notice. I refer to what has been called the shaking palsy 
— paralysis agitans. Allusions to this form of disease are to be found in many 
of the older systematic writers on physic; but it never was much attended to in 
this country until Mr. Parkinson published an essay upon it in the year 1817; 
and a very interesting little pamphlet it is. He defines the disease thus: — "In- 
voluntary tremulous motion, with lessened muscular power, in parts not in action, 
and even when supported: with a propensity to bend the trunk forwards, and to 
pass from a walking to a running pace: the senses and intellects being uninjured.'* 
The latter symptoms constitute the scelotyrbe festinans of Sauvages ; and the 
former symptoms of the definition are not always attended by the latter. In old 
persons you may often observe incessant and involuntary nodding and shaking of 
the head, without any tendency to run forwards. There is an old woman whom 
I see regularly sitting in the aisle at church every Sunday ; she walks to her seat 
slowly and steadily enough, and sufficiently upright; but her head never ceases 
to nod, and wag, and tremble in various directions. It may be that she is in the 
less advanced stage of the malady ; but I have remarked her for three or four or 
more years, and I see no change. 

Mr. Parkinson's notice was first called to the disease during his professional 
attendance upon a person affected by it. From observation of that case, and of 
several others that he subsequently met with, his account of the disorder was 
drawn up. He states that its first approach is insidious, and its progress often so 
slow and imperceptible that the patient cannot recollect precisely when it began. 
A sense of weakness, and a disposition to trembling, fastens on some particular 
part : sometimes it is the head, but more commonly it is one of the hands or arms. 
These symptoms gradually become more decided; and at length the morbid 
influence is felt in some other part. At a still more advanced period the patient 
is foundjo be less strict than usual in preserving an upright posture, even when 
standing or sitting, but especially when walking. By degrees he finds a difficulty 
in making the hand obey the dictates of the will when he is engaged in any deli- 
cate manipulation — in writing, for example; and he is obliged to walk with 
circumspection and care: his legs are not raised to that height, nor with that 
promptitude which the will directs ; so that much attention is necessary to pre- 
vent frequent falls. Then, as the malady proceeds, the propensity to lean 
forwards becomes more strong — the patient is forced to step on the toes and fore- 
part of the feet, while the upper part of the body is thrown so far forward as to 
render it difficult to avoid falling on the face: in some cases he is irresistibly 
impelled to take much quicker and shorter steps than common, and thereby to 
adopt unwillingly a running pace. When once this state has been pointed out, I 
make no doubt that some of you may recognize it in old persons whom you 
may have seen walking about. But the disorder does not stop here; the unhappy 
patient becomes unable to feed himself; or to walk at all without an attendant, 
who walks backwards before him, and prevents his falling forwards by the pres- 
sure of his hands- against the fore part of the patient's shoulders : his powers of 



MERCURIAL TREMOR. 



421 



speech and deglutition fail ; and the saliva dribbles from his mouth ; he can no 
longer retain his urine or feces ; and at length death closes the miserable scene. 

Mr. Parkinson conjectures that this complaint results from some chronic- 
change of the upper part of the spinal cord, or of the medulla oblongata: but 
dissections are wanting to support or to refute that conjecture. Some of the 
patients, whose cases he has given, had been intemperate livers; hard drinkers; 
others had not been guilty of any such excesses : several had suffered a good 
deal from rheumatism, which he thought might have laid the foundation of their 
lamentable disease. But a more exact pathology of the shaking palsy is still 
needed. Dr. M. Hall observes that the symptoms have, in several particulars, 
a marked resemblance to the effects observed by M. Serres (and related in his 
Anatomie du Cerveau) of disease of the tuber annulare, or of the tubercula 
quadrigemina. 

Nor have we any ascertained means of curing this disease ; or rather this state 
of decay. Dr. Elliotson indeed says that he succeeded in one instance (of 
which, however, the particulars are not given), with the carbonate of iron ; but 
that he had tried the same medicine in vain in several other cases. We must 
administer to symptoms, and endeavour to set those functions right which may 
be obviously wrong ; to regulate the bowels, to procure sleep, to nourish and 
uphold the patient without unduly stimulating him ; and this is all that I can tell 
you of the shaking palsy. / 

Another analogous disorder, meriting a moment's notice, is that peculiar kind 
of trembling which is apt to occur in persons who are much exposed to the 
poisonous fumes of mercury: mercurial tremor it is called; and popularly, the 
trembles. It consists of a sort of convulsive agitation of the voluntary muscles, 
which is most violent whenever efforts are made to move the limbs by the help 
of those muscles; whenever, in fact, volition is brought to bear upon them. It 
differs, therefore, from the shaking palsy, inasmuch as the tremor ceases when the 
muscles are supported, or are not called into action. It is also more susceptible 
of relief by medicine. The last person in whom I have witnessed this curious 
affection has been twice my patient in the Middlesex Hospital, and has twice got 
well there. John Chattin, 33 years old, was first admitted in August, 1837. He 
was led into the room, walking with uncertain steps, his limbs trembling and 
dancing as though they had been hung upon wires. While sitting on a chair he 
was comparatively quiet; you would not have supposed that he ailed any thing ; 
but as soon as he attempted to rise and to walk, his legs began to shake violently 
with a rapid, incessant, and irregular motion. He could neither hold them steady, 
nor direct them with precision. Indeed without support he must have fallen 
down. His arms were agitated with similar involuntary movements. His tongue 
was tremulous, and he spoke in a hurried, abrupt, interrupted, staccato manner, not 
natural to him. He had no fever. His pulse was 66, and soft; his skin natural ; 
his bowels costive. He complained of slight nausea. At the end of six weeks he 
went out well, or with very slight remaining weakness of his knees, and a little 
occasional tremor upon unusual exertion. In June, 1839, he again presented 
himself, in a similar state of agitation and helplessness. 

This man was a water-gilder; and had been employed in that business for 18 
years. Till somewhat more than a twelvemonth prior to his first appearance at 
the hospital, he had been free from disease. Then he began to tremble a little ; 
but for a fortnight before his admission the shaking had become so much worse 
that he could not go up stairs, nor even walk upon uneven ground. The 
trembling, when once brought on by efforts to move, did not cease until he sat 
down, or got one of his fellow-workmen to grasp his limbs tightly. 

This singular disorder is produced by the agency of mercury as a poison upon 
the body ; and especially by the absorption of that metal when raised into vapour 
by heat, and inhaled in breathing. It is accordingly very common among water- 



422 



MERCURIAL TREMOR. 



gilders. Water-gilding is the gilding of metals, and of silver in particular, by- 
means of fire. It is called water- gilding, I believe to distinguish it from other 
kinds of gilding, called gilding in oil. The silver to be gilded is covered with an 
amalgam of gold and mercury, and then is placed over a charcoal fire, by which 
the mercury is raised in fumes and driven off, and the gold alone is left adher- 
ing. To these fumes the workmen are necessarily exposed; and numbers 
of them become affected with this tremor, which is not a common result of 
mercury applied to the system in other ways. The same complaint is frequent 
among the workmen in the quicksilver mines of Friuli and of Almaden, where the 
crude ore is purified by the aid of heat. Dr. Bateman relates, in the 8th volume 
of the Medico- Chirurgical Transactions, some cases like that which I have been 
describing. But the best account of the disorder that I have seen is given by 
Merat, in an appendix to his book on the Coliqae Metallique. 

The malady comes on sometimes suddenly, more often by degrees. The 
patient is less sure of his arms than usual: they become tremulous, and at last 
shake, and, if he continues to pursue his employment, the force of the trembling 
goes on increasing, till at length it is so general and violent that he can persist no 
longer. His power of locomotion is impaired ; his mastication, his speech, all 
his manual operations, are interfered with ; he becomes unable to convey food to 
his mouth, and is obliged to be attended to and fed, like an infant; and by and by, 
if he does not quit the poisonous atmosphere, graver symptoms supervene — 
wakefulness, delirium, loss of consciousness. 

As the tremor increases, the digestive organs become disordered ; the appetite 
falls off; nausea is fell, the tongue becomes furred, and gas collects in the intes- 
tines. The patients acquire a remarkable brown hue ; and their teeth turn black. 
The pulse is generally full and slow. 

The time required for the production of these effects varies much in different 
cases; from two years to five-and-twenty. Something depends no doubt upon 
the quantity and intensity of the fumes. Chattin told us that the workmen 
became ill whenever they had a large job on hand. In both his severe attacks 
(and very often besides, both in him and his companions) the mercury produced 
salivation. This was unfrequent in the patients observed by Merat. The dura- 
tion of the complaint is considerable : it may last two or three months, or longer; 
and sometimes it is not completely recovered from at all. Yet it is not a fatal 
disorder. 

Although the visible affection is of the muscles, the mischievous operation of 
the poison is really upon the nerves, weakening their natural influence. When 
the will is directed upon the muscles, they contract unsteadily, and with frequent 
remissions ; their action is not sustained ; and it is a general observation by all 
who have written upon the disease, that it is aggravated by all kinds of mental 
emotion, by alarm, anger, surprise. My patient's shaking was, at first, aug- 
mented by the shock of the shower-bath : and always became excessive in thun- 
dery weather. So, on the other hand, it has been noticed that whatever tends to 
stimulate and fortify the nervous power, does temporary good : a glass of wine, 
for example. Chattin informed us that, while the malady was coming on, he 
could not get up stairs to his work without first swallowing half a quartern of gin; 
and that he was obliged to drink porter two or three times a day. 

The treatment consists in withdrawing the patient from the injurious atmo- 
sphere, and in administering tonics. 

Conium has been recommended by Mr. M'Whinnie. Quina has been found 
useful. But I have most faith in preparations of iron. My patient Chattin 
mended decidedly and rapidly when he began to take steel. It was not the mere 
avoidance of the cause of the complaint that produced the improvement, for he had 
been away from his work for a fortnight before he applied for admission. 

To prevent this effect of mercury, the workmen should be instructed to avoid, 
as much as possible, inhaling the poisonous fumes, to ventilate the room tho- 
roughly, and to pay great attention to cleanliness. I believe the furnaces may be 



HYSTERIA. 



423 



so built that the metallic vapour shall not reach the operator. If he cannot avoid 
being involved in it, perhaps some sort of respirator might afford protection.* 

I proceed to the subject of hysteria: a subject highly interesting and important, 
as well as obscure and difficult. I scarcely know how to arrange what I have to 
say, so as to present the disorder to your notice in the most intelligible manner. 
Hysteria has characters peculiar to itself: but it is apt also to assume the form, 
and mimic the symptoms, of various other diseases of a much graver nature. If 
we are not capable of distinguishing the true malady from that which is its double, 
we shall be constantly committing most serious mistakes in the prognosis, to our 
own damage and discredit; and in the treatment, to the injury of our patient. I 
shall first attempt to describe to you the phenomena which are peculiar to hys- 
teria; and then to point out the class of persons who are most subject to it; and 
afterwards I shall briefly advert to the imitative freaks which we are almost daily 
witnessing in hysterical constitutions, and to some other points connected with 
this extraordinary complaint. 

I need not tell you that the hysterical paroxysm is almost exclusively confined 
to women.t It occurs under a great variety of forms, but they may all be reduced, 
for convenience of description, to two. The first of these has a general resem- 
blance to an epileptic fit. The trunk and limbs of the patient are agitated with 
strong convulsive movements; she struggles violently, like a person contending; 
rises into a sitting posture, and then throws herself back again ; forcibly retracts 
and extends her legs, while her body is twistetj from side to side; and so power- 
ful are these muscular contortions that it often is all that three or four strong 
persons can do to restrain a slight girl, and prevent her from injuring herself or 
others. The head is generally thrown backwards, and the throat projects; the 
face is flushed; the eyelids are closed and tremulous; the nostrils distended; the 
jaws often firmly shut; but there is no distortion of the countenance : the cheeks 
are at rest, unless when, as often happens, the patient is uttering screams, or 
exclamations. If the hands are left at liberty, she will often strike her breast 
repeatedly and quickly, or carry her fingers to her throat, as if to remove some 
oppression there ; or she will sometimes tear her hair, or rend her clothes or 
attempt to bite those about her. With all this her breathing is deep, labouring, 
irregular; and the heart palpitates. After a short time this violent agitation is 
calmed: but the patient lies panting and trembling, and starting at the slightest 

* [A very peculiar form of convulsive disease has recently been described. It is charac- 
terized by repeated bobbings of the head forward, at first slight and occasional, but becom- 
ing, in process of time, so frequent and powerful, as to cause a heaving of the head forwards, 
towards the knees, succeeded by an immediate return to the upright position, somewhat 
similar to the attacks of emprosthotonos. In one case, related by J. W. West, these bob- 
bings were repeated at intervals of a few seconds, ten, twenty, or more times, in each attack, 
■which continued from two to three minutes, and recurred twice, thrice or oftener in the 
day; the attack occurring whether the patient was sitting or lying. Daring the attack, the 
child retained his consciousness. The other cases that have been since recorded by Drs. 
Barton and Bennett, in their general symptoms, differ in no degree from that of Mr. West, 
with the exception of that of Dr. Bennett, in which the disease was of a more aggravated 
character. Sir Charles Clarke has seen four cases of the disease, and from the peculiar 
bobbing of the head, has named it the Salaam Convulsion; Dr. Locock has seen two cases. 
One of Sir Charles Clarke's patients recovered perfectly, the other became paralytic and 
idiotic and died at the age of seventeen. Mr. West has heard of two other cases — one of 
the patients lived to the age of seventeen; the other to nineteen, — both became idiotic. The 
sex and ages of the patients whose cases are on record, are one female of seven years, 
and two boys of one and six years — death did not occur in either; in the female and one 
of the boys the disease appears to have ceased. 

Of this strange form of convulsions, the pathology is still a subject for future investiga- 
tion; and until that is ascertained, its treatment must be tentative and experimental. — C.] 

f [We have repeatedly seen all the phenomena characteristic of hysteria in the male 
subject. The fact of their occurrence in males is also stated by Sydenham, Louyr Vil- 
lermay, Georget, Ferriar, Frotten, Conolly and others. See also the admissions of Dr. Wat- 
son towards the close of his remarks on the pathology of the disease. — C] 



424 



HYSTERIA. 



noise or the gentlest touch; or sometimes she remains motionless during the 
remissions, with a fixed eye; till all at once the convulsive movements are re- 
newed: and this alternation of spasm and quiet will go on for a space of time that 
varies considerably in different cases : and the whole attack frequently terminates 
in an explosion of tears and sobs, and convulsive laughter. 

There is a variety of this form of hysterical paroxysm, in which the patient 
suddenly sinks down insensible, and without convulsions : with slow and inter- 
rupted breathing, a turgid neck and flushed cheeks; and she recovers from that 
condition, depressed in spirits, fatigued, and crying. 

You will observe that the symptoms I have been enumerating belong to the 
nervous system ; and indicate great derangement in the functions of animal life. 
In the other of the two forms to which all the various modifications of the attack 
may be reduced, the principal marks of disturbance are referable to some of the 
viscera. The patient experiences a sense of uneasiness in some part of the 
abdomen, frequently towards the left flank ; a ball appears to roll about, and to 
rise first to the situation of the stomach, and then to the throat, where the patient 
feels a choking sensation; the action of swallowing is frequently repeated; the 
abdomen becomes distended with wind, loud rumblings and sudden eructations 
take place ; there is much palpitation of the heart, the patient is sad and sorrowful, 
and prone to shed tears. 

After the paroxysms, these patients commonly void a large quantity of limpid, 
pale urine, looking almost like water ; and this is sometimes expelled during the fit. 

Such is a brief, and, I am aware, incomplete account of the hysterical paroxysm. 
It sets forth, however, in outline, the two principal varieties of the attack : and 
you are to observe that the last, the quieter form, is often the prelude to the con- 
vulsive ; but it not seldom also occurs alone, and then is as indicative of hysteria, 
as ihe petit mal, to which it is somewhat analogous, is of epilepsy. 

And before I go any further, let us again inquire into the circumstances which 
distinguish the paroxysms of those two diseases, epilepsy and hysteria. I have 
shortly adverted to these discriminative circumstances before; but we shall be 
better able to appreciate them now that the main features of each diseased state 
have been under our consideration. It is of great importance to be able to render 
the diagnosis certain and accurate. It is a dreadful announcement to have to make 
to a father or a mother that their child is epileptic ; whereas hysteria, though it is 
sufficiently distressing, is attended, in nine hundred and ninety-cases out of a 
thousand, with no ultimate peril either to mind or body. In some instances the 
diagnosis is perfectly easy: in others it is dubious and full of anxiety. Whenever 
you fail to satisfy yourselves completely as to the nature of a given case, you will 
do well, in legal phrase, to give your patient the benefit of your doubt, and acquit 
her of epilepsy; or pronounce her guilty of the minor offence of hysteria. 

The points of resemblance, and the points of distinction, belonging to the hys- 
terical and epileptic paroxysm respectively, have been very clearly summed up 
by Foville. 

There are two principal forms of each disorder. In each, one of these forms 
is convulsive, and the other is not. The non-convulsive form of epilepsy relates 
exclusively to the sensorium : it is characterized by vertigo, and by a suspension 
(however brief, and transitory) of the mental powers. The non-convulsive form 
of hysteria has little apparent connection with the animal functions: its palpable 
phenomena consist in derangement of the organic functions of the thorax and 
abdomen. It is the ganglionic portion of the nervous system that seems chiefly 
disturbed. 

In the epileptic Jit there is an entire loss of consciousness. The patient, on 
emerging from the paroxysm, recollects nothing of what has been going on during 
its continuance. It is not so in the hysterical fit. The loss of consciousness is 
very seldom complete; and it never occurs at the outset of the attack. The pa- 
tient often is able to repeat (though she may not always choose to confess it) what 
has been said by the bystanders during the period when she seemed insensible. 



HYSTERIA. 



425 



This is a point of distinction well worth remembering, for more reasons than one. 
It not only helps the diagnosis when the fact comes out; but it suggests certain 
cautions to ourselves. We must take care not to say any thing by the bed-side of 
an hysterical patient which we do not wish her to hear; and we may take advan- 
tage of her apparent unconsciousness, and pretend to believe in it, and speak of 
certain modes of treatment which she will not much approve of, but the very men- 
tion of which may serve to bring her out of the fit. 

In the epileptic paroxysm the face is usually livid; and foam, which is frothy 
with air, or red with blood, escapes from the patient's mouth. These are symp- 
toms which we do not see in the fits of hysteria. The convulsive movements 
even, ofTer some characteristic shades of distinction. In epilepsy they are often 
more marked on one side of the body than on the other, and less irregular: the 
same movements are rapidly repeated: there is a strangling rattle in the breath- 
ing: while in hysteria the forcible flexion and extension of the limbs, and the 
contortions of the trunk, are more sudden, and, as it were, capricious ; the respi- 
ration is deep, sighing, mixed with cries, and sobs, and often with laughter. But, 
perhaps, the convulsive motions differ most in the face. The epileptic expression 
is usually frightful: the eyelids half open, the eyeballs rolling, the mouth drawn 
to one side, the teeth grinding, the gums exposed by the retraction of the lips, 
the tongue protruded and bleeding, the complexion leaden: while in hysteria the 
cheeks are red, but at rest; the eyelids are closed and trembling; if you raise the 
upper one, you will see the eye fixed, perhaps, but it is bright, and very different 
from that of the epileptic, which, if it be not rolling, is dull, projecting, and the 
pupil usually dilated. 

Foville states that when, besides a sudden loss of consciousness with convulsive 
movements, there are also lividity of the face, and an escape of frothy saliva from 
between the lips, and the convulsions are more pronounced on the one side of the 
body than on the other, the disease is epilepsy, and not hysteria : and I think he 
is right. 

By Dr. Marshall Hall the grand distinction between the two diseases is affirmed 
to be this : — that in hysteria, much as the larynx may be affected, it is never closed ; 
in epilepsy, it is closed. Accordingly, in the former we have heaving, sighing 
inspiration; in the latter, violent ineffectual efforts at expiration. In the very out- 
set of the epileptic paroxysm the respiration, I believe, is thus suspended. 

The hysterical seizure may be over in a quarter of an hour, or in less time than 
that; or it may last many hours, or even several days. 

The hysterical seizure is almost peculiar to women : and it seldom occurs in 
them except during that period of their lives in which the menstrual function of 
the uterus is or ought to be in activity. In this country it is most apt to occur 
between the ages of fifteen and forty; and in the vast majority of patients who do 
suffer it, you will find some marked derangement of that particular function. 
These facts alone afford a strong corroboration of the ancient theory, which 
ascribed the whole of the phenomena to uterine disorder ; and named the disease 
accordingly. You will hear or read of disputes as to whether the womb, with 
its appendages, or the nervous system, is the seat of hysteria. But such disputes 
are merely verbal, I conceive. No doubt the convulsive movements, and the 
mental affection, and the unnatural sensations, depend upon some altered condi- 
tion of the brain and nerves ; but it does not follow that the disease originates in 
that altered condition. We know that the uterus or the ovaries cannot of them- 
selves determine the muscles to contract; but if they be in an unhealthy state they 
may act upon the muscles through the medium of the nervous system : and such 
1 take to be the fact. How they do so we no more know than we know how the 
little finger is bent when we resolve to bend it. 

But, say some, we every day meet with diseased conditions of the uterus and 
ovaries — amenorrhcea, dysmenorrhcea, menorrhagia, even disorganization — with- 
out any of these nervous symptoms. True ; and we cannot always fathom the 
mystery of this. But one thing is certain, that there exists in some persons a 



426 



HYSTERIA. 



much greater readiness to take on the disease, upon the application of the exciting 
cause, than in others. This predisposition I have had occasion to advert to again 
and again, since I began to speak of the spasmodic diseases of the nervous sys- 
tem. Such diseases occur in certain individuals only ; and in these individuals 
there pre-exists a peculiar condition of the nervous system, " for which," says 
Dr. Alison, " we have no more precise or definite expression than nervous irrita- 
bility, or mobility ; a condition which is more common in women and children 
than in men ; and more common in all persons when in a state of weakness, than 
when in the full enjoyment of muscular strength ; in women, particularly, more 
common about the menstrual periods, and immediately after delivery, than at other 
times ; more common likewise in those in whom the monthly discharge is habitu- 
ally excessive or altered as in leucorrhcea, or suddenly suppressed, or more 
gradually obstructed in the different forms of amenorrhea, than in others. In 
this condition of mobility, both sensations and emotions are intensely felt; and 
their agency on the body is stronger and more lasting than usual ; continued vol- 
untary efforts of mind, and steady or sustained exertions of the voluntary muscles 
are difficult, or impossible ; the muscular motions are usually rapid and irregular, 
and the ' animus, nec sponte, varius et mutabilis.' " In persons of this movable 
temperament, spasmodic complaints are easily excited : and the tendency to their 
recurrence is increased by each repetition of them. 

Now the persons who suffer hysteria are of this class. They are commonly- 
young women, in whom the process of menstruation is in some way or other dis- 
ordered ; and who either are naturally of a feeble constitution, or have been debili- 
tated by disease, or by their habits of life. They often are pale ; have cold hands 
and feet; are subject to chilblains; eat but little, and do not fancy meat, which 
they sometimes absolutely dislike and refuse ; or their taste is depraved and capri- 
cious ; they will devour wax candles, wafers, chalk, sealing wax, slate pencil, and 
such trash. And, what is very curious and characteristic, although they often 
abstain almost entirely from animal food for weeks or months together, and take 
very little nourishment of any kind, they do not in general emaciate. You might 
expect that, under such a mode of life, they would waste away : but they continue 
round, and plump, and smooth. Some of them are even ruddy. 

And belonging to women of this peculiar constitution there is one other very 
remarkable character, which it behoves us to make ourselves thoroughly acquainted 
with. Almost any part of the nervous system, in these persons, is liable, under 
the influence of slight causes, and even without any obvious cause, to fall into a 
disordered state of action and suffering more or less resembling that which inflam- 
mation or organic disease might excite in the same part. 

This is a most important fact ; because if we erroneously ascribe symptoms which 
really result from inflammation to mere nervous or hysterical disorder, we may 
suffer the patient to perish for want of active measures that would have saved her: 
and on the other hand, if we apply to these nervous, imitative, hysteric complaints, 
the treatment proper for inflammation, we shall generally, indeed, relieve our 
patient for the time ; but we shall leave her more prone to the nervous affection 
than before, and permanently damaged by our mischievous activity.* 

I say that almost every kind of serious disease may be mimicked by what we 
must call hysteria. And your skill will sometimes be severely tasked to deter- 
mine the true import of the symptoms, and the real nature of the case. 

One of the diseases which is most often copied by hysteria, is inflammation of 
the peritoneum. You will find a patient complaining of acute pain of the abdo- 
men, aggravated by the slightest pressure ; and she shall have, perhaps, a hot 
skin, a quick pulse, and a furred tongue., When you meet with such symptoms 
in a young female, in whom there is any derangement or irregularity of the ute- 
rine functions, you will do well, before you bleed her to syncope, and cover her 

* [On the subject of the pathology of hysteria the reader is referred to the very judicious 
paper of Dr. Conolly in the 2d vol. of the Cyclopaedia of Practical Medicine, Philadelphia 
edition, 562 et seq. — C.] 



HYSTERIA. 



427 



abdomen with leeches, to ask yourselves whether all this suffering may not be 
simply nervous. Search into her previous history as narrowly as you can; if 
you rind that she has had similar attacks before ; if she has been known to suffer 
hysterical fits ; and if the tenderness is excessive, and, as it were, superficial, felt 
upon the slightest touch as much as when firmer pressure is made, you may 
generally spare the blood-letting, purge the patient well, and cause an assafetida 
enema to be thrown into the rectum ; and in a few hours you will find that the 
peritonitis has vanished. 

Among the pains which infest females of the hysteric constitution, and which 
are apt to be erroneously ascribed to inflammation, stitches and pains in the hypo- 
chondria are probably the most common. They are oftener complained of in the 
left hypochondrinm than in the right. These things are much more generally 
understood now than they used to be even a few years ago. I cannot tell you 
how many persons I have seen who had been diligently treated with leeches, and 
blisters, and blue pill, for supposed chronic inflammation of the liver or spleen, 
or still more actively depleted for presumed pleurisy or pericarditis, when no such 
inflammation existed, and when the treatment, by reducing the strength, tended 
to rivet that mobility of system which was the chief predisposing cause of the 
pains. 

You would scarcely suppose that palsy — perfect hemiplegia or paraplegia — 
could be simulated by hysteria: yet this certainly is the case ; and I have seen 
instances of it even among hospital patients. They are difficult and perplexing 
cases. The sudden occurrence of the paralysis, without any of the other symp- 
toms which commonly mark the real disease, its sudden disappearance, and, 
above all, the supervention of an hysterical paroxysm, will often disclose the true 
nature of the affection. Hysterical affections referred to the throat are very com- 
mon. Aphonia, for example: the voice being lost on a sudden, and returning as 
suddenly. Mock laryngitis. I remember being asked by Sir Charles Bell some 
years ago to see a young woman in the Middlesex Hospital under his care. She 
had recently arrived, and was breathing with the stridulous noise peculiar to 
inflammation of the larynx. She had twice before, in the country, had tracheotomy 
performed for similar attacks ; and there were the scars of the operations on her 
neck: but both Sir Charles and myself were satisfied, upon considering all the 
circumstances of the case, that the difficult inspirations were spasmodic and hys- 
terical ; and she recovered under the remedies which do good in hysteria. Ina- 
bility to swallow, dysphagia, is another of the hysterical vagaries relating to the 
parts about the throat. Dr. Bright has a very instructive case of that kind. A 
patient was sent to Guy's Hospital for stricture of the oesophagus. It was stated 
that the difficulty of deglutition had existed for several weeks, and was increasing. 
The surgeon under whose care she was admitted was instantly struck by certain 
circumstances which did not seem to consist very well with the notion that there 
was organic disease. Her appearance belied it, and her age. But he thought it 
right to examine the oesophagus by means of a probang ; and no sooner was the 
instrument introduced, than the patient went into an hysterical fit, which was fol- 
lowed immediately by hysteria in several females in the same ward. The 
complaint turned out to be nothing but an hysteric constriction, and was soon 
completely removed. 

Surgeons are familiar with the " hysterical breast." The mamma becomes 
painful, tender, enlarges somewhat perhaps. The girl fears that a cancer is 
breeding. She communicates her alarm to her friends, and a medical man is 
consulted. If he happens to be timid and inexperienced, he makes matters infi- 
nitely worse by applying leeches and fomentations ; by examining the breast at 
every visit ; and by keeping the patient's attention anxiously fixed upon it. 
Whereas the treatment ought to be directed to the state of the general system ; 
and the local uneasiness spoken lightly of, or disregarded. 

Among the hysteric affections of the air-passages, there is a peculiar kind of 
cough which you ought to be acquainted with. It is loud, harsh, dry, more like 



428 



HYSTERIA. 



a bark than a cough. Sometimes it is incessant, sometimes it occurs in paroxysms 
which, I verily believe, are more annoying to hear than to suffer. Hysterical 
affections of the diaphragm again are by no means rare. I had a very obstinate 
case of that sort in one of my hospital patients. She would sit in her bed all day 
long, uttering every eight or ten seconds a loud and most discordant hiccup. And 
I remember an out-patient, who presented a picture of perfect health, and who 
came week after week, to be cured of what I could consider nothing but an hys- 
terical eructation: it was continual and distressing, and prevented her from 
obtaining any employment as a servant. Hysterical vomiting is also frequent, 
simulating cancer of the stomach. Nay, hysterical hsematemesis. A romantic 
girl was for some months under my care in the hospital with that complaint. She 
vomited such quantities of dark blood, (which did not coagulate, however,) as I 
would not have believed if I had not seen them. Day after day there were pot- 
fuls of this stuff ; yet she did not lose her flesh, and she menstruated regularly ; 
and what was very curious, the vomiting was always suspended during the men- 
strual period, and recurred again as soon as the natural discharge ceased. I said 
she was romantic ; but I should rather have said that she had that peculiar mental 
constitution which belongs to hysterical females. She used to write me long 
letters of thanks for my attention, though I was heartily tired of her ; and these 
were couched in all the fine language of the Minerva press. At last I sent her 
away : just as bad as when she came into the hospital. This was five or six 
years ago ; and last year she called at my house with a present of some game, and 
told me that she had got married to a hair-dresser, and was quite recovered. 

There is a kind of sanguineous expectoration belonging to females of this class, 
and very likely to mislead the unwary. I meet with two or three instances of it 
every year. The patient excreates daily, or at irregular intervals, a thinnish fluid 
something like saliva, more or less tinged and streaked with brown or florid blood. 
A young hand investigates diligently the source of the bleeding, and puzzles him- 
self to determine whether the case be one of hsematemesis or of haemoptysis. Nine 
times out of ten it is neither the one nor the other. The blood comes from the 
mouth or the fauces. 

Hysterical affections of the joints are very common. A young girl became my 
patient in the hospital for some trifling ailment, and after a short time she began 
to complain of great pain in her knee and hip ; she could not stand upon the limb, 
nor bear to have it moved or touched. I got Sir Charles Bell to see her: he was 
so satisfied of the nature of the case — so convinced that it was a genuine example 
of inflammation and ulceration of the hip-joint — that he gave a little lecture to the 
pupils who stood round the bed upon the characteristic position in which the 
patient lay ; and he took her into one of the surgical wards to be under his own 
care. Some time afterwards I had occasion to go into that ward, and there I 
found my former patient with her heel drawn tight up against her buttock. It 
turned out that she had had no serious disease of the hip at all : both it, and the 
rigid contraction, gave way under measures which could have done no good to an 
ulcerated joint. I think the first clue to the real nature of her malady was the 
occurrence of a fit of hysteria. Sir Benjamin Brodie says, that among the higher 
classes of society, at least four-fifths of the female patients who are commonly sup- 
posed to labour under diseases of the joints, labour under hysteria, and nothing else. 

Another prank belonging to hysteria, and one which it is very necessary that 
you should be on your guard against, is that of mimicking disease of the bones of 
the spine. The patient complains of pain and tenderness in her back, and of 
weakness probably in her lower extremities ; and it is now become notorious that 
scores of young women have been unnecessarily confined for months or years to 
a horizontal position, and have had their backs seamed with issues, for supposed 
disease of the bodies of the vertebrae, who had really nothing the matter with them 
but hysteria, and who would probably have soon ceased to complain if, instead of 
being restricted to that unnatural imprisonment and posture, they had taken a 
daily gallop on horseback. 



HYSTERIA. 



429 



It is curious enough to notice how the mind is apt to become affected in some 
of these cases. After the patient has been lying supine for some weeks, she is 
unable to stand or walk, simply because she thinks she is unable. The instant 
she makes a fair effort to use her limbs again, she can and does use them. Her 
condition is at once reversed. Potest quia posse videtur. Mr. Corfe, the present 
apothecary to the Middlesex Hospital, has no little trouble with patients of this 
kind ; but he generally succeeds in making them walk, and in convincing them, 
as well as himself, that they may do so with impunity. Sometimes, though the 
authority of the doctor may not be efficacious in this respect, some stronger influ- 
ence prevails. A lady told me not very long ago that an acquaintance of hers, a 
member of a family of distinction, had been lying I know not how long on her 
back ; that position having been prescribed to her by some medical man for a pre- 
sumed disease of the spine. She lost all power of using her legs ; but she got 
quite fat, as, indeed, well she might, for her appetite was remarkably sharp, and 
she lived chiefly upon chickens ; and the number of chickens she devoured was 
incredible. She lived at some little distance from town, and at last Sir Benjamin 
Brodie was sent for to her. Now Sir Benjamin, to use a vulgar phrase, is up to 
these cases ; and he wished to see her try to walk : but she declared that the at- 
tempt to do so would kill her. He was resolute, however, and had her got out 
of bed : and in a few days time she was walking about quite well, and very grateful 
to him for his judicious conduct. A medical man of less name, or of less deter- 
mination, would probably have failed. Dr. Bright has a good example of a some- 
what similar kind ; showing the $*>wer of another form of influence. He was 
asked to see a young lady who had been confined to her bed for nine months. If 
she attempted to move she was thrown into a paroxysm of agitation, and of excru- 
ciating agony, affecting more particularly her abdomen. She had almost lost the 
use of the lower extremities ; and she and her friends seemed to have given up 
all hope of her restoration. But she presented no appearance of important dis- 
ease ; her countenance bore no marks of visceral mischief ; nor was it possible to 
discover any proof of organic change. Dr. Bright set the case down in his own 
mind as one of hysteria. She seemed to have derived relief from some stimulating 
injection, and from certain pills. As her friends were in moderate circumstances, 
Dr. Bright talked seriously to the mother, and recommended that simple water 
should be employed for the injection, and that bread pills should be substituted 
for those the girl had been taking. The mother soon perceived that these means 
produced the same tranquilizing effects on her daughter which had hitherto been 
ascribed to the medicine. " My visits," he says, " became less frequent; I was 
absent a fortnight: on my renewing my visit, no change had taken place. I at- 
tempted to get her shifted gently from the bed to the sofa, but it was impossible; 
the paroxysm almost overcame her. Once (after having attended altogether 
about nine months) I called after an absence of nearly a month ; her sister met me 
at the street-door with a smiling face to tell me that our patient was quite well : 
and on inquiry, she related how, three mornings before, under a deep religious 
impression, she had completely recovered all her powers ; and I found her sitting 
up, working and amusing herself as if she were completely convalescent from 
some ordinary illness." 

These are the cases which suit the purposes of miracle-mongers. A few years 
ago all the journals belonging to a certain party in the religious world were full of 
an instance of miraculous cure. The patient was a young woman ; her legs had 
been paralytic, or contracted, I forget which ; some enthusiastic preacher had in- 
fluence enough with her to make her believe that if on a certain day she prayed 
for recovery with a strong faith, her prayer would be successful, she would reco- 
ver at once ; and she did so. No one can doubt that it was just such a case as 
those I have now been mentioning. Many of these pseudo-diseases terminate 
suddenly under some strong moral emotion. A fall — a fire in the house — any 
overwhelming terror, will sometimes put an end to them. And where the joints 
have been the parts affected, several patients have declared that they felt a sensa- 



430 



HYSTERIA. 



tion as if something had snapped or given way in the part, immediately before 
the sudden recovery took place. 

Some of the shapes assumed by this pathological Proteus are hideous and 
disgusting. Paralysis of the muscular fibres of the bladder, or spasm of its 
sphincter, sometimes really occurs, sometimes is only aped, in hysteria. It is a 
common trick with these patients to pretend that they labour under retention of 
urine ; and that, although the bladder is full, they cannot make water. The daily 
introduction of the catheter by a dresser or apprentice appears to gratify their 
morbid and prurient feelings. Sometimes, no doubt, the difficulty is real ; but it 
is oflener feigned or exaggerated. I have again and again known it disappear 
upon the patient's being left, without pity, to her own resources. But girls have 
been known to drink their urine, in order to conceal the fact of their having been 
obliged and able to void it. The state of mind evinced by many of these hysterical 
young persons is such as to entitle them to our deepest commiseration. The decep- 
tive appearances displayed in the bodily functions and feelings find their counterpart 
in the mental. The patients are deceitful, perverse, and obstinate: practising, or 
attempting to practise, the most aimless and unnatural impositions. They will 
produce fragments of common gravel, and assert that these were voided with the 
urine : or they will secrete cinders and stones in the vagina, and pretend to be 
suffering under some calculous disease. A young woman contrived, in one of our 
hospitals, to make the surgeons believe that she had stone in the bladder; and she 
actually submitted to be placed upon the operating table, and to be tied up in the 
posture for lithotomy, before a theatre-full of^tudents ; and then the imposture 
was detected. Sometimes they simulate suppression of urine, and after swallow- 
ing what they have passed, vomit it up again, to induce the belief that the secre- 
tion has taken place through the new and unnatural channel. 

It is impossible, I say, not to pity the unhappy victims of this wretched dis- 
order, when their morbid propensities drive them to such acts as these. I men- 
tion them because yon must expect to meet with such cases; and because, while 
you take care not to express your suspicions prematurely, or on light evidence, 
you should be upon your guard against the mortification of being deceived, by 
the false signals held out, into active and ill-directed measures of treatment. 

There is another very common hysterical pain which I ought to have men- 
tioned, viz., a pain occupying some one point in the head ; the patient speaks of 
it as a sensation like that which would be caused by driving a nail into the part ; 
and the affection has therefore been called the clavus hystericus. It is often 
situated just above one eyebrow; and it sometimes comes on every day, at the 
same hour. Now in these cases it imitates very closely the hemicrania, which con- 
stitutes no uncommon form of an intermittent, and is called, accordingly, the brow 
ague. The distinction between the two — whether the affection, I mean, be hys- 
terical or aguish — is not of any great consequence : but in many of the previous 
examples of hysterical pain mimicking organic or inflammatory disease, the diag- 
nosis is obviously of the greatest moment. 

How, then, is it to be made? You may, generally, I believe, be led to a right 
judgment if you look to the several points that I have incidentally touched already. 
You may guess that the affection is hystericarif the patient be a young unmarried 
woman : if there be any disorder or irregularity in the uterine functions; if you 
can gather any history of former hysterical disease ; and especially if she is sub- 
ject to Jits of hysteria. The suspicious symptoms may often be traced back, and 
found to spread themselves over a considerable previous period of time : yet there 
is no such wasting, or commensurate deterioration of the general health and 
strength, as might be expected in organic disease. When the complaint simulated 
is some acute local inflammation, and there is pain increased upon pressing the 
part, you will find that the pain is aggravated by the gentlest touch ; it is more 
felt if you brush your hand over the surface, or slightly pinch the integuments, 
than when firm pressure is made : and you will find also that this exquisite tender- 
ness is not limited to the part complained of. Suppose it is the abdomen, the 



HYSTERIA, 



431 



patient will shrink and exclaim if you suddenly put your finger on her neck, or 
her arm. The suspicion that the disorder is nervous or hysterical will also be 
corroborated if the symptoms which resemble the symptoms of inflammation arise 
and subside rapidly, without obvious cause for such fluctuation ; and if various 
organs appear to be attacked in succession. Between the several symptoms that 
mark real disease there is always (as we learn by experience) a certain congruity 
and relation ; but in the simulative displays of hysteria the symptoms are apt to 
be irregular, inconsistent, contradictory. When, after the most careful investiga- 
tion of the case, you still doubt, it will be right either to pause, or to treat it upon 
the most imfavourable supposition. The consequences of suffering active inflam- 
mation to go on unchecked would be far worse than the temporary and slight and 
remediable injury to the system which might result from once applying the reme- 
dies of inflammation to a case of mere hysteria. There is another hazard also 
which you must be aware of, and seek to avoid ; that of overlooking real disease, 
when it is mixed with, and masked by hysterical symptoms. It is not easy to lay 
down positive rules of action for all these supposable cases ; but I trust that I have 
said enough to convince you of the importance of making the diagnosis of hys- 
teric complaints a careful object of your future study. 

I have hitherto spoken of hysteria as if it were exclusively a malady of 
females. Etymologically to apply that term to the diseases of males would be 
absurd. But that peculiar modification of the nervous system, which is observed 
in hysteric girls does certainly present itself, though rarely, in young men. I 
have seen two or three instances of what I could give no other name to than 
hysteria in males. One of them was in the person of a young surgeon who 
had been house-surgeon to the Middlesex Hospital. I believe he applied to not 
less than a dozen medical men for advice ; and in that batch I happened to have 
my turn. He had some of the symptoms that are ascribed to hypochondriasis ; 
i. e., he was exceedingly attentive to his own sensations, and fancied he had a 
number of diseases which had no existence but in his own imagination: he 
showed great unsteadiness and infirmity of purpose; was what is called " very 
nervous ;" and had occasional bursts of choking, and tears, and laughter, exactly 
resembling those which we so often witness in the other sex. Many cases of 
hysteria in the male have been recorded by different writers. The same mova- 
ble state of the nervous system, and the same symptoms referable to that sys- 
tem, may exist in both sexes. In females, in nine cases out of ten or in a much 
larger proportion, the exciting cause of the hysteria is connected with the 
sexual functions ; and that is all that can be meant when it is asserted that, for 
the female, the complaint is not badly named, but has an intimate dependence 
upon the uterine sympathies. At the same time it is quite true that the " uterus 
is not the only organ of which the irritation may so affect the nervous system as 
to produce hysteria." 

As in epilepsy, so also in hysteria, the treatment to be adopted regards, first, 
the paroxysm itself; secondly, the condition of the patient during the absence of 
the paroxysm. 

One object, during the paroxysm, is to prevent the patient from injuring her- 
self, by her hands, or by her teeth, or in her convulsive movements. Her dress 
should be loosened ; but it may be necessary to confine her hands and arms. 
The next thing to be aimed at is the putting an end to the fit. Various measures 
are found more or less useful for that purpose. The patient should be surrounded, 
as far as that is possible, with cool fresh air. If she is able to swallow, you 
may sometimes shorten the attack by administering a couple of ounces of the 
mistnra assafetida ; or half a drachm of ether, with fifteen or twenty minims of 
laudanum, in camphor julep ; or a draught containing a drachm of the ammo- 
niated tincture of valerian. When the patient cannot or will not swallow, she 
may sometimes be brought about by stimulating volatile substances offered to the 
nostrils. Signal good may also be effected by fetid or stimulant enemata ; the 
enema assafetida, for example, made by mixing two drachms of assafetida with 



432 



HYSTERIA. 



S^alf a pint of water, by means of the yolk of an egg; or the turpentine injec- 
tion, made in the same manner, and containing half an ounce of turpentine ; or 
the same quantity of ice-cold water thrown into the rectum, or applied to the 
pudenda, will often bring the fit to a speedy termination. Indeed I believe there 
is more virtue in cold water, in hysterical diseases, than in any other single 
remedy. In the paroxysm it may be freely and repeatedly sprinkled, or dashed 
with some force, upon the face and chest. Active purges are beneficial and 
requisite in almost all these cases. There is commonly a costive, sometimes 
an obstinate, and always an unnatural, state of the bowels. 

In those long paroxysms — if they may be so called — in which some other dis- 
ease is simulated by hysteria, the cold affusion is a most valuable resource : espe- 
cially in those forms of the disorder in which a limb is permanently bent, or 
incapable of motion. In several instances, in which such contraction had existed 
for a long time, it has yielded in the Middlesex Hospital, to a few minutes' appli- 
cation of the cold douche. Mr. Corfe, as I stated before, takes much pains with 
these cases : he pours cold water from a tea-kettle, or any other convenient vessel, 
in a small stream, from a moderate height, upon the contracted limb. It has been 
bent up for weeks perhaps ; no power that you are able to exert can extend it ; 
and any very forcible attempts to straighten it give the patient extreme pain. — 
After the stream of water has been kept up for a short time, the patient complains 
of it very much; but Mr. Corfe is inflexible — more so than the culprit limb — he 
goes on. Presently the limb begins to tremble, the tight state of the muscles is 
evidently on the point of yielding, and in no long time they are entirely relaxed 
and manageable, and the member becomes as lithe and movable as ever. It often 
happens that the state of contraction recurs ; but a repetition of the douche has 
always the same good effect, and by degrees the habit is broken, and the patient 
set free. It requires some determination to put this expedient in practice. The 
patient looks upon you as a monster of cruelty: and, in private, the friends will 
not always allow such " rough" treatment, as they consider it. Sir Charles 
Clarke, who necessarily sees a great number of these cases — they are more com- 
mon in the upper than the lower classes of society — is a great advocate of this 
ducking system. A paper of his upon the subject was read before the College 
of Physicians a few years ago. He recommends a "sudden and lavish" appli- 
cation of water to the face; or the immersion of the whole body. He describes 
the class of patients, in whom the hysterical affection which is curable by that 
method occurs, as being generally females of a pasty complexion, fat, pale, and 
weak ; or such as evince the ordinary signs of debility, a feeble pulse, cold extre- 
mities, and purpieness of parts distant from the centre of circulation. The age 
of the patients varied from ten to thirty years; in many of them menstruation was 
imperfect, or absent. 

A medical practitioner whom I met lately at a patient's house, told me he had 
just come from another patient, upon whom he had seen a surprising cure per- 
formed. A young lady, for many days, had been affected with trismus. She 
was unable to open her jaws, and therefore could neither speak nor eat. At last 
Sir C. Clarke was called in to see her. He presently comprehended the nature 
of her ailment, had her placed with her head hanging over a tub by the side of 
the bed : and proceeded to pour pitchers of water on her face. Before he had 
emptied the second the patient began to scream and complain, giving very audible 
indications that she could open her mouth. I say although these patients get 
great relief by the treatment, they do not like it ; and if they are convinced that it 
will be put in force, they will generally contrive not to require it. 

Of all the spasmodic affections, hysteria is that which is most readily propaga- 
ble by what may be called moral contagion. If, in a large ward, one girl goes off 
in a fit, half a dozen others perhaps, all who happen to possess the hysteric dia- 
thesis, will experience a strong inclination to follow her example. But this 
chorus, as it were, of hysteria, is much more common in some wards than in 



CATALEPSY. 



433 



others. A stern nurse, or a general order that the cold affusion shall at once be 
employed in every instance of an hysterical fit, will keep the complaint wonder- 
fully in check: and on the other hand, great sympathy with such patients has a 
striking effect in encouraging the paroxysms. These facts show that the symp- 
toms are, to a certain degree, under the patient's control. The fits are not wholly- 
wilful ; neither are they wholly unconquerable. 

I have but little to say respecting the medical management of such patients in 
the intervals between the paroxysms. The objects to be aimed at are, to restore 
the nervous system to the requisite degree of stability : and to correct the disor- 
dered functions of the uterine system. Now much the same plan of treatment is 
applicable to both these objects ; and I spoke of the remedies that are found most 
beneficial for giving tone and firmness to the system, when I was upon the sub- 
ject of epilepsy, and other nervous spasmodic ailments. The following points 
must be kept in view. The regulation of the bowels, which are mostly slug- 
gish, by aloetic aperients ; the exhibition of some form or other of steel ; the steady- 
employment of the shower bath; regulated exercise, both on foot and on horse- 
back ; the avoidance of hot rooms and of late hours, both in respect to going to 
bed, and to rising from it ; the avoidance also of strong moral emotions, of novel 
reading, and of all the other thousand modes of dissipation, mental and bodily, 
which always accompany and abate the blessings of, a high state of civilization. 
Marriage often proves a cure : sometimes it does not. 

The disposition to hysterical disorder may be more easily prevented than cured; 
but upon this point medical men are not consulted. Parents do not foresee the 
misery they are often laying up for their daughters by the unnatural mode of life 
to which they are subjected for the sake of filling them with fashionable accom- 
plishments. I cannot close this subject, and this lecture, better than by quoting 
Sir Benjamin Brodie's remarks on the same point, as I find them in a little work 
recently published by him, and containing many highly valuable observations and 
instructions in respect to local hysterical affections. 

"You can render (he says) no more essential service to the more affluent 
classes of society, than by availing yourselves of every opportunity of explaining 
to those among them who are parents, how much the ordinary system of educa- 
tion tends to engender the disposition to these diseases among their female chil- 
dren. If you would go further, so as to make them understand in what their 
error consists, what they ought to do, and what they ought to leave undone, you 
need only point out the difference between the plans usually pursued in the 
bringing up of the two sexes. The boys are sent at an early age to school, where 
a large portion of their time is passed in taking exercise in the open air; while 
their sisters are confined to heated rooms, taking little exercise out of doors, and 
often none at all, except in a carriage. Then, for the most part, the latter spend 
much more of their time in actual study than the former. The mind is over edu- 
cated at the expense of the physical structure: and after all with little advantage 
to the mind itself: for who can doubt that the principal object of this part of 
education ought to be, not so much to fill the mind with knowledge,, as to train 
it to a right exercise of its intellectual and moral faculties ; or that, other things 
being the same, this is more easily accomplished in those whose animal functions 
are preserved in a healthy state, than it is in others." 



LECTURE XXXIX. 

Catalepsy. Ecstasy. Neuralgia: Tic Douloureux ; Sciatica; Hemicrania. 

There are yet some strange forms of nervous disorder which require to be 
mentioned; but upon which I do not intend to dwell. Catalepsy is one of these; 
28 | 



434 



CATALEPSY, 



and what is called ecstasy another. These affections are very rare as well as very 
wonderful: so wonderful and rare, that weak and superstitious persons have 
referred them to the interposition of supernatural agents in human affairs ; and 
stronger-minded persons, who happen never to have witnessed such diseases, 
deny their occurrence as fabulous, or laugh at them as the tricks and cheatings of 
imposture. They certainly do happen, however; and they happen mostly in the 
same class of persons in whom hysterical and nervors complaints of all kinds are 
most common. They often appear to be produced by similar causes with these ; 
they resemble hysteria in being seldom attended with any danger to life : their 
pathology is, if possible, still more obscure than that of hysteria : and if I were 
to speak of the treatment which would seem to be most suitable for their cure or 
prevention, I should merely have to repeat what I said upon the treatment and 
prevention of hysteria, in yesterday's lecture. I shall content myself, therefore, 
with a short description of these two affections, that you may be aware of their 
characteristic phenomena, and not be taken by surprise in case either of them 
ghould occur to you in your practice. 

A fit of catalepsy implies a sudden suspension of thought, of sensibility, and of 
voluntary motion ; the patient remaining, during the paroxysm, in the position in 
which she (for it is almost always a female) happened to be at the instant of the 
attack, or in the position in which she may be placed during its continuance; and 
all this without any notable affection of the functions of organic life. 

This is certainly a very curious state, and one different from any that we have 
yet contemplated. We have had the muscles rigidly contracted with tonic spasm, 
while the powers of the mind, and the sensibility of the body, were unimpaired. 
We have had the same muscles shaken with clonic convulsions ; both with and 
without coexistent disorder of the intellectual functions. But here we have a 
new phenomenon : the mental faculties are in abeyance, and the sensibility is 
abolished, and so also is the function of voluntary motion ; but the limbs are not 
tied down by spasm ; nor agitated by successive contraction and relaxation of 
their muscles ; nor yet left, like portions of dead matter, passively obedient to 
the laws of gravity: they assume any posture, however absurd, however (to all 
appearance) inconvenient and fatiguing, and that posture they retain, until some 
new force from without is applied to them, or until the paroxysm is at an end. 
The patient so affected, with open staring eyes often, and outstretched limbs, 
looks like a waxen figure ; or an inanimate statue ; or a frozen corpse. Indeed, 
Hoffman seems to have formed the strange conclusion that, as catalepsy, so far 
as he knew, occurred most frequently in winter, it must depend on congelation of 
the nervous fluid. 

These singular attacks occur in paroxysms ; and they have been known to 
alternate with well-marked hysteria ; and to take place in connection with insanity. 
I have never seen an instance of perfect catalepsy ; which I now regret, as I once 
had an opportunity of doing so of w hich I did not avail myself. Dr. Gooch has 
described a case of it, as he witnessed the disease in a patient who suffered puer- 
peral mania. She had long been subject to the common forms of hysteria. This 
is illustrative of what I have often stated respecting the consanguinity of these 
nervous disorders. It had become necessary to confine this patient in a straight 
waistcoat ; she was attended by Dr. Gooch and Dr. Sutherland. I will quote 
Dr. Gooch's account of the cataleptic state ; for it is authentic and modern. He 
says, " A few days after our first visit we were summoned to observe a remarkable 
change in her symptoms : the attendants said she was dying, or in a trance. She 
was lying in bed, motionless, and apparently senseless. It had been said that the 
pupils were dilated, and motionless, and some apprehensions of effusion on the 
brain had been entertained : but on coming to examine them closely, it was found 
that they readily contracted when the light fell upon them ; her eyes were open, 
but no rising of the chest, no movements of the nostrils, no appearance of respi- 
ration, could be seen ; the only signs of life were her warmth and pulse ; the latter 
was, as we had hitherto observed it, weak, and about 120." 
I 



ECSTASY. 



435 



«« The trunk of the body was now lifted, so as to form rather an obtuse angle 
with the limbs (a most uncomfortable posture), and there left with nothing to 
support it ; there she continued sitting while we were asking questions and con- 
versing; so that many minutes must have passed. One arm was now raised, 
then the other; and where they were left, there they remained. It was now a 
curious sight to see her, sitting up in bed, her eyes open, staring lifelessly, her 
arms outstretched, yet without any visible sign of animation. She was very thin 
and pallid, and looked like a corpse that had been propped up, and had stiffened 
in this attitude. We now took her out of bed, placed her upright, and endea- 
voured to rouse her by calling loudly in her ears ; but in vain. She stood up, 
but as inanimate as a statue. The slightest push" put her off her balance. No 
exertion was made to regain it. She would have fallen if I had not caught her." 

" She went into this state three several times. The first time it lasted fourteen 
hours, the second time twelve hours, and the third time nine hours ; with waking 
intervals of two days after the first fit, and one day after the second. After this 
the disease resumed the ordinary form of melancholia ; and three months from 
the time of her delivery she was well enough to resume her domestic duties." 

There is a minor form of this affection described, in which the patient is inca- 
pable of moving or speaking, but is conscious of all that goes on around him at 
the time. I saw a lady last year, who was subject to these attacks of imperfect 
catalepsy ; which have been whimsically, but very expressively, called also attacks 
of daymare. From her time of life, her habits, and some other points in the his- 
tory of the disease, I concluded that in her case these seizures of temporary loss 
of muscular power without loss of consciousness were dependent upon a diseased 
state of the blood-vessels of the brain. She afterwards consulted Dr. Chambers ; 
and he told me that he had formed the same opinion of the nature and cause of 
the symptoms. 

r In what is called ecstasy, the state is different. The patient is lost to all exter- 
nal impressions ; but wrapt and absorbed in some object of the imagination. The 
muscles are sometimes relaxed ; sometimes rigid as in slight tetanus : but the loss 
of voluntary power over them is not complete or universal, for these patients often 
speak in a very earnest manner, or sing. They are, as the term ex6ta<tt,s imports, 
out of the body at the time, wholly engrossed in some high contemplation. This 
state is not uncommon as forming a part of religious insanity : and sometimes it 
runs into ordinary hysteria. Nervous and susceptible persons are apt to be thrown 
into these trances under the influence of animal magnetism : and grave authors 
assure us that the intelligence which then deserts the brain concentrates itself in 
the epigastrium ; or at the tips of the fingers : that people in that state read letters 
which are placed upon their stomach, or applied to the soles of their feet ; answer 
oracularly, enigmatical questions ; describe exactly their own internal organic 
diseases; and even foretell future events. Credat Judaeus Appeila, Non ego. I 
take for granted that they who were in the habit of speaking, a few years since, 
in some of our places of worship, in what they called unknown tongues, were 
either gross impostors, who deserved to be publicly whipped, or persons labouring 
under this disease, and wanting physic. Dr. Copland mentions a curious fact in 
connection with this subject. He says that many of the Italian Improvisator! are 
in possession of their peculiar faculty only while they are in a state of ecstatic 
trance ; and that few of them enjoy good health, or consider their gift as otherwise 
than something morbid. 

I repeat that I can add nothing respecting the pathology or the management of 
these diseases, to what I have already said in reference *to the whole class to 
which they belong. 

Leaving these nervous disorders, in which the function of voluntary motion is 
so curiously modified ; and in which there sometimes is no alteration of the intel- 
lectual faculties, and sometimes very great disturbance, or the complete suspension 
of them j I would beg to turn your attention to another class of complaints, in 



436 



NEURALGIA. 



which the nervous system is still the part principally interested, but in which the 
deviation from the natural state is manifested chiefly in the function of sensation; 
the powers of thought and of voluntary motion, being scarcely affected, or not 
affected at all. Complaints, I mean, in which the sensibility is perverted, and 
augmented ; cases of nervous pain. We have considered before that modification 
of sensation which consists in numbness, or anaesthesia, i.e., in the diminution of 
the natural sensibility, or its total privatiqn. We have noticed also incidentally 
many perversions of sensation ; such as giddiness, nausea, faintness, and the like; 
and in the same incidental way the morbid exaltation of the sensibility which is 
called pain, has come before us, as a symptom of various other diseases ; of 
inflammation, and of hysteria. But there are diseases which consist of pain, and 
of nothing else, that we can perceive. They are often attended by no inflam- 
mation, no detectable change of structure in the painful part, no fever. These 
affections are included under the general term, neuralgia. Now pain is one of 
the things which we are oftenest consulted about; and these neuralgic pains are 
apt to be excessively severe and troublesome ; and it cannot but be of importance 
to understand what has been ascertained of their nature, and causes, and capability 
of cure. 

That pain is owing to some morbid condition, or to some irritation of a particu- 
lar nerve, we may sometimes know, by finding that it occupies exactly the course, 
and follows the distribution of that nerve. But when, as often happens, the pain 
is confined to a certain spot, we then conclude it is neuralgic, if and because we 
can find no other explanation of its existence. 

What increases the difficulty of making out the cause and origin of these nervous 
pains, is that they may be produced by some source of irritation situated at a 
distance from the part in which the pain is felt. It may be placed in the brain 
itself, or in the spinal cord ; or in the trunk of the nerve that supplies the affected 
part; or in one of the branches of the same trunk, which branch is distributed to 
another part. If you strike the inside of the elbow in a certain way, so that the 
blow lights upon the ulnar nerve, a peculiar tingling sensation is felt in the little 
finger: that is, not in the part struck, but in the sentient extremity of the same 
nerve ; and the same thing happens continually in disease. There is an excellent 
paper on this subject, by Sir Benjamin Brodie, published in owe of the earlier 
volumes of the Medical Gazette, in which he has collected numerous and striking 
illustrations of the production of nervous pain by irritation situated in a distant 
part. Thus, to take a case in point; a man was admitted into St. George's 
Hospital on account of severe pain on the inner side of his knee. The joint was 
carefully examined, but no mark of disease could be detected in it. On tracing 
the limb upwards, however, an aneurism of the femoral artery, as big as an orange, 
was discovered in the thigh. This the patient thought nothing of; his only con- 
cern was the pain in his knee. Sir E. Home performed the usual operation for 
aneurism : and the moment the ligature was drawn firmly round the artery in the 
upper part of the thigh, the tumour ceased to pulsate, and the pain in the knee 
ceased also. This man died four or five days after the operation : and upon 
inspection of the limb after his death, the aneurism was found reduced to one-half 
its former size; and some branches of the anterior crural nerve, which passed 
over it, and which must have been kept on the stretch previously to the operation, 
were seen to terminate in the part to which the pain had been referred on the 
inside of the knee. There is just such another case related by Dr. Denmark, in 
the Medico- Chirurgical Transactions. A sailor was wounded by a musket-ball 
in the arm. The woiwid healed ; but the patient remained affected with agonizing 
pain, beginning in the extremities of the thumb and fingers, except the little 
finger, and extending up the fore-arm. His sufferings were so great that he 
willingly submitted to have the limb amputated : and the operation gave him com- 
plete and immediate relief. When the amputated limb was dissected, a small 
portion of lead, which seemed to have been detached from the ball when it struck 
against the bone, was found imbedded in the fibres of the median nerve. 



NEURALGIA. 



437 



These examples teach us, when we receive complaints of pain in any part, and 
can discover no cause of pain in the part itself, to look for some possible source 
of irritation in the trunk of the nerve, from which the part in question is supplied 
with nervous fibrils. 

But the source of irritation may be further back than this : it may depend upon 
a diseased state of the spinal marrow, or of the brain. Of this we have had so 
many examples before us already, that I need not seek for any new illustrations 
of it. 

Sometimes, again, irritation applied in the course, or at the extremity of one 
branch of a nerve, will give rise to pain at the extremity of another branch of the 
same nerve. The sensation appears to be reflected, as it were, along the branch 
which is not, directly, the subject of the irritation. Thus filaments of the phrenic 
nerve penetrate the diaphragm and communicate with the ganglia that lie around 
the caeliac artery; other filaments are distributed to some of the muscles about the 
shoulder; and in this way has been explained the well-known fact, that disease or 
irritation of the liver is very apt to be accompanied with pain in the shoulder. 

Thus also we have pain in the glans penis, from irritation of the bladder, 
produced by a stone there; pain of the thigh and testicle, from irritation of the 
kidney: pain in the left arm, from disease of the heart: pain in the feet, from 
stricture and irritation of the urethra. 

There are many pains also, plainly enough connected with irritation of distant 
parts, although no other nervous connection can be traced between the parts, 
except that which is afforded by the nervous centres. In such cases we must 
suppose that the morbid impression travels to the brain, and then the sensation is 
referred to the part affected through another nervous channel of communication. 
Dr. Wollaston was accustomed to relate the following story of himself. He had 
eaten some ice-cream after dinner one day ; and his stomach did not seem to be 
capable of digesting it. Some time afterwards, when he had left the dinner table 
for the drawing room, he found himself rendered lame by a violent pain in one 
ankle. Suddenly he became sick, the ice-cream was vomited, and instantaneous 
relief of the pain followed its ejection from the stomach. " A gentleman (says 
Sir Benjamin Brodie) awoke in the middle of the night, labouring under a severe 
pain in one foot. At the same time certain other sensations, to which he was not 
unaccustomed, indicated the existence of an unusual quantity of acid in the sto- 
mach. To relieve the latter he swallowed a large dose of alkaline medicine. 
Immediately on the acid in the stomach having been thus neutralized, the pain in 
the foot left him." 

The lesson that we learn from all these facts is this : than when we can find no 
explanation of a pain in the very spot in which it is felt, we should look for some 
condition that may explain it in the trunk of the nerve supplying that part: or in 
the parts supplied by other branches of the same nerve ; or (if we are still unsuc- 
cessful), we look for other indications of disease in the brain or spinal marrow: 
and if these be wanting, we should extend our search, and inquire whether there 
be any intelligible disorder or cause of irritation elsewhere, which, operating 
through the medium of the nervous centres, may have occasioned the sympathetic 
pain of which our patient complains. 

I say we should institute this search, because, if it be successful, it may teach 
us, on the one hand, that the cause of the pain is fixed and irremediable ; or, on 
the other, it may enable us by some simple and obvious expedient to cure the pain. 
But sometimes we shall be quite disappointed in all this seeking. We shall find 
nothing, either in the living patient, or in the dead body, which throws the smallest 
light upon the cause of the neuralgia. 

Now with respect to those neuralgic pains, for which we can discover no 
adequate cause, either in any diseased structure, or in any morbid action of the 
blood-vessels, there are certain general facts observable which I will mention 
before I specify any particular forms of neuralgia. They occur in all parts of the 
body; but they are more frequent about the head than in any other part; and 



438 



NEURALGIA. 



next of all, probably, in the abdomen. In the head, or face, the branches of the 
fifth pair of nerves are very frequently the seat of neuralgia; and to such pain, in 
that situation, the name of tic douloureux is generally given. The painful affec- 
tion called hemicranici is another example of neuralgia of the head. Certain 
forms of angina pectoris, and of gastrodynia, seem to belong to the same class 
of disorders: and sciatica — which depends on different causes in different cases 
— is often rather a neuralgic than a rheumatic pain. I have stated that the pains 
sometimes follow the track of certain nerves ; but this is not, I think, very com- 
mon. Inflammation of the nerve, or of its investments, generally causes pain 
having that property : but the truly nervous pains are much better characterized 
by the suddenness with which they come on, and the suddenness with which they 
sometimes go off also; by their intermittence in many cases, and the regularity 
of the period at which they often, though not always, return ; by the total absence 
(in most cases) of heat and swelling, and often of tenderness too, when they are 
external, and of febrile symptoms when they are internal, even although their 
intensity be extreme ; by their apparent dependence, in numerous instances, upon 
sudden changes of the weather ; by their occurring chiefly in persons of a nervous 
temperament in whom the health is otherwise disordered ; and by their frequently 
abating under tonic remedies, or what are called specifics, rather than under 
antiphlogistic treatment. (Alison's Outlines.) There is another circumstance, 
characteristicof these pains, which has been mentioned by Sir Benjamin Brodie, and 
I do not know that the same thing has been noticed by other writers. These pains 
are often suspended by sleep. " A person suffering from tic douloureux in the 
face may for a time be prevented from falling asleep, but if once asleep, his sleep 
is likely 1o be sound and uninterrupted for many hours." He says that though 
there may be exceptions to this rule, they are comparatively rare. Now this, 
you will observe, is quite analogous to what takes place in certain spasmodic 
affections of the muscles also. The jactitations of chorea are almost always sus- 
pended during sleep. It is the same with the spasmodic wry neck, in which the 
involuntary contraction of some muscle, commonly the sterno-cleido-mastoideus, 
drags the chin round, and the head awry. Persons affected with that sort of 
deformity when awake, have their necks flexible enough, I believe, while they are 
sleeping. 

I mentioned just now one character of these neuralgic pains, viz , the total 
absence in most cases, when they occupy the surface, of heat, redness, swelling, 
or tenderness ; and I said in most cases, because there are unquestionably excep- 
tions to this. After these pains have been long-continued and intense, they may 
give rise even to a moderate degree of inflammation of the part ; which will become 
tender to the touch, manifestly vascular, and even swollen a little. " In a gentle- 
man," mentioned by Sir B. Brodie, " who suffered for a great length of time 
what was regarded as a most severe tic douloureux in the face, at first the parts 
to which the pain was referred retained their natural appearance, but ultimately 
they became swollen, from an effusion of serum into the cellular texture, and so 
exquisitely tender that they could not bear the slightest touch. In a patient who 
had laboured for some time under pain in the testicle, depending on a calculus 
passing down the ureter into the bladder, the testicle became lender and con- 
siderably swelled." 

The attacks of neuralgia may recur at intervals of a few seconds only ; or they 
may take place daily, or every other day : or they may be separated by much 
longer intervals, regular or irregular. Sometimes there is continual pain, but it 
is wonderfully exalted and aggravated by fits. It is described as being sharp, 
sudden, twinging, like an electric shock in its momentary duration. Sometimes 
it is attended by a feeling of constriction and cramp, although no muscular con- 
traction accompanies it. I suppose, that is one reason why such pain is so often 
spoken of, even by medical men, and almost always by the vulgar, as spasm. 
Whenever a patient tells me he has spasms here or there, I am obliged to request 
that he will explain himself further. I want to know how he construes spasm ; 



TIC DOULOUREUX, 



439 



and nine times out of ten I find that he intends a sudden and sharpish, and gene- 
rally a transitory attack of pain: whereas the term spasm really signifies, and 
ought to be restricted to, involuntary muscular contractions. When a medical 
man prints a case in which he states that spasms occurred in such or such a part, 
it is impossible to tell what he means, unless that term is explained by the con- 
text. Pray avoid this inexactness. 

The most common of these neuralgic pains, as I have said, is that which has 
been called, xav s^oxyv, tic douloureux, and which is situated in the facial 
branches of the fifth pair of nerves ; nerves, as you know, of sensation ; and it is 
usually restricted to one of the three branches that emerge severally to supply the 
parts in their neighbourhood. Sometimes two, sometimes all of them, are impli- 
cated. The middle one of these branches, the infra-orbitary, is, I believe, the 
most commonly affected in the severer forms of the complaint. The torture 
occasioned by this dreadful malady is sometimes excessive. The sufferers speak 
of it as anguish that is scarcely endurable ; and you see, in their quivering features 
and restless limbs, that the acute bodily pang is, indeed, hard to bear. 

When the uppermost branch of the trifacial nerve is the seat of the complaint, 
the pain generally shoots from the spot where the nerve issues through the super- 
ciliary hole ; and it involves the parts adjacent, upon which the fibrils of the nerve 
are distributed ; the forehead, the brow, the upper lid, sometimes the eyeball 
itself. The eye is usually closed during the paroxysm, and the skin of the fore- 
head on that side corrugated. The neighbouring arteries throb, and a copious 
gush of tears takes place. In some instances the eye becomes blood-shott m at 
each attack ; and when the attacks are frequently repeated, this injection of the 
conjunctiva may become permanent. 

When the pain depends upon a morbid condition, or morbid action, of the mid- 
dle branch of the nerve, it is sometimes quite sudden in its accession, and some- 
times comes on rather more gradually ; being preceded by a tickling or pricking 
sensation of the cheek, and by twitches of the lower eyelid. These symptoms 
are shortly followed by pain at the infra-orbitary foramen, spreading in severe 
flashes (so to speak) over the cheek, affecting the lower eyelid, ala nasi, and upper 
lip, and often terminating abruptly at the mesial line of the face. Sometimes it 
extends to the teeth, the antrum, the hard and soft palate, and even to the base of 
the tongue, and induces spasmodic contractions of the neighbouring muscles. 

When the pain is referrible to the inferior or maxillary branch of the fifth pair 
of nerves, it darts from the mental foramen, radiating to the lips, the alveolary 
processes, the teeth, the chin, and to the side of the tongue. It often stops exactly 
at the symphysis of the chin. Frequently it extends in the other direction to the 
whole cheek, and to the ear. During the paroxysm the features are liable to be 
distorted by spasmodic action of the muscles of the face, amounting sometimes to 
tetanic rigidity, and holding the jaw fixed and immovable. 

The paroxysms of suffering in this frightful disease are apt to be brought on 
by apparently trivial causes ; by a slight touch, by a current of air blowing upon 
the face, by a sudden jar or shake of the bed in which the patient is lying, by a 
knock at the door, or even by directing the patient's attention to his malady by 
speaking of it, and asking him questions about it. This was remarkably manifest 
in a patient who came into the hospital under my care for another complaint ; but 
who had for some time been subject to tic douloureux. The necessary move- 
ments of the face in speaking, or eating, are often sufficient to provoke or renew 
the paroxysm. At the same time firm pressure made upon the painful part fre- 
quently gives relief, and causes a sense of numbness to take the place of the pre- 
vious agony. 

This cruel malady occurs most commonly in persons who exhibit, in other 
respects, the signs of an unsound, or deranged, or debilitated system. It is more 
apt to fasten upon those who are pale, and asthenic, and upon individuals whose 
powers have been broken by advancing years. It is not unfrequently attended 
with some obvious disorder of the digestive organs, and ceases or is mitigated 



I 

440 TIC DOULOUREUX. 

when that disorder is corrected. Sometimes it is clearly connected with a dispo- 
sition to rheumatic affections; coming on in persons who suffer rheumatism in 
other parts, and even alternating with rheumatism in other textures. It is observed 
to be common among fishermen, and the inhabitants of marshy districts; and in 
some of these sufferers it may be attributable to their habitual exposure to cold 
and moisture ; and this nerve, lying superficially, and being unprotected by any 
artificial covering, is more likely, perhaps, for that reason, to be affected by vicis- 
situdes of temperature ; but in many of these cases the disease seems to be pro- 
duced by the malaria, which is prevalent in those situations. The paroxysms 
are then not only intermittent, but periodical, and they will frequently yield to the 
remedies which have been ascertained to be specific against ague and its various 
modifications. Sometimes the facial neuralgia is evidently dependent upon some 
general state of the system : for it will cease in the face, and fix itself in some 
other place ; and in this way it may come to occupy several distant parts of the 
body in succession. There are other cases again in which the disease has a local 
origin, and results from some diseased bone, or exostosis, in the neighbourhood 
of the painful spot. The late Dr. Pemberton afforded a well-known example of 
this. He was seized with tic douloureux in the very zenith of his reputation, 
and when he was in the fullest practice of his profession in this town. It com- 
pletely ruined him : compelled him to give up business. He ultimately died of 
apoplexy. When his head was examined after death, the os frontis was found 
to be unusually thick, and on the falciform process of the dura mater, at a little 
distance from the crista galli, a small osseous substance was discovered, nearly 
half an inch long, and almost as broad. Sir Henry Halford has recorded several 
other instances in which the disease was connected with some morbid condition 
of the bones of the head or face. 

Now tic douloureux is one of those complaints for the cure of which there exists a 
numberof specific remedies. But whatl have been stating of this disease will suffice 
to convince you that, asitdepends upon different causes and different persons, it is 
absurd to expect that any single drug — or even any one plan of treatment — will 
always remove it. Our first care, in every example of it that comes before us, must 
be to investigate all the particulars of the case. We must not be satisfied with 
learning that the complaint is tic douloureux, and then go on prescribing one after 
another the reputed specifics for tic douloureux. It may happen that the origin 
of the disease is plain, and the remedy obvious. We must endeavour to make 
out whatever is amiss in the system at large, or in the state of particular functions. 
Very rarely, I believe, tic douloureux is dependent upon a condition of general 
plethora. Mr. John Scott gives the case of a gentleman who suffered severely 
from it for some time ; at length he had an attack of apoplexy, and for this last 
disorder he was copiously bled, and the bleeding seemed to cure the neuralgia. 
Much more frequently we find evidence of a feeble or a shattered state of the 
system ; debility and paleness : and then we may expect to do good by the treat- 
ment so strongly recommended by Mr. Hutchinson, viz., by giving the carbonate 
of iron. This remedy has been put largely to the test, since Mr. Hutchinson 
wrote in commendation of it, by- Dr. Elliotson, and subsequently by others. Dr. 
Elliotson states it as the result of his experience that, "in all cases of neuralgia, 
whether exquisite or not, unaccompanied by inflammation, or evident existing 
cause, iron is the best remedy." I have already explained the manner of admin- 
istering the carbonate of iron, the quantity in which it may be given, and the 
limits within which I should be inclined to restrict the doses. Sir Benjamin 
Brodie thinks it probable that the carbonate of iron proves beneficial by its me- 
chanical operation on the internal surface of the intestines : but I should rather 
ascribe its good effect to the well-known property of preparations of iron, to give 
firmness to the nervous system: apparently by increasing the quantity of red 
blood that circulates in it. However, it is of the utmost consequence that the 
state of the digestive organs should be attended to. Mr. Abernethy used to relate, 
in his lectures, many instances of tic which he had been successful in curing by 



TIC DOULOUREUX. 



441 



measures which were solely directed to the improvement of the stomach and 
bowels. He had a notion, that in patients who suffer under this disorder, there 
were always two functions wrong ; those of the nervous system on the one hand, 
those of the digestive system on the other. And I am sure you will commonly 
find indications of a faulty state of both these systems. " The two," he used to 
say, " were the common parents of a numerous progeny of very dissimilar local 
diseases. In tic douloureux, you must seek to put the digestive organs right, or 
to soothe the nervous system, according as the one or the other may seem to be 
the principal and primary cause of the disease. Take away one of the parents, 
and there will be no more propagation." 

In these cases, the unhealthy state of the digestive apparatus may be marked 
by obvious signs; a furred tongue, loss of appetite, costive bowels : or it may 
reveal itself by no other symptom than the pain. It may depend upon the mere 
presence of acid in the stomach. Dr. Rigby tells us that having suffered in his 
own person an intense attack of tic douloureux, which opium did not assuage, 
he swallowed, at the suggestion of a friend, some carbonate of soda dissolved in 
water. The effect was almost immediate : carbonic acid was eructed, and the 
pain quickly abated. More often the cause of offence appears to lie in some part 
of the intestines ; and purgatives do good. Sir Charles Bell — drawing a bow at 
a venture — -achieved the cure of a patient upon whom much previous treatment 
had been expended in vain, by some pills composed of cathartic extract, croton 
oil, and galbanum. He mixes one, or two, drops of the oleum tiglii, with a 
drachm of the compound extract of colocyntli ; and gives five grains of this mass 
with ten grains of the compound galbanum pill at bed-time. I mention the 
exact proportions and dose, because other cases have been since reported, both by 
Sir Charles and by others, in which the same prescription was followed by the 
same success. 

When the disease occurs in a rheumatic individual, and especially when, as is 
sometimes the case, it alternates with rheumatism of other tissues, the remedies 
which have been found useful in rheumatism deserve a fair trial ; guaiacum ; col- 
chicum ; calomel and opium. 

When all has been done that can be done towards restoring or improving the 
general health we may turn our thoughts to local remedies. It is plain that these 
must be inefficient when the local pain results from constitutional causes that are 
unredressed, or perhaps incurable. Yet even then topical measures may soothe 
the pain for a while. 

One of these topical expedients, which promised well when first thought of, is 
the division of the trunk of the painful nerve, so as to cut off the nervous com- 
munication, through that main channel at least, between the painful part and the 
brain. This was originally proposed by Dr. Haighton, and was at first attended 
with some little success ; but in a great number of instances it has signally failed, 
as indeed might have been expected. In Dr. Pemberton's case the several 
branches of the fifth pair were cut by Sir Astley Cooper: but in vain. When 
there is any reason to think that the disease has a constitutional origin, or a local 
distant origin, the division, or even the excision, of a part of the nerve must be 
perfectly useless. It would be as reasonable (as Mr. Abernethy has observed) 
to expect to cure gout by cutting the nerve that goes to the great toe : or to per- 
form castration with the view of remedying that pain in the testicle which is apt 
to be produced by the passage of a calculus through the ureter. Nevertheless 
there are cases, in which the division of the nerve, or some other surgical opera- 
tion, is required. If you can make out that there is any tumour pressing upon 
or adherent to some part of the nerve — or if some foreign body, as a splinter, or 
a shot, should be ascertained to be in contact with the surface of the nerve, or to 
be entangled in its substance, the tumour or the foreign body may be removed by 
the knife, with the strong expectation that a cure will be thus effected. And if 
this cannot be done, or if the nerve itself be altered in structure, either from disease 
or injury, (I am referring now to neuralgia in general, and not merely to that In 



442 



TIC DOULOUREUX. 



which the facial branches of the fifth pair of nerves are implicated,) under those 
circumstances it will become a very proper subject of deliberation whether the 
nerve should be divided, or even the limb amputated. 

In the Medical and Physical Journal there is a case described by Mr. Jeffries, 
of a violent facial neuralgia, cured by the removal of a small fragment of china, 
which had been lodging in the cheek for fourteen years. And Mr. Descot men- 
tions an instance in which a very severe affection, of ten years' standing, was 
removed by the extraction of a carious tooth. I saw, not many days ago, a young 
woman whose finger had been amputated for very acute neuralgic pain which she 
had suffered in it ; and the amputation had been successful in liberating her from 
that pain. 

Sometimes we may hope to afford relief to the suffering patient by means 
which tend to remove or lessen the exciting cause of the paroxysms. Of this I 
may mention one remarkable example, which fell in part under my own observa- 
tion : although I had nothing to do with the treatment. I was asked, a few years 
ago, by a friend, to go with him to call upon a relation of his, who laboured, he 
said, under tic douloureux : he did not wish me to see her professionally, but was 
desirous that I should witness what he considered an extraordinary complaint. 
• I saw a young girl, about twelve or thirteen years old, very pale and delicate, 
lying on a sofa; and I learned from her and from her mother that she was subject 
to the most excruciating agony in one side of her face and neck. The pain came 
on whenever she swallowed anything: the act of deglutition proved invariably 
the exciting cause of the torment. She was at that time under the care of a prac- 
titioner who had desired that she might eat mutton-chops three or four times a 
day. Of course this was a sentence full of misery to her ; but so desirous was 
she to get rid of her disease, that she resolved steadily to follow the directions 
enjoined her. This plan was to be tried for at least a month ; after that time, if 
she were no better, her mother had resolved to consult another practitioner who 
had been much recommended to her. I should say that she had already consulted 
a great number of medical men; for the malady had existed nearly two years. 
At the end of the month she was worse than at the beginning; and the new prac- 
titioner, Mr. Pennington, was called in. He acted, like a man of sense and 
sagacity, upon the fact that the act of swallowing always gave rise to the pain; 
and he advised that she should not attempt to swallow for twenty-four hours. 
That period passed without any return of the pain; but it immediately recurred 
upon her eating a morsel of bread. The result of this experiment, however, 
encouraged him to hope that the morbid habit might be broken through by a 
sufficiently long abstinence from swallowing. And as she had been subjected to 
a great variety of fruitless treatment, he gave her no medicine, but advised that 
she should refrain altogether from taking food or drink by the mouth. Nourishing 
injections, composed of beef tea with an egg beat up in it, or of milk, were thrown 
into the rectum, two or three times a day. This plan was persisted in for a longer 
time than I should have supposed she could have endured it. No nutriment 
whatever was taken by the mouth for five weeks and three days, and no paroxysm 
of pain occurred. At the end of that period the pulse sank suddenly, from between 
seventy and eighty, to thirty-five beats in a minute; and thereupon Mr. Penning- 
ton thought he had carried his experiment far enough; and deemed it advisable 
to administer by the mouth a dessert-spoonful of beef-tea twice a day. This was 
continued for four days without producing any return of the pain. A small piece 
of fish was then allowed, and afterwards some chicken ; and proceeding thus 
cautiously, in the course of a month she was able to eat and drink any thing, 
without the slightest inconvenience. 

I should state, however, that some time afterwards, the neuralgia returned in 
another situation, affecting the left knee : and this was remedied by a different 
mode of treatment. She is since dead. 

When other means fail, or in' conjunction with other means, local applications 
to the affected part may be tried. Belladonna will sometimes materially palliate 



TIC DOULOUREUX. 



443 



the pain ; so will opium : but within the last few. years a new anodyne has been 
brought into use ; and it really seems to have been of essential service in several 
instances of this most painful disorder. I allude to aconitine : the active principle 
of the monkshood. The property belonging to this plant, of benumbing sensation, 
has long been known. Sir Benjamin Brodie found many years ago that after 
chewing its leaves, a remarkable numbness of the lips was left, which lasted some 
hours. We may understand therefore the beneficial operation of the aconitine 
upon a part of which the sensibility is unduly exalted. It is only very recently 
that pure aconitine has been procured ; and consequently it has not yet been very 
extensively employed, and the less so on account of its very high price : but what 
experience we have of it, as a benuinber of pain, is highly encouraging. It has 
been of singular benefit to a surgeon who formerly lived in Charterhouse Square, 
and whose case is well known, I believe, to the profession. Mr. Spry had suffered 
greatly, for eight years, under very acute neuralgia affecting the parts supplied 
by the lowermost or mental branch of the fifth pair of nerves. After exhausting 
almost every expedient that ever has been recommended for tic doloureux, except 
that of dividing the nerve, he was induced to make trial of the aconitine. It was 
mixed with cerate, in the proportion of one grain to one drachm, and a small 
portion of this was smeared over the track of the painful nerve once or twice a 
day for six days. By that time he had entirely lost the pain. He states, I under- 
stand, that the application of the ointment produced a sense of numbness, which 
continued for twelve, or eighteen hours. Dr. Hue, who first told me of Mr. 
Spry's case, told me at the same time that he knew of two others in which the 
same application had been equally successful. This encouraged me to try it upon 
my patient, whom I mentioned before, and who happened at that time to be in 
the hospital. I bought, for ten shillings, five grains of the aconitine at Mr. Mor- 
son's, in Southampton Row, where I knew it would be genuine. One-third of a 
drachm of ointment, containing one-third of a grain of the alkaloid, was smeared 
two or three times a day over my patient's face, and the attacks presently dimi- 
nished in intensity, and in a few days ceased altogether. He soon after left the 
hospital, so that I cannot tell whether the cure was permanent. I presume it was 
so, as he did not return. The particulars of Mr. Spry's case have been published 
by Mr. Skey in the nineteenth volume of the Medical Gazette. It is now (1841) 
six years since the aconitine was applied, and the pain (as Mr. Skey has recently 
informed me) has never recurred. It used to be excited by gentle friction of the 
hand, or by a current of cold air, but Mr. Spry " can now face any wind or tem- 
perature with impunity."* In the same paper Mr. Skey relates another instance 
of the utility of this substance in facial neuralgia. It occurred in one of his 
patients at St. Bartholomew's Hospital. 

This is a remedy therefore which is not to be neglected. Even if it only allay- 
ed the pain for a time it would be highly valuable. But, judging from the in- 
stances now referred to, we may hope that, in some forms of tic douloureux, the 
aconitine may be found equal to their cure. It seems probable that the recurrence 
of the pain is sometimes kept up by the influence of habit; and will cease if the 
habit can for a while be broken. You must take care, however, to obtain a gen- 
uine article. The manufacture of aconitine is difficult, and therefore the cost is 
considerable. Mr. Skey, in the Bartholomew case, failed with some aconitine 
that had been imported into this country, but succeeded at once when he em- 
ployed the same quantity of Mr. Morson's preparation. 

A few years ago Mr. John Scott published a little book on the disease we are 
now considering, with the professed object of introducing to general notice a spe- 
cies of local treatment which he had found successful in several long-standing and 
previously obstinate cases. It is well to be aware of these things, though probably 
the aconitine ointment will beat Mr. Scott's. Mr. Spry used Mr. Scott's oint- 
ment, but without benefit. It consists of the iodide of mercury, mixed with lard, 



This gentleman is since dead. 



444 



SCIATICA— HEMICRANIA. 



in the proportion of two scruples- to the ounce : and it is rubbed into, or placed in 
contact with, the affected surface, until some degree of irritation is produced.* 

There is a kind of face-ache, which cannot properly be reckoned as a species of 
neuralgia, for it does not occur in short stabbing paroxysms, nor is the pain acute 
enough to entitle it to the name of tic douloureux ; but which is very common, 
very distressing, and under ordinary treatment sometimes very intractable. It is 
called by some a rheumatic pain; it occupies the lower part of the face, the jaw 
principally, and the patient cannot tell you exactly whereabouts it is most intense. 
It is often thought to proceed from toothache, and bad or suspected teeth are ex- 
tracted, but with no good effect. Now I allude to this for the sake of saying that 
some years ago I was instructed by an experienced old apothecary, that this face- 
ache might be almost always and speedily cured by the muriate of ammonia; — 
a medicine that we seldom give internally here, although it is so much used in 
Germany. And I have again and again availed myself of this hint, and been much 
thanked by my patients for the good I did them with this muriate of ammonia. — 
It does not always succeed ; but it often does. It should be given in half-drachm 
doses, dissolved in water, or in almost any vehicle, three or four times a-day. If 
the pain does not yield after four doses, you may cease to expect any benefit 
from it. In two or three instances of a similar kind that I have recently had to 
treat, I have found the iodide of potassium, in doses of five or six grains, work a 
speedy and permanent cure. This induces me to suppose that the pain in some 
of these cases is periosteal. I so judge from the ascertained efficacy of the iodide 
in other periosteal affections attended with pain. 

Tic douloureux is the principal form of severe neuralgia which you may 
expect to meet with, in regard to acuteness of suffering and difficulty of cure. 
Two other forms, more common, and luckily more tractable, are generally spoken 
of under the same head : sciatica, namely, and hemicrania. I have very little to 
say, in this place, of either of these. Sciatica, or pain radiating from the sciatic 
notch, and following the course of the sciatic nerve, is sometimes an inflammatory 
eomplaint, and yields to the remedies of inflammation — bleeding and blistering: 
sometimes it is plainly a part of rheumatism ; and then may often be relieved by 
calomel and opium, or by colchicum : sometimes, again, it results from irritation 
within the pelvis, affecting the nerve before it emerges externally ; this irritation 
may be connected with a disordered state of the kidney, and I suspect that it is in 
such cases that the oil of turpentine is of so much use : lastly, it is sometimes a 
purely nervous and neuralgic pain : and then the treatment applicable to facial 
neuralgia will, mutatis mutandis, be applicable to it. I had some time ago, a 
butler under my care at the hospital, whom I am afraid I did not manage well. 
He suffered severe sciatica, and I had him cupped and blistered, and gave him a 
variety of medieines, for some time, to little purpose: at last he got what I ought, 
I suppose, to have given him at first, viz., the carbonate of irOn, and was presently 
well. 

Hemicrania is simply headache, confined to one side, and occupying generally 
the brow and forehead, but sometimes affecting very exactly one moiety of the 
head. It is the migraine of the French, the megrim of our vernacular language; 
each of these terms being obviously traceable to the same Greek root. It is often 
attended with siekness ; and in many instances it is periodical, coming on every 
day at a certain hour, lasting a certain time, and then subsiding. Like the other 
forms of neuralgia, hemicrania may be produced by various causes, which are, 
however, almost all of them such as tend to debilitate the system : it sometimes 

* [In several cases of neuralgia, of different parts of the body, which, for a number of 
years, had resisted a variety of plans of treatment, we have seen almost immediate relief, 
and in a few, a permanent remoyal of the disease result from acupuncturation. In other 
cases, however, no benefit has resulted from the operation. — C.J 



INTERMITTENT FEVER. 



445 



occurs in connection with hysteria; sometimes it plagues women who have 
suckled their infants too long; sometimes it acknowledges the same cause as 
ague ; and sometimes also it occurs independently of all other disease, and when 
no obvious exciting cause can be traced. 

Whatever maybe its origin, it is usually a very manageable complaint. "When 
it is associated with evident anaemia, steel and the shower-bath may be expected 
to cure it. When its visits are strictly periodical, it will yield to quina. Arsenic 
is considered by many to have a specific power over the complaint; and I believe 
that four or six drops of the liquor arsenicalis, given three or four times a day, with 
due attention to the state of the bowels, will be almost sure to remove hemicrania 
in nine cases out of ten in which it occurs. But steel or bark, being milder and 
safer drugs, are, casteris paribus, to be preferred. 

I say this disorder often acknowledges the same cause as ague; namely, the 
miasm of marshes, or malaria : and as that cause, mysterious as it is in some 
respects, exerts apparently its primary or chief influence upon the nervous system, 
and as ague has no definite seat in the human body, if it be not in the nervous 
system, 1 shall not find a more convenient place in these lectures for the consi- 
deration of ague than here, at the close of the remarks which I had to make 
respecting the diseases of the brain and nerves. In the next lecture, then, I shall 
begin to speak of Intermittent Fever. 



LECTURE XL. 

Intermittent Fever. Phenomena of an Ague Fit. Species and varieties of 
Intermittent s. Predisposing causes. Exciting cause. Malaria: known 
only by its effects ; places which it chiefly infests ; conditions of its produc- 
Hon; its effects upon the human body ; influence of soils in evolving it. 

I am now to enter upon the consideration of that disorder of which the trivial 
English name is ague, and which is called by nosologists intermittent fever. 
This is one of the diseases which are known to us only in their respective group 
of symptoms. Before we can inquire successfully into its history, it is neces- 
sary that we have the group of symptoms which identify it set fairly before us. 
I must first, therefore, describe the phenomena of ague. 

You will observe that ague resembles several other maladies that essentially 
belong to the nervous system, in being paroxysmal. A certain series of symp- 
toms occurs, and then the patient reverts to a state of health : but this alternation 
commonly happens (or would happen if the disease were left to itself) a great 
many times. You may therefore look upon this succession of attacks as so 
many repetitions of a short distemper; or you may regard the whole period 
during which the attacks continue to recur at brief intervals, as being occupied 
witn one single disease. 

An ague fit is composed of three distinct stages ; and they are severally named, 
from the phenomena that characterize them, the cold, the hot, and the sweating 
stages. 

A person who is on the brink of a paroxysm of ague, experiences a sensation 
of debility and distress about his epigastrium ; becomes weak, languid, listless, 
and unable to make any bodily or mental exertion. He begins to sigh, and yawn, 
and stretch himself ; and he soon feels chilly, particularly in the back along the 
course of the spine; the blood deserts the superficial capillaries ; he grows pale, 
his features shrink, and his skin is rendered dry and rough, drawn up into little 
prominences, such as may at any time be produced by exposure to external cold, 
and presenting an appearance somewhat like the skin of a plucked goose : hence 
it is called goose's skin, and in Latin cutis anserina. Presently the slight and 



446 



INTERMITTENT FEVER. 



fleeting sensation of cold, first felt creeping along the back, becomes more 
decided and more general; the patient feels very cold, and he acts and looks just 
as a man does who is exposed to intense cold, and subdued by it; he trembles 
and shivers all over ; his teeth chatter, sometimes so violently that such as were 
loose have been shaken out ; his knees knock together ; his hair bristles slightly 
from the constricted state of the integuments of the scalp ; his face, lips, ears, 
and nails turn blue ; rings which before fitted closely to his fingers become loose; 
his respiration is quick and anxious ; his pulse frequent sometimes, but feeble ; 
and he complains of pains in his head, back, and loins : all the secretions are 
usually diminished ; he may make water often, though generally he voids but 
little, and it is pale and aqueous; his bowels are confined, and his tongue is dry 
and white. 

After this state of general distress has lasted for a certain time, it is succeeded 
by another of quite an opposite kind. The cold shivering begins to alternate 
with flushes of heat, which usually commence about the face and neck. By 
degrees the coldness ceases entirely ; the skin recovers its natural colour and 
smoothness; the collapsed features and shrunken extremities resume their ordi- 
nary condition and bulk. But the reaction does not stop here ; it goes beyond 
the healthy line. The face becomes red and turgid ; the general surface hot and 
pungent and dry ; the temples throb; a new kind of head-ache is induced ; the 
pulse becomes full and strong, as well as rapid ; the breathing is again deep, but 
oppressed ; the urine is still scanty, but it is now high-coloured ; the patient is 
exceedingly uncomfortable and restless. At length another change comes over 
him : the skin, which, from being pale and rough had become hot and level, but 
harsh, now recovers its natural softness ; a moisture appears on the forehead and 
face; presently a copious and universal sweat breaks forth, with great relief to the 
feelings of the patient ; the thirst ceases; the tongue becomes moist; the urine 
plentiful but turbid ; the pulse regains its natural force and frequency ; the pains 
depart ; and by and by the sweating also terminates, and the patient is again as 
well, or nearly as well, as ever. 

This is surely a very remarkable sequence of phenomena : and it would 
appear still more remarkable if it were less familiar to us. The earlier symp- 
toms are all indicative of debility, and of a depressed state of the nervous system. 
There is the same sensation of exhaustion, with incapacity of exertion, which is 
produced by fatigue. The sighing, yawning, and stretching, all notify debility. 
The paleness of the surface, and constriction of the skin, and collapse of the fea- 
tures, are all owing to the retirement of the blood from the superficial capillaries. 
The skin shrinks, but the parts containing the bulbs of the hairs cannot contract 
so much as the other parts, and therefore the surface becomes rough, and the 
hairs bristle up, or become erected in some degree. Horripilatio is the learned 
term for this state of the surface. The coldness of the skin is another conse- 
quence of the emptiness of its blood-vessels; and the tremors which are always 
indicative of debility, seem to depend upon the coldness. The chattering of the 
jaws has been (it is said) so violent as to fracture the teeth. This you may 
believe or not as you please, but certainly the whole bed is often strongly shaken 
by the shiverings of the patient. The necessary accumulation of the blood in 
the larger and internal vessels offers a reasonable explanation of the distressed 
and anxious breathing. 

In their attempts to render a " ratio symptomatum," authors have sometimes 
spoken of the hot stage as though it were a necessary consequence of the cold. 
But if the cold fit be in any sense or degree the cause of the hot fit, it can onl)*- 
be so partially. There must be some other cause for these reasons. The cold 
stage may occur and never be followed by the hot ; or the hot stage may come on 
without any previous cold stage; and when they do both happen, they are not by 
any means proportioned to each other. When we thus see that a supposed cause 
is not always followed by the effect, and that the effect is sometimes produced 
without the agency of the supposed cause, and also that the supposed cause and 



INTERMITTENT FEVER. 



447 



the effect are not proportioned to each other, we cannot but conclude that the sup- 
posed cause is at most but a partial and accessory cause. We ean more easily 
conceive how the hot fit may conduce to bring on the sweating stage. The 
stronger action of the heart and the more forcible propulsion of the blood will fill 
the superficial vessels, and in this way the natural secretions may be restored. 
We see exactly the same thing happen when the force of the circulation is in- 
creased by exercise : the extreme vessels receive a larger supply of blood, and 
sweat ensues. 

There are many curious facts to be observed in respect to the paroxysm of an 
intermittent, such as it has been now, in general terms, described. In the first 
place the paroxysm returns. Cullen makes this a part of his definition ; and 
quibbling objections to his statement have been made, which are scarcely deserv- 
ing of mention. Thus it is said that this circumstance should not have been 
introduced into the definition, because it is not necessarily or universally true; 
that the patient may die in the very first paroxysm ; or that he may be cured by 
the proper remedies of ague, before a second paroxysm has time to show itself. 
But all this is captious trifling. The paroxysms, if the disease be left to itself, 
will recur for a certain length of time ; and, unlike the paroxysms in many of the 
spasmodic diseases which we have lately been speaking of, they recur at regular 
periods, and often with singular punctuality. This is a circumstance which we 
should waste our time in attempting to account for. Dr. Cullen has tried to 
explain it on the principle of some diurnal habit of the body ; but the truth is, 
that no satisfactory explanation of it has ever been given, and we must be con- 
tent, for the present at least, to receive it as an ultimate fact ; and, doubtless, a 
very strange and interesting fact. 

For distinguishing some equally curious varieties of these successions and 
alternations of disorder and health, certain terms have, by common consent, been 
adopted by pathologists; which terms it is necessary that I should explain. The 
period that elapses between the termination of one paroxysm and the commence- 
ment of the next is called an intermission; while the period that intervenes be- 
tween the beginning of one paroxysm and the beginning of the next, is called 
an interval. As the paroxysms are liable to vary in length, the intermissions 
may be very unequal, even when the intervals are the same. When the inter- 
missions are perfect and complete, the patient resuming the appearance and sen- 
sations of health, the disorder is an intermittent fever. When the intermissions 
are imperfect, the patient remaining ill and feverish and uncomfortable in a less 
degree than during the paroxysm, then the complaint is said to be a remittent 
fever. 

But, confining ourselves for the present to intermittents, it is another curious 
property of this complaint that, although the intervals are commonly constant in 
each case, and quite regular, they differ in duration in different cases. Upon this 
circumstance is founded a division of agues into species. When the paroxysm 
occurs at the same hour every day, the patient is said to have quotidian ague. 
When it comes on at the same hour every other day, appearing and remaining 
absent day by day alternately, he is said to labour under tertian ague. The 
paroxysm, strictly speaking, repeats itself every second day: and if the species 
I first mentioned be fitly termed quotidian, that in which the fits occur on alter- 
nate days ought to be styled secundan. But nosologists have chosen to reckon 
the day on which the preceding fit happens as the first : and then the day on which 
the fit next to it will happen, in the species now under consideration, is the third. 
In the same way, when a paroxysm absents itself for two whole days, and then 
recurs, the complaint is called a quartan ague. These are the three principal 
species or types of intermittent fever. It follows, of course, from what I have 
been stating, that in the quotidian type, the interval is twenty-four hours ; in the 
tertian, forty-eight; and in the quartan, seventy-two. 

Each of these types has some other characters peculiar to itself. Thus, the 
paroxysms of the quotidian ague begin in the morning ; those of the tertian, at 



448 



INTERMITTENT FEVER. 



i 



noon; those of the quartan, in the afternoon. These are the rules. You are not 
to expect to find them always or rigidly observed ; for the most part you will find 
that they are observed. It is probable that quotidian paroxysms, occurring at 
noon or at night, have sometimes been ascribed to ague, when they were merely 
symptoms of some local disease or inflammation; or perhaps accessions of hectic 
fever. It is observed also of the paroxysms, that when the disease is about to 
yield, they often occur later day after day, before they take their final departure. 
This is called postponing: and when they occur earlier than their stated hour, 
the paroxysms are said to anticipate. Now a postponing quotidian may be 
deferred till noon. But when the disease is pursuing its regular undisturbed 
course, the rule is such as I have mentioned. 

The three principal types differ from each other, not only in their respective 
intervals, and in the periods of the day at which the paroxysms severally com- 
mence, but also in the duration of the paroxysms ; and in the proportions which 
the stages of these paroxysms bear to each other. The average duration of the 
paroxysm in the quotidian is ten or twelve hours; and of course the average 
duration of the intermission is nearly the same. The tertian paroxysm commonly 
begins at noon, and is finished the same evening; its average duration may be 
estimated at six or eight hours. And that of the quartan does not exceed four or 
six hours. 

You must observe also that while the quartan has the longest interval and the 
shortest paroxysm, it has the longest cold stage ; whereas the quotidian has the 
shortest interval and the shortest cold stage, but the longest paroxysm. To 
express these facts in mathematical language, the length of the paroxysm varies 
inversely as the length of the cold stage ; inversely also as the length of the interval. 

Of these three principal types or species, the tertian is by much the most com- 
mon : but the quotidian and quartan are neither of them unfrequent wherever 
ague is rife. 

I should tell you that there are other types also spoken of, as quintans and 
sextans : but they are scarcely worth our attention. It is probable that when they 
are observed (and that is very rarely) they are merely irregular quartans, postpon- 
ing perhaps for a day or two. They never prevail epidemically. Galen describes 
one of these; so does Van Swieten. Boerhaave talks of a septiman, and even 
octavans are mentioned ; or if you want still more of the marvellous, Pliny, the 
naturalist, informs us that a certain Improvisatori was in the habit of having a 
paroxysm once a year, and that exactly on his birth-day ; yet he died at a good 
old age. 

There are, however, some curious modifications of the three principal types; 
or rather of two of them, the tertian and the quartan. For instance, a paroxysm 
may occur daily, and yet the ague not be of the quotidian type, but of the tertian. 
The paroxysm of one day will differ from the paroxysm of the next, but exactly 
resemble that of the third day ; while the paroxysm of the second day will be like 
that of the fourth ; and so on alternately. And these differences will be decidedly 
marked ; the paroxysms of two consecutive days will come on at different hours, 
and will differ in duration and severity. This form of ague is called the double 
tertian. One case of this kind, very distinctly characterized, was some time ago 
under my care in the hospital. 

There is another form of double.tertian. Two fits will occur on the same day 
— Monday, for example, one in the morning, the other in the evening; on Tues- 
day there shall be no fit; on Wednesday again two: on Thursday none; and so 
on. The Latin nomenclature is more precise than the English in denoting these 
variations. The form I have last mentioned, in which two dissimilar paroxysms 
occur every other day, is called tertiana duplicata, while the other form, in which 
there is a fit every day, but those on the alternate days resemble each other, is 
called tertiana duptex. 

In the same way you may have a double quartan. In that case, a paroxysm 
occurs on two days in succession, and leaves the third day free ; then it returns 



INTERMITTENT FEVER. 



449 



on the fourth day as it was on the first, and on the fifth as it was on the second, 
and leaves the sixth day free like the third, and so on. This is the quartana 
duplex. But two fits may happen in one day — say on Monday ; none on Tues- 
day or Wednesday ; and two again on Thursday. This is the quartana duplicata. 
Nay, the paroxysm of quartan ague may recur every day, and so far resemble a 
quotidian ; but the fit of the first day will differ from those of the second and third, 
and resemble that of the fourth: the fit of the second day will be dissimilar from 
that of the first or that of the third, and like that of the fifth ; and the fit of the 
third will be unlike that of either of the two preceding days, and find its counter- 
part in that of the sixth. This is a triple quartan ; and where three paroxysms 
occur on the first day, which we will again suppose to be Monday, and none on 
Tuesday or Wednesday, but three again on Thursday, corresponding respectively 
to the first three, we have the quartana triplicata. And there are other complica- 
tions still, with which I need not trouble you. In Dr. Cleghorn's book on the 
diseases of Minorca, you may find a very good and authentic account, evidently 
drawn from nature, of the irregular types and varieties of ague. They are well 
worthy of the attention of any among you who may be likely to practice abroad. 

Some physicians have used the words double tertian, and so on, in the literal 
sense, and have supposed that two or more distinct agues coexisted. This savours 
a good deal of the error that I formerly warned you against, of looking upon dis- 
eases as separate entities, and not merely as modes of being and of acting differ- 
ent from those which are proper to the state of health. The vulgar always re- 
gard disorders in this light. A coachman by whose side I sat while traveling 
from Broadstairs to Margate, was speaking of the rarity of ague in that part of 
the Isle of Thanet. His father, he said, once had the complaint, and when he 
was on a visit to him, the coachman, at Ramsgate, a fit came on. The son ad- 
ministered to his suffering parent a glass of brandy : whereupon " he threw the 
agy off his stomach ; and it looked for all the world like a lump of jelly." That 
was the only occasion on which he had ever " seen the agy." 

Besides these varieties in type, some other deviations from the normal and regu- 
lar paroxysms require to be noticed. 

Sometimes the paroxysm is incomplete : it is shorn of one or more of its stages : 
the heat and sweating occur without any previous rigors; or the patient shakes, 
but has no subsequent heat; or the sweating stage is the only one of the three 
that manifests itself. These fragments of a fit are often noticeable when the com- 
plaint is about to take its departure; but they may also occur at other periods of 
the disease. Sometimes there is no distinct stage at all : but the patient experi- 
ences frequent and irregular chills, is languid and uneasy, and depressed. This 
state is commonly known among the inhabitants of our fenny and aguish districts 
as the dumb ague, or the dead ague ; the patient is said not to shake out. 

Again, there is often observed a tendency to a change of type in the course of 
the same disease affecting the same person. The quotidian will be transformed 
into a tertian ; a tertian into a quartan ; or, on the other hand, a quartan into either 
of these. I have already noticed the fact that the paroxysms will also alter their 
time of invasion, sometimes coming later and later in the day, at each recurrence, 
sometimes earlier and earlier. When the paroxysm thus postpones, the disease 
is growing milder: when it anticipates its usual period of attack, the disease is 
increasing in severity. The postponement or anticipation, therefore, of the fit, 
has a close relation to the prognosis. 

There are yet other cases, in which from first to last no determinate type or 
order of succession is observed by the paroxysms ; and these cases authors speak 
of as erratic forms of ague. 

There are also many modifications or complications observable in the symp- 
toms which constitute the fits. Occasionally each paroxysm is attended by vio- 
lent delirium : this is most common, I believe, in the hot stage. This symptom 
has been known to be almost constant throughout an epidemic. Sometimes the 
29 



450 



INTERMITTENT FEVER. 



patient is convulsed in the paroxysm ; or syncope comes on ; or tetanic rigidity ; 
or petechiae take place on the skin, and disappear with the paroxysm. These 
deviations from the common and regular kind and ord6r of the symptoms may 
sometimes depend upon the constitutional predispositions of the person affected; 
but there is another way also in which they may be explained. I shall presently 
havea good deal to say upon the one grand — I may say sole — exciting cause of 
intermitients. Now exposure to that cause, a residence in aguish districts, will 
sometimes impart a periodic character to other diseases : and I apprehend that this 
explanation will apply to many of the instances which have been observed of 
hysterical, tetanic, or other paroxysmal complaints, occurring at perfectly regulaT 
intervals. 

The duration of ague — of the whole disease, and not merely of a separate pa- 
roxysm — it is not easy to estimate. If persons who laboured under it were always 
removed at once from the influence of the exciting cause, and were always suffered 
to remain without treatment calculated to check the malady, we might then find 
materials for determining its average natural duration. But we have not these data. 
In point of fact, ague sometimes consists of a very few paroxysms only, half a 
dozen, or four, or three, or even of one fit ; and on the other hand, they may be 
protracted over a space of several weeks, or months ; nay, of many years. 

An ague may attack a person at any time; but they are much more common 
in spring, and in autumn, than in the other seasons of the year : so that you will 
hear and read a good deal of vernal intermittents, and of autumnal intermittents. 
The autumnal agues are, cseteris paribus, the more severe and dangerous. The 
quotidian is most common in the spring ; the quartan in the autumn ; and the 
tertian is frequently met with both as a vernal and as an autumnal ague. You 
will bear in mind that in all this I am stating the prevailing rules ; which are 
liable to numerous exceptions. 

Ague is one of those disorders of which (as of common inflammation) all per- 
sons, at all periods of their existence, seem to be susceptible, when submitted to 
the influence of the specific exciting cause. Individuals of all ages, from sucking 
infants to persons of four score, are liable to it, but they are not equally subject 
to it. It is less likely (cseteris paribus) to affect the very young, and the aged, 
than those of middle life. However, the very old are by no means exempt from 
the operation of the cause of ague : and with respect to the very young, some 
extremely curious statements have been made. It is said that persons have had 
ague before they were born. We know that the period of intra-uterine life is ob- 
noxious to many forms of disease ; for we trace the consequences of such disease, 
in visible changes of structure, immediately after birth. Pulmonary tubercles 
constitute one malady to which the foetus in utero is liable : hydrocephalus is 
another: acute inflammation of the peritoneum a third. And there can be no 
doubt that various specific poisons influence, occasionally, the included being, 
even although they may have no sensible effect upon the parent. The fetus may 
thus contract small-pox, which sometimes proves fatal to it, sometimes not. The 
daughter of my bed-maker at Cambridge had a child ill of hooping-cough in the 
house with her while she was in the last months of pregnancy; and the infant in 
the womb must have caught the disease, for I was assured that he hooped the 
very day he came into the world. The sins of the parent are thus visited often 
upon the child, when, before its first breath is drawn, its frame is contaminated 
by the virus of syphilis. And in like manner unborn infants are capable of being 
affected by the poison that produces ague. One case in proof of this is recorded 
by Dr. Russell, in his History of Aleppo. The woman had tertian ague, which 
attacked her, of course, every other day: but on the alternate days, when she was 
well and free, she felt the child shake ; so that they both had tertian ague, only 
their paroxysms happened on alternate days. Bark was prescribed for her; and 
it cured the little one first, and afterwards it cured the mother. 

One probable reason why ague more commonly affects persons about the middle 



INTERMITTENT FEVER. 



451 



period of life, than those near its extremes, is, that the former are much more 
likely to be exposed to the primary exciting cause. And the same reason may 
be given, I presume, for another fact ; viz., that the complaint is much more fre- 
quently seen in men than in women. 

Among the circumstances which predispose to ague, debility has a powerful 
influence. It is important to be aware of this, as it concerns the prophylaxis, and 
the management of the patient after the disease has been subdued. Soldiers have 
been exposed to the exciting cause, without becoming affected by it, while strong 
and in good health ; and have fallen ill of intermittent fever upon being weakened 
by exertion and fatigue. When I have told you that debility, any how produced, 
constitutes a predisposition to intermittent fever, I need scarcely add that all the 
multiform causes of debility may also be regarded as predisposing causes of this 
same disease ; as they are of so many others. 

But the strongest predisposing cause of all is an actual occurrence of the disease 
itself. The effect of former intermittents upon the system is such that the com- 
plaint may be reproduced by agencies which under any other circumstances would 
be quite inoperative in exciting ague. I have stated already my persuasion that, 
strictly speaking, there is but one exciting cause of intermittent fever ; but in mak- 
ing that statement I refer to its first production. The disease leaves the body in 
a condition in which other injurious influences may, of themselves, be sufficient 
to renew it. It brings into play a new order of exciting, or rather of re-exciting 
causes. If a person were never exposed to the malaria, he would never, as I be- 
lieve, have ague: but having once had ague, he may many times have it again, 
although he should never again be subjected to the direct influence of the malaria. 
The late Dr. James Gregory, of Edinburgh, had a brother-in-law who illustrated 
well in his own person the effects of predisposing circumstances in respect to 
ague. This gentleman was a strong, active man, and commanded a battalion in 
the West Indies ; and he escaped for a long time* while others were falling down 
around him in remittent fever. At last he was wounded by a musket-ball which 
passed through his shoulder. He insisted, much against the will of the surgeon 
of the regiment, on resuming his duties before his strength was completely re- 
stored ; and the consequence was that he was immediately attacked by a remittent 
fever of such violence*, that his life was for some time despaired of. But this was 
not all. The remittent disease assumed by degrees a distinctly intermittent form, 
and became a tertian : and at last he got well, and strong, and came over to this 
country. But for a long while, though to all appearance his health was re-estab- 
lished, ague fits would from time to time occur; and they came precisely at the 
day and hour on which they would have happened if the tertian had continued 
with its original type ; and slight causes were sufficient to reproduce them. He 
had marked in an almanack, the days of the expected accession ; and on those 
days it recurred, for some time, whenever the east wind blew. This very cir- 
cumstance, the east wind, is a common re-exciting cause in such cases ; exposure 
to cold in any way is another. 

The exciting cause of intermittent and remittent fevers — the primary exciting 
cause I mean, that without which ague would never occur at all — deserves a 
somewhat particular consideration. I need scarcely say that it consists in certain 
invisible effluvia or emanations from the surface of the earth, which were formerly 
called marsh miasmata, but to which it has, of late years, become fashionable to 
apply the foreign term malaria. In some respects the latter designation is the 
more convenient of the two. 

The malaria is a specific poison, producing specific effects upon the human 
body. In its medical sense, it is not simply bad air, or impure air, although the 
word is loosely employed by many to express any mixed kind of contamination 
of the atmosphere. Thus we hear of the malaria of London : but ague, even 
when it occurs in London, is very seldom indeed, now-a-days, of London growth. 
The impure air incident to large and populous cities is prejudicial enough to 



452 



INTERMITTENT FEVER. 



health, as I formerly took occasion to show you : but it does not generate fever: 
neither continued fever, nor intermittent.* 

The emanations which cause ague have been called marsh miasmata, because 
they are notoriously common in marshy places. But they are not peculiar to 
marshy places. For this reason, and for brevity's sake, I prefer using the single 
word malaria. In this country, thank God, we witness its milder evils only, and 
those not very often ; but it is the bane and scourge of large portions of the 
world. Whether you practice here or abroad, it is very fit that you should know 
the qualities, habitats, and habits, of this wide-spread poison. The mildest form 
of fever to which it gives birth is the intermittent fever, or ague ; but in climates 
and places where it exists in greater abundance and intensity, the fever becomes 
remittent, or even assumes the continued form. This has led to strange errors, 
and proved a fertile source of difference and controversy amongst medical men : 
not a few of whom confound the severe continued fevers which spring from the 
malaria, and which are never contagious, with the severe continued fevers usually 
called typhous, which are unquestionably communicable from person to person. 

The effluvia which thus form the sole exciting cause of intermittent and remit- 
tent fevers proceed from the surface of the earth, and are, probably, gaseous, or 
aeriform : at any rate they are involved in the atmosphere. But they are imper- 
ceptible by any of our senses. Of their physical or chemical qualities we really 
know nothing. We are made aware of their existence only by their noxious 
effects ; and the inference that they exist was not made till within the last century 
and a half, Time out of mind, indeed, it had been matter of common observation 
that the inhabitants of wet and marshy situations were especially subject to these 
definite and unequivocal forms of disease. But the Italian physician, Lancisi, 
was the first, so far as I know, to put forth distinct ideas concerning malaria, in 
his book, published about 1695, Be noxiis paludum effluviis. This is the great 
original work upon the subject, " 

To the production of this deleterious agent, a certain degree of temperature 
seems necessary. It does not appear to exist within the arctic circle : nor does it 
manifest itself during the colder seasons of more temperate climates. It is very 
seldom traceable beyond the 56th degree of north latitude; and it is supposed to 
req-uire for its development a continuous temperature higher, than 60° of Fahren- 
heit's thermometer. The nearer we approach the equator, the more abundant, 
virulent, and pernicious does the poison become, wherever it is evolved at all. — 
In this climate it gives rise to intermittents, and principally to tertians. As we 
go south, in Spain, and along the shores of the Mediterranean, the remittent be- 
comes the predominant form ; and (what is very instructive) remittents there, con- 
tracted often improve into intermittents upon the removal of the patient to a colder 
climate. Under the tropical heats, in the West Indies, for example, the fevers 
very frequently assume the continued form. 

And another condition of the development of the poison soon becomes apparent. 
It requires a certain degree of moisture. Of all these regions, malaria, snowing 
itself always by its effects alone, infests certain parts only ; which parts are, most 
generally, remarkable for their humid and swampy character. Thus, in this 
island, intermittents are produced chiefly, I may say almost exclusively, along the 
eastern coast; in parts of Kent, Essex, Cambridgeshire, Norfolk, Lincolnshire, 
and the East Riding of Yorkshire : and in each of these counties there are marshes, 
or fens, or low grounds and lands that are occasionally overflowed. Many of 

* [The author certainly cannot mean to assert, as his language would seem to imply, 
that no form of fever is generated by "the impure air incident to large and populous cities," 
but that all fevers are produced by " a specific poison," resulting from other causes than 
those by which the atmosphere is rendered impure in the crowded, unventilated, and filthy 
lanes, courts, and alleys, which abound in suburbs of most large cities. That typhus and 
typhoid, bilious, and yellow fevers are generated in large and populous cities, no one, we 
presume, will pretend to deny, but of their dependence upon a specific aerial poison we 
have not as yet been furnished with any satisfactory evidence. — C] 



INTERMITTENT FEVER. 



453 



these spots have, within the last fifty years, been drained, and brought under 
cultivation ; and agues are consequently much more rare in England than they 
formerly were. In Sydenham's time they were very frequent, and very fatal in- 
deed, in this metropolis. James I. and Oliver Cromwell both died of ague con- 
tracted in London. At present (as I said before) we seldom meet with them. — 
Except in the year 1827, 1 have never, since I have been in practice, known ague 
to be at all common here. This comparative freedom from malaria is mainly 
owing, no doubt, to the improved character of the draining and sewerage. 

Agues, or aguish fevers, are endemic along every part of the low and level 
coast of Holland. In Italy, the Pontine marshes, near Rome, have possessed for 
ages an infamous celebrity of the same kind. The whole of the district called 
the Maremna, which stretches for about thirty leagues along the shores of the 
Mediterranean, and which in some places is ten or twelve leagues broad, is ren- 
dered dangerous, and almost uninhabitable, by the vast quantity of malaria annu- 
ally evolved from its soil. In America large districts are, for the same reason, 
prolific of disease. The late Bishop Heber, in his Narrative of a Journey 
through the Upper Provinces of India, gives the following striking picture of the 
influence of the malaria in that part of the world. It seems to be alike pestiferous 
to man and beast. 

"I asked Mr. Boulderson if it were true that the monkeys forsook these woods 
during the unwholesome months. He answered that not the monkeys only, but 
every thing which has the breath of life, instinctively deserts them from the 
beginning of April to October. The tigers go up to the hills ; the antelopes and 
wild hogs make incursions into the cultivated plain ; and those persons, such as 
dak-bearers, or military officers, who are obliged to traverse the forest in the 
intervening months, agree that not so much as a bird can be heard or seen in the 
frightful solitude. Yet during the time of the heaviest rains, while the water falls 
in torrents, and the cloudy sky tends to prevent evaporation from the ground, the 
forest may be passed with tolerable safety. It is in the extreme heat, and imme- 
diately after the rains have ceased, in May, the latter end of August, and the early 
part of September, that it is most deadly. In October the animals return. By the 
latter end of that month the wood-cutters and the cow-men again venture, though 
cautiously. From the middle of November to March troops pass and repass, and 
with common precaution no risk is usually apprehended." 

Persons who live in England might perhaps be disposed to think lightly of the 
malaria, had not such fearful evidence of its appalling power been brought home 
to the experience of our countrymen, in the early part of the present century, by 
the result of the unfortunate expedition to Walcheren. Sir Gilbert Blane has 
given an account of the ravages it there committed among our troops. You may 
see his paper, to which I shall presently again refer, in the third volume of the 
Medico- Chirurgical Transactions. 

Not only a certain degree of heat, and a certain quantity of moisture, but the 
presence of all the four elements of the ancients, would appear to be requisite for the 
production of this poison. Air of course there must be; and earth also is essential. 
If heat and moisture were alone adequate, we should find the fever prevailing 
among sailors when out at sea: but it is not so, whatever may be the temperature 
under which they cruise. It is when they approach the coast, or land upon it, 
that they are attacked. The water of marshes has been examined under the 
microscope, and analyzed again and again, with a view to the discovery of the 
nature of this pestilential agent; but in vain. A more likely way to detect the 
noxious material would seem to be by examining the air of malarious districts ; 
and this has been done carefully and repeatedly by expert chemists ; and with the 
same want of success. The poisonous principle eludes the test of the most 
delicate chemical agents. 

Where there are much heat, and much moisture, there we usually find also much 
and rank vegetation, and much vegetable dissolution and decay. The belief was 
as natural, therefore, as it has been general, that the putrefaction of vegetable 



454 



INTERMITTENT FEVER. 



matters was somehow or other requisite to the formation of the poison that exists 
so commonly in swampy situations. This belief has descended, almost unques- 
tioned, from the time of Lancisi ; and it obtains almost universal acceptance, I 
fancy, among physicians of the present day. Yet very strong facts have been 
adduced to show that the decomposition of vegetable substances is only an acci- 
dental, though a frequent, accompaniment of the miasm ; and not by any means 
an essential condition of its evolution. 

In the first place, the decomposition of vegetable matter goes on abundantly 
without the production of malaria. The rotting cabbage-leaves of Covent Garden, 
and those which taint the air of the streets from the neglected dust-holes of Lon- 
don, during the hot weather of summer give rise to no ague. The same may be 
said of the putrefying and offensive sea-weed, which is deposited in large quanti- 
ties upon some very healthy parts of our sea-coast. But the converse facts are 
the most remarkable and conclusive. I have stated that marshes are not neces- 
sary to produce malaria; but Dr. William Ferguson — a physician who has had, 
and who has well used, very sufficient opportunities of investigating the question 
— shows that vegetation is not necessary : that the peculiar poison may abound 
where there is no decaying vegetable matter, and no vegetable matter to decay. 
As the prevailing belief is, in my opinion, an erroneous one, and as it is really of 
great importance that correct views of this subject should be taken and dissemi- 
nated by medical men, I will mention a few of the most striking of the facts 
detailed by Dr. Ferguson. They are contained in a very interesting paper " On 
the Nature and History of the Marsh Poison" published in the Edinburgh 
Philosophical Transactions. 

In August, 1794, after a very hot and dry summer, our army in Holland en- 
camped at Rosendaal and Oosterhout. The soil, in both places, was a level plain 
of sand, with a perfectly dry surface, where no vegetation existed, or could exist, 
but stunted heath plants. It was universally percolated to within a few inches of 
the surface, with water which, so far from being putrid, was perfectly potable. 
Here fevers of the intermittent and remittent type appeared among the troops in 
great abundance. It is interesting to observe that the soil in Walcheren is pre- 
cisely similar. Sir Gilbert Blane describes it as consisting " of a fine white sand, 
known in the eastern counties of England by the name of silt, and about a third 
part of clay." It was after a hot and dry summer also that the British army suf- 
fered in that island from the endemic fever, to a degree which Dr. Ferguson speaks 
of as "being almost unprecedented in the annals of warfare." 

In the year 1809, several regiments of our army in Spain took up an encamp- 
ment in a hilly ravine which had lately been a water-course. Pools of water still 
remained here and there among the rocks, so pure that the soldiers were anxious 
to bivouack near them for the sake of using the water. Several of the men were 
seized with violent remitting fever before they could move from the bivouack the 
next morning. "Till then (says Dr. Ferguson) it had always been believed 
amongst us that vegetable putrefaction (the humid decay of vegetables) was essen- 
tial to the production of pestiferous miasmata; but in the instance of the half-dried 
ravine before us, from the stony bed of which (as soil never could lie for the tor- 
rents) the very existence even of vegetation was impossible ; it proved as pestife- 
rous as the bed of a fen." 

After the battle of Talavera, the army retreated along the course of the Guadiana 
river, into the plains of Estremadura. The country was so arid and dry for want 
of rain, that the Guadiana itself, and oil the smaller streams, had in fact ceased to 
be streams, and were no more than lines of detached pools in the courses that had 
formerly been rivers. The troops there V suffered from remittent fevers of such 
destructive malignity, that the enemy, and all Europe, believed that the British 
host was extirpated." 

Cividad Ivodrigo is situated on a rocky bank of the river Agueda, a remarkably 
clear stream ; but the approach to it on the side of Portugal is through a bare open 
hollow country, that has been likened to the dried-up bed of an extensive lake ; 



INTERMITTENT FEVER. 



455 



and upon more than one occasion, when this low land, after having been flooded 
in the rainy season, had become as dry as a brick-ground, with the vegetation 
utterly burned up, there arose to- our troops, fevers which, for malignity of type, 
could only be matched by those before mentioned on the Guadiana. 

Many more facts to the same purpose are related in Dr. Ferguson's paper, 
which is in every way well worth your perusal. He tells us " that in the most 
unhealthy parts of Spain, we may in vain, towards the close of the summer, look 
for lakes, marshes, ditches, pools, or even vegetation. Spain, generally speaking, 
is then, though as prolific of endemic fever as Walcheren, beyond all doubt one 
of the driest countries of Europe; and it is not till it has again been made one of 
the wettest, by the periodical rains, with its vegetation and aquatic weeds restored, 
that it can be called healthy, or even habitable with any degree of safety." 

Our time will not allow of my extracting any further evidence on this point; 
one circumstance of contrast, however, I am unwilling to omit. 

The river Tagus is, at Lisbon, about two miles broad; and it separates a 
healthy from a very unhealthy region. On the one side is a bare hilly country; 
the foundation of the soil, and of the beds of the streams, being rock, with free 
open water-courses among the hills. This is the healthy side. But the Alentejo 
land, on the other side, though as dry superficially, being perfectly flat and sandy, 
is most pestiferous. Moreover, in and near Lisbon there are numerous gardens, 
where they keep water, during the three months' absolute drought of the summer 
season, in stone reservoirs. These reservoirs, containing water in the most con- 
centrated state of foulness and putridity, are placed close to the houses and sleep- 
ing rooms : the inhabitants literally live and breathe in their atmosphere. "Yet 
no one ever heard or dreamt of fever being generated amongst them from such a 
source ; though the most ignorant native is well aware that were he only to cross 
the river, and sleep on the sandy shores of the Alentejo, where a particle of water 
at that season had not been seen for months:, and where water, being absorbed 
into the sand as soon as it fell, was never known to be putrid, he would run the 
greatest risk of being seized with remittent fever." 

Now these facts, and facts like these, seem to prove that the malaria, and the 
product of vegetable decomposition, are two distinct things. They are often in 
company with each other, but they have no necessary connection. Whoever, in 
a malarious country, waits for the evidence of putrefaction, will wait, says Dr. 
Ferguson, too long. For producing malaria it appears to be requisite that there 
should be a surface capable of absorbing moisture, and that this surface should be 
flooded and soaked with water, and then dried : and the higher the temperature, 
and the quicker the drying process, the more plentiful and the more virulent 
(more virulent probably because more plentiful) is the poison that is evolved. 

The putrefaction of animal matter is sometimes spoken of as an element in the 
formation of the malarious poison. But the evidence I have just set before you 
refutes this supposition as completely as it excludes the alleged necessity of vege- 
table decay. I hope to prove to you, in a future part of the course, that neither 
animal nor vegetable decomposition is sufficient to generate fever of any kind. 

Dr. Ferguson's facts are generally in accordance with the observations which 
others have made upon the same subject : and his views will be found to account 
for some phenomena which the ordinary theory of vegetable putrefaction did not 
cleverly explain. 

There is good reason for believing that in all cases the poisonous emanations 
proceed from parts of the surface that have been flooded and then dried, rather 
than from parts that are still wet, or putrid. And this elucidates a circumstance 
very often noticed, viz., that neighbouring places — especially high and low lands 
lying near each other—change their character in respect to salubrity upon the 
occurrence of rains. The low grounds, which had previously been very danger- 
ous, become healthy when they are flooded over; and the higher lands, which 
are made wet, and which rapidly dry again, produce the malaria abundantly. For 
the same reason, the edges or borders of swamps, which of course expand or con- 



456 



INTERMITTENT FEVER. 



tract according to the wetness or dryness of the season, are more unsafe than their 
centres. The drying and half-dried margins of the purest streams may be prolific 
of the evil, when, from the want of confining -banks, those margins have been 
flooded by the rising of the waters. 

There is no observation more general than that, in malarious places, agues and 
remittent fevers abound more in hot and dry years than in those which are cold 
and moist. And this influence of temperature it is which mainly determines the 
differences observable in regard to these fevers at different elevations, and in dif- 
ferent seasons of the year. In the higher grounds of the West Indies agues occur, 
as in this country: as you descend, and the mean atmospheric temperature 
increases, remittents are met with : and in the lowest and hottest parts the fever 
becomes continued. The following instructive facts are stated by Dr. Ferguson. 
In 1816, the British garrison of English Harbour, in Antigua, was disposed in 
three separate barracks, on fortified hills surrounding the dock-yard. One of the 
barracks was on an eminence named Monk's Hill, six hundred feet above the 
level of the marshes. The other two were situate on an eminence called the ridge, 
one at the height of five hundred, and the other at the height of three hundred 
feet. So pestiferous were the marshes among which the dock-yard was placed, 
that it often happened to a well-seasoned soldier, coming down from Monk's Hill, 
and mounting the night-guard in perfect health, to be seized with furious delirium 
while standing sentry, and to expire within less than thirty hours after being 
carried up to his barracks, with a yellow skin, and having had black vomiting. 
Those in the barracks on Monk's Hill, who did not come down, the superior 
officers, the women, children, and drummers, had no fever of any kind. Seven- 
teen artillerymen, in the barrack at the height of three hundred feet, did not come 
down to the night-guards. (We shall see hereafter that malarious places are 
always most dangerous at night.) Every one of these men was attacked with 
remittent fever, of which one of them died. At the barrack on the top of the 
ridge, at the height of five hundred feet, there scarcely occurred any fever worthy 
of notice. Thus, in the same place, the malaria, in the level plain, caused con- 
tinued fever, resembling, and I believe identical with, yellow fever : at the eleva- 
tion of three hundred feet it gave rise to remittent fever: and at the height of five 
hundred or six hundred feet its influence was scarcely felt at all. In the neigh- 
bourhood of the Pontine marshes you see the villages perched curiously on the 
intervening hills; the Italians having been taught by experience that these elevated 
spots afforded comparative security against the effects of the miasmata. 

Wherever the malaria prevails, it produces its peculiar consequences chiefly in 
certain seasons: and it is in the autumn especially that agues and aguish fevers 
oecur ; that is to say, after the heats of summer : and the hotter and drier the pre- 
ceding summer, the more frequent and fatal are the autumnal fevers. The 
Pontine marshes lie to the southward of Rome ; and Horace, you know, says or 
sings, 

Frustra per autumnos nocentem 
Corporibus metuemus austrum. 

The effects of these morbific effluvia upon the human body vary much under 
different circumstances. Where they are most concentrated and deadly, their 
operation may be almost immediate. Witness their speedy influence upon the 
soldiers who descended at night from Monk's Hill. So also sailors, who have 
gone on shore for a single night only, have been attacked by the fever before they 
could return to the ship. On the other hand, when the emanations are less 
copious, or less virulent, there is sometimes a long and uncertain period of incu- 
bation. The disease remains latent, or the poison lies dormant, for a considerable 
space of time. Many of the soldiers who were exposed to the malaria at Wal- 
cheren did not experience its bad effects until after they had returned, and had 
even resided several months in England. In the same way, labourers, especially 
the itinerant Irish, will go down in the autumn for harvest work into Lincolnshire, 
and bring back the seeds of the disorder within them, and yet may not be attacked 



MALARIA. 



457 



with ague for weeks or months ; upon the occurrence of an east wind perhaps, or 
after unusual exposure to cold and wet. We trace in all this some analogy with 
the animal contagions ; but the period of incubation is more irregular and acci- 
dental ; and it is probable that in many instances the ague would not happen at 
all, but for the concurrent operation of some other malign influence. 

Another fact worthy of notice in respect to the agency of the malaria upon the 
human frame, is that it affects strangers much more readily and decidedly than 
the natives of the place. In other words, habit mitigates the injurious effects of 
the poison. Persons become seasoned to it. At Walcheren, though almost every 
adult among the lower classes had laboured, in the course of his life, under the 
endemic intermittent, yet they were infinitely less subject to it than strangers : and 
they will not believe that their beloved birth-place is unhealthy. Sir Gilbert Blane 
says that persons of education, and even medical men, denied indignantly that 
their country was less healthy than any other; and attributed the sickness which 
raged among our troops to some trivial circumstances of diet or habits, and not to 
any insalubrity of the air. This is a curious moral feature; but a very general 
one. In the pestilential plains of Estremadura the superstitious natives, unable 
or unwilling to account for a disease of a type so uncommon, among the soldiers, 
from any unwholesomeness of the air, declared that they had all been poisoned by 
eating mushrooms. 

It was found, also, at Walcheren, that the strangers who survived the first attacks 
became thereafter much less liable to the endemic fevers. The French general, 
Monnet, who had held the command at Flushing for seven years, had acquired a 
knowledge of this fact, and endeavoured to turn it to practical account. He re- 
commended that troops should not be frequently changed; for when it was the 
.custom to send battalions from Bergen op Zoom every fourth night in succession, 
to work on the lines of Flushing, these men never failed, upon their return, to be 
taken ill in great numbers. General Monnet therefore advised, however displeasing 
it might be to the officers, that a stationary garrison should be retained at Wal- 
cheren, in order that the men might be habituated or seasoned to the air, (accli- 
mates,) and he adduced the instance of a French regiment which suffered in the 
second year of its being stationed there only one-half the sickness and mortality 
which it suffered during the first year ; and hardly suffered at all in the third 
year. 

But although the natives and residents in malarious places are not so liable as 
new comers to the violent and distinct forms of fever, they are chronically affected 
by the insalubrity of the atmosphere. They are spoken of by travelers as being 
puny, sallow, and sickly ; feeble in body and spiritless in mind ; as having yellow 
faces, swelled bellies, and wasted limbs; as being subject to dropsies and fluxes; 
phlegmatic, melancholy, and short-lived. 

One remarkable exception is mentioned by Dr. Ferguson. From some pecu- 
liarity or idiosyncrasy (which he conjectures may be somehow connected with 
the texture of the skin) the negro appears to be proof against endemic fevers. 
" To him marsh miasmata are in fact no poison ; and hence his incalculable value 
as a soldier, for field service, in the West Indies. The warm, moist, low, and 
leeward situations where these pernicious exhalations are generated and concen- 
trated, prove to him congenial. He delights in them, for there he enjoys life 
and health, as much as his feelings are abhorrent to the currents of wind that 
sweep the mountain tops, where alone the whites find security against endemic 
fevers." 

No very certain or extensive observations have yet been made in respect to the 
kind of soil from which the miasmata are most apt to be extricated. Such as is 
loose, penetrable, porous, and sandy, appears highly favourable to their formation. 
So are soils which, containing much clay, are very retentive of moisture. One 
curious fact, however, bearing upon this question, seems to have been made out : 
viz., that what is termed peat-bog, or peat-moss, is not productive of malaria. 
Many parts of Scotland and of Ireland, that are occupied by large tracts of marsh 



458 



INTERMITTENT FEVER. 



in which the peat-moss abounds, are completely free from these fevers. Dr. 
Bisset affirms that the exhalations from black peat-moss do not occasion intermit- 
tents, " at least in high moors under a clear sharp air." Now in the climate of 
Virginia, this counteracting influence of a sharp air can scarcely be looked for : 
yet it is a remarkable fact, that though the provinces of North America, especially 
North and South Carolina and Virginia, are full of ague, that disease is never seen 
among the inhabitants near the country of the Dismal Swamp, a moist tract of 
150,000 acres on the frontiers of Virginia and North Carolina. Weld, the 
traveller, informs us, that this immense tract is covered with trees and abounds 
with water, which appears the moment the shallowest trench is dug. The 
water is brown, like brandy, but quite clear, and not unpalatable. Its colour 
is ascribed by the inhabitants to the roots of juniper; and it is said to be diuretic. 
(Craigie.) 



LECTUkE XLI. 

Ague, continued. Speculations respecting its periodicity. Habits and proper- 
ties of the malaria; most noxious at night ; lies near the ground ; is carried 
along by winds; cannot pass across water; attaches itself to trees ; is dimi- 
nished by the increase of cultivation and of population. Ultimate effects of 
the poison on the body. Ague formerly thought salutary. Prognosis. Pro- 
priety of stopping the disease. 

You will remember the progress we made, at our last meeting, in the subject 
of intermittent fever. I described the ordinary phenomena of a paroxysm of ague ; 
and afterwards mentioned certain unusual symptoms with which it is sometimes 
complicated. The three principal types of ague were also delineated ; the quotidian, 
the tertian and the quartan : as well as their respective characters, and intervals 
and varieties, and changes of type. I spoke, too, of the predisposing causes of 
intermittent fever, which may all be briefly included under the head of circum- 
stances that tend to debilitate the body : the strongest predisposing cause of all 
being a former attack of the disease. And I- began to consider the great exciting 
cause of agues and aguish fevers — the malaria. I first directed your attention to 
the circumstances under which the malaria appears to be evolved. Since the time 
of Lancisi it had been very generally supposed that the humid putrefaction of 
vegetable substances was necessary to the production of this peculiar and wide- 
spread poison ; and that heat accelerated the putrefactive process. That was Dr. 
Bancroft's opinion. That also is (I believe) the opinion held, and stated in lec- 
tures, by many pathologists at the present time. I showed you, from facts which 
rest upon Dr. Ferguson's authority, that this notion is founded in mistake : that 
the products of vegetable decay and decomposition may and do often coexist with 
malaria, but are distinct and separable from it, and by no means essential to its 
formation. There is reason to believe that the flooding of a porous earthy sur- 
face with water, and a subsequent drying of that surface under a certain degree of 
heat, constitute the sole or main conditions of the generation of the poison. We 
found that the effects of the malaria are modified by the temperature of the place : 
that in low and hot situations it may give rise to an affection not distinguishable 
in its symptoms from yellow fever; and that in proportion as the locality is 
higher and cooler, the fever tends to assume first the remittent, and then the inter- 
mittent type : that the period of incubation — the period which intervenes between 
exposure to the malaria and the invasion of the fever — is extremely variable in 
duration : that the poisonous effluvia affect strangers more certainly and more 
severely thati natives of the place : that persons may become in some sort sea- 
soned to the malarious districts : but that, with the exception of the negroes in 



INTERMITTENT FEVER. 



459 



the West Indies, the inhabitants of places much infested with the peculiar mias- 
mata, are feeble, and sickly, and short-lived. 

There was one point which I briefly adverted to, and dismissed perhaps too 
unceremoniously : I mean the very curious fact of the regular periodic recurrence 
of the paroxysms of intermittent fever. I ought, I think, to have informed you of 
the views which pathologists have entertained respecting the explanation of that 
singular circumstance ; although it must be confessed that the solution of the phe- 
nomenon is still to be sought for. A great number of persons have tried their 
hands, however, upon this question. Many of the earlier attempts at explanation 
are either quite hypothetical, or totally insufficient and illogical. Willis ascribed 
the intermission to a periodic development of the fermentable matter in the blood. 
But if any such development took place (of which we have no evidence) we should 
be no nearer the mark : the question would still recur, why the development of 
this matter should happen periodically : and the same remarks apply to various 
other so-called explanations brought forward by different writers of considerable 
reputation. Reil referred the intermittence of fevers to some general law of the 
universe; by which he meant, I believe, some vague generalization of such facts 
as the alternation of light and darkness, the periodic recurrence of the seasons, 
the ebbing and flowing of the tides, the succession of appetite and satiety, of "the 
states of sleeping and waking, and so on ; but this evidently is no explanation at 
all. M. Bailly offers a very singular conjecture upon the subject: he attributes 
the periodic phenomena to the modification necessarily induced in the human 
system, and particularly in the function of circulation, by the alternate change of 
position from the upright to the recumbent, and from the recumbent to the upright, 
every twenty-four hours ; and he adduces in corroboration of this notion the 
alleged fact that animals, which undergo no such oscillation of posture, are not 
subject to intermittent fevers ; but this is said not to be a fact. Rodet and Char- 
pentier affirm that horses are liable to such complaints. Dr. Macculloch refers 
to the case of a dog which laboured under a regular tertian ague for some years ; 
the cold paroxysms taking place always at three o'clock in the afternoon. Even 
if this were not so, M. Bailly's theory fails to account for the occurrence of con- 
tinued fevers. If his views were correct, then wq might avoid having ague by 
refraining from these changes of position from the vertical to the horizontal during 
sleep, and back again upon awaking. Recently M. Roche has put forth the 
opinion that the attacks of ague are periodic, because the causes of them are 
periodic. And if this could be made out, the conjecture would carry with it some 
show of reason. He observes that the spring and the autumn are the seasons in 
which intermittent fevers chiefly break out, especially the autumn : and that during 
those periods there is a very sensible difference in the temperature and humidity 
of the atmosphere by day and by night, and even within the space of three or 
four hours ; that a consequent alternation of action and reaction is thus produced 
in the human body, and soon becomes an established habit. Throughout a part 
of the twenty-four hours, the operation of the miasmata is slight, or not manifest 
at all ; while during another part of that period it is in full energy, and at about 
the same time daily. The emanations (which he conceives to proceed from putre- 
fying vegetable matter) are most abundantly disengaged during the hottest part of 
the day ; these watery effluvia are dissolved by the warm air to a certain amount ; 
but after sunset, they are again deposited, and deposited the more copiously in 
proportion to the coldness of the atmosphere at that time ; and coming in contact 
with the surface of the body, with the mucous membrane of the air passages, and 
perhaps also with that of the digestive organs, and being absorbed by those sur- 
faces, it occasions the phenomena which constitute an ague fit. The influence of 
the miasmata being intermittent, we need not wonder, he says, that their effects 
should be intermittent too : and then he goes on to ascribe the repetition of the 
paroxysms, after the cause has ceased to be applied, to that tendency observable 
in the animal system to reproduce certain actions, simply because they have been 
produced before : in one word, to the effect of habit. At length the habit wears 



460 



INTERMITTENT FEVER. 



out ; whieh accounts for the spontaneous recovery of those who are removed from 
the malarious district. 

It seems to be a very serious objection to M. Roche's theory, that the disease 
does not show itself, sometimes, for weeks or months after the patient has been 
exposed to the miasmata. His theory fails altogether also to account for the 
different types of intermittent fever. The differences of type are indeed opposed 
to the theory. 

After all it is most probable that Cullen had discovered a part though not the 
whole of the truth respecting the periodicity of intermittent fevers, when he 
ascribed it to some law of the animal economy whereby it is subjected, in many 
respects, to a diurnal revolution. " Whether this depends," he says, " upon the 
the original conformation of the body, or upon certain powers constantly applied 
to it, and inducing a habit, I cannot positively determine; but the returns of sleep 
and watching, of appetites and excretions, and the changes which regularly occur 
in the state of the pulse, show sufficiently that in the human body a diurnal revo- 
lution takes place." But he also is much perplexed with the differences of type; 
and all that he can say 'on that point amounts to this — that as the three principal 
types observe, severally, a particular time of day for their accession, and as quar- 
tans and tertians are apt to become quotidians, these to pass into the state of. 
remittents, and these last to become continued ; and that as even in the continued 
form daily exacerbations and remissions are generally to be observed — all this 
marks the power of diurnal revolution. 

A most interesting experiment, as it appears to me, performed by M. Brachet 
upon himself, shows in a strong light the influence of acquired habit in continuing 
certain unnatural states of the system when once they have been originated : the 
experiment connects itself also with the peculiar phenomena of intermittent fever. 
Towards the end of the month of October, in the year 1822, M. Brachet took a 
cold bath, at midnight, for seven nights in succession, in the river Saone. On 
the first occasion he remained a quarter of an hour in the river ; on the second 
half an hour ; till at length he was able to stay in the water a full hour at a time. 
After each bath he betook himself to a warm bed, and in a short time became 
affected with considerable heat, followed by copious perspiration, in the midst of 
which he fell asleep. At the end of the seven days M. Brachet ceased to repeat 
this experiment ; but what was his surprise at finding, on the following nights, 
between twelve and one o'clock, that all the phenomena of a true ague fit appeared 
in due order and succession ! As, however, this artificial paroxysm was not very 
severe, and as he felt quite well during the day, M. Brachet determined not to 
interfere with it ; but to observe the result. Six times it recurred with great regu- 
larity. On the seventh night after he had omitted the baths, he was summoned, 
towards midnight, to a woman in labour : the ride to her house heated him, and 
on his arrival he kept up the heat by placing himself before a large fire, and from 
that time the febrile phenomena ceased to recur. 

The facts and theories which I have thus brought roughly together, in respect 
to the periodicity of agues, are not without interest, but they show that we have 
yet much to learn on this subject. Granting that habit may have its share in 
continuing the regular recurrences, we want some explanation of the return of the 
second and third fit, after certain determinate intervals, to give a beginning to the 
habit. In respect to the quotidian, Dr. Cullen's diurnal revolution might come 
to the rescue; but this principle evidently will not apply to the tertian type. I 
know of no two-day, or bidual habit. And the objection holds still more strongly 
in regard to quartans. Indeed in quotidians themselves there is much difficulty 
in applying the explanation, for though by anticipating, or postponing, they may 
come on at different hours of the day, yet their usual and natural paroxysms occur, 
not in the evening, but in the morning, when, on the principle of diurnal habit, 
there should be the least tendency to exacerbation of febrile action.* 

* I would beg to refer the reader to Dr. Holland's interesting chapter (in his Medical 
Notes and Reflections, published since these lectures were delivered) " On Morbid Actions 
of Intermittent kind."— T. W. 



MALARIA. 



461 



In yesterday's lecture, I pointed out the favourite habitats, if I may so speak, 
of the malarious poison. I have still a few observations to make respecting its 
ascertained habits and properties. Some of the laws to which it is subject are of 
great practical importance, and ought to be popularly known ; much more ought 
every medical man to be familiar with them. 

In the first place, all malarious districts are (as I have already hinted) much 
more dangerous at night than in the day time. Whether the poison be then more 
copiously evolved, or whether it be merely condensed and concentrated by the 
diminished temperature, or whether the body be at that time more susceptible of 
its influence, it certainly is most active and pernicious during the hours of dark- 
ness. To sleep at night in the open air in such places is almost to ensure an 
attack of the fever. Lancisi was quite aware of this, and devotes a chapter to the 
question. " Cur juxta paludes noctu praesertim indormientes magis quam vigi- 
lantes laedantur ?" It has repeatedly been observed among the crews of ships, 
when off a malarious coast, that the sailors could go on shore in the day to cut 
wood, or for other purposes, with impunity; while the men who remained on 
shore through the night guarding the water casks, were many or all of them seized 
with the fever. Take one instance as a sample of many. It is recorded by Dr. 
Lind. In 1766 the Phoenix ship of war was returning from the coast of Guinea. 
The officers and ship's company were perfectly healthy till they touched at the 
island of St. Thomas. Here nearly all of- them went on shore. Sixteen of the 
number remained for several nights on the island. Every one of these contracted 
the disorder, and thirteen of the sixteen died. The rest of the crew, consisting 
of 280 men, went in parties of twenty or thirty on shore in the day, and rambled 
about the island, hunting, shooting, and so on: but they returned to the ships at 
night; and not one of those who so returned suffered the slightest indisposition. 
Exactly similar events occurred the following year, with the same ship, at the 
same place, where " she lost eight men out of ten, who had imprudently remained 
all the night on shore;'''' while the rest of the ship's company, ** who, after spend- 
ing the greatest part of the day on shore, always returned to their vessel before 
night, continued in perfect health." Many more examples of the same kind are 
stated or referred to by Dr. Bancroft in his book on the Yellow Fever : a book 
which is rich in information respecting the malaria. 

The reapers in the " Campo Morto" — a well-named part of the Maremna 
which I yesterday mentioned — are permitted to sleep for two hours about noon. 
They do so at that time without danger: but when the dews of evening have 
fallen down upon the earth, which serves them for their bed, it is then that the 
poison puts forth its most deadly power. Upon this principle Lancisi admonishes 
those who in summer travel through the Pontine marshes, not to do so by nighty 
as many had been accustomed to do, in order to avoid the greater heat of the day: 
and similar advice is still given at Rome to all strangers. Though the passage 
requires but six or eight hours, there are numerous instances of travelers who, in 
consequence of their having crossed these fens during the night, have been at- 
tacked with violent and mortal fevers. 

The practical lesson to be derived from a knowledge of this fact is too obvious 
to dwell upon. In malarious countries the open air at night must be avoided. — 
" Early to bed" is always a good and wholesome rule ; but the other half of the 
proverb " early to rise" becomes, in such countries, an unsafe precept. At least 
it is hazardous to leave the house early. 

Secondly, the malaria loves the ground. It tends downwards. Whether this 
results from its specific gravity ; or from its adhering to the moisture suspended 
in the lower strata of the atmosphere ; or from some peculiar attraction for the 
earth's surface; I cannot tell you. There is reason to suppose that the poison 
combines somehow, or becomes entangled, with fog: and fogs usually brood and 
settle, at night especially, upon the surface. This may be one reason why lying 
down to sleep in the open air at night is so very perilous. The lower rooms of 
the same house may contain the noxious effluvia, while the upper are free. " In 



462 



INTERMITTENT FEVER. 



all malarious seasons and countries," says Dr. Ferguson, " the inhabitants of 
ground floors are uniformly affected in a greater proportion than those of the 
upper stories. According to official returns during the last sickly season at Bar- 
foadoes, the proportion ofcthose taken ill with fever in the lower apartments of the 
barracks exceeded that of the upper by one-third, throughout the whole course of 
the epidemic. At the same time it was observed that the deep ditches of the forts, 
even though they contained no water — and still more the deep ravines of rivers 
and water-courses — abounded with the malarious poison." Dr. Hunter, in his 
work on the diseases of the army in Jamaica, says, " The barracks of Spanish 
Town consist of two floors, the first upon the ground, the second on the first. 
The difference in the health of the men on the two floors was so striking as to 
engage the attention of the Assembly of the island : and upon investigation it ap- 
peared that three were taken ill on the ground floor, for one on the other. The 
ground floor was not therefore used as a barrack afterwards." Mr. Ralph, in a 
table printed as an appendix to a paper of Dr. Ferguson's in the eighth volume of 
the Medico- Chirurgical Transactions, states the results of an inquiry into the 
comparative healthfulness of the upper and lower apartments of barracks in Bar- 
badoes, to have been that the individuals residing in the lower apartments were 
attacked in the proportion of two to one of those living in the upper : and with 
certain apparent exceptions, which I shall notice presently, experience is uni- 
formly in favour of the proposition that the poison is most prevalent and destructive 
near the surface of the earth, and does not rise high into the atmosphere. 

To specify the sanatary precautions dictated by an acquaintance with this pro- 
perty of the malaria, must be quite superfluous. 

Thirdly, the malaria is movable by the wind. It is capable, therefore, of 
being carried from the spot where it was generated, and to other places which 
might else be free from it and healthy. In this respect it is analogous to a heavy 
fog or vapour : and, in some cases, it is accompanied by a palpable mist ; to which, 
perhaps, it may cling. The following passage relative to this subject occurs in 
Bishop's Heber's Journal. " From Cheeta Talao our road lay through a deep 
and close forest, in the lowerparts of which, even in the present season, the same 
thick milky vapour was hovering as that which I saw in the Terrai, and which is 
called essence of owl." This Terrai is the region which I mentioned in the last 
lecture as being so pestiferous, that it is deserted, during certain parts of the year, 
by every living creature. 

This conveyance of the poison, like a cloud or fog, from one part of the sur- 
face of the ground to another, it is very important to attend to in all places ; and 
especially so in tropical climates, where the wind blows for a long time together 
from the same quarter. We are thus enabled to account for the apparent excep- 
tions to the last-mentioned property of the malaria, viz., its preference of low to 
elevated situations. You will readily understand how the miasmata may roll up, 
and hang accumulated upon, the side of a hill towards which a current of air sets 
steadily from or across a neighbouring marsh. Nay, the poison may be thus 
blown over a hill, and deposited on the other side of it. In this way, I presume, 
are to be explained the following curious facts, related in Dr. Ferguson's paper. 

The beautiful port of Prince Rupert's, in the island of Dominica, is a penin- 
sula which comprehends two hills of a remarkable form, joined to the main land 
by a flat and very marshy square isthmus to ivindward, of about three-quarters of 
a mile in extent. The two hills jut right out on the same line into the sea, by 
which they are on three sides encompassed. The inner hill of a slender pyra- 
midal form, rises from a narrow base nearly perpendicular, above and across the 
marsh from sea to sea, so as completely to shut it out from the port. The outer 
hill is a round-backed bluff promontory, which breaks off abruptly, in the manner 
of a precipice above the sea. Between the hills runs a very narrow clean valley, 
where all the establishments of the garrison were originally placed ; the whole 
space within the peninsula being the driest, the cleanest, and the healthiest sur- 
face conceivable. It was speedily found that the barracks in the valley were very 



MALARIA. 



463 



unhealthy ; and to remedy this fault, advantage was taken of a recess or platform near 
the top of the inner hill, to construct a barrack which was completely concealed by 
the crest of the hill from the view of the marsh on the outside, and at least three hun- 
dred feet above it: but it proved to be pestiferous beyond belief. In fact no white 
man could possibly live there, and it was obliged to be abandoned. At the time 
this was going on, it was discovered that a quarter which had been built on the 
outer hill, on nearly the same line of elevation, and exactly five hundred yards 
further removed from the swamp, was perfectly healthy ; not a single case of fever 
having occurred in it from the time it was built." 

There is a striking anecdote given by Lancisi, showing, on a small scale, the 
effect of the wind in carrying the malaria with it. Thirty ladies and gentlemen 
had sailed to the mouth of the Tiber on an excursion of pleasure. Suddenly the 
breeze shifted to the south, and began to blow over a marshy tract of land situated 
to windward of them. Twenty-nine of the thirty were immediately after at- 
tacked with tertian ague. So also Humboldt informs us that the town of Cariaco 
is afflicted with intermittents by the north-west wind conveying across it the mi- 
asmatic emanations of the Laguna of Campona. 

And as the wind may thus transport the malaria to a distance, and thereby ren- 
der a spot unhealthy which naturally would not be so : so also it is often of ser- 
vice in clearing the poison from other places, and preventing its concentration. 

A knowledge of these facts ought to be valuable in determining the choice of 
encampments, and of sites for dwelling-houses in aguish districts. Settlers in hot 
climates, especially where trade-winds prevail, would do well to avoid founding 
towns on the lee side of any swampy or suspicious ground. The outlets of 
rivers are commonly selected, for the convenience of commerce: and there is 
often a right and a wrong bank. I believe that most of the principal towns in 
the West Indies are built, for the advantage of the outward bound vessels, upon 
the western, or lee side of the islands. 

Fourthly, it is a singular, but well-ascertained fact, that the miasmata lose their 
noxious properties by passing over even a small surface of water. Probably 
they are absorbed by it. And this is another proof of their tendency down- 
wards. Many instances have already been referred to, where some of the crew 
of a ship have landed on a malarious coast, and have all been attacked by the 
fever ; while the rest of the sailors, who remained on board, continued all healthy 
and well, though the ship was close to the shore. You could not have a better 
or more striking example of this than what took place at Walcheren. " Not only 
the crews of the ships in the road of Flushing were entirely free from the ende- 
mic ; but also the guard-ships which were stationed in the narrow channel be- 
tween this island (Walcheren) and Bevelaud. The width of this channel is about 
six thousand feet, yet, though some of the ships lay much nearer to one shore 
than to the other, there was no instance of any of the men or officers being taken 
ill with the same disorder as that with which the troops on shore were affected." 
This Sir Gilbert Blane has told us ; and it is curious that Sir John Pringle made 
the very same remark in the very same place in 1747. He is speaking of the 
diseases of the campaign in Dutch Brabrnt ; especially in reference to four bat- 
talions which had remained for some time in Zealand: and he says, "But Com- 
modore Mitchell's squadron, which lay all this time at anchor in the channel 
between South Beveland and the island of Walcheren, in both which places the 
distemper raged, was neither afflicted with the fever nor the flux, but amidst all 
that sickness enjoyed perfect health ; a proof that the moist and putrid air of the 
marshes was dissipated, or corrected, before it could reach them." 

It is probable that this peculiarity has led to an erroneous and contracted esti- 
mate of the space through which the poisonous effluvia can be carried upon land, 
by the wind. Although the distance to which they are capable of being so con- 
veyed, without losing their morbific power, has never been precisely defined, 
there can be no doubt that it is considerable. In Italy, according to Dr. Maccul- 



464 



INTERMITTENT FEVER. 



loch, the poisonous exhalations of the lake Agnano have been ascertained to reach 
as far as the convent of Camaldoli, situated on a high hill three miles distant. 

Fifthly, another remarkable property of the marsh poison, is its attraction 
towards, and its adherence to, the foliage of lofty umbrageous trees: so that it is 
very dangerous, in malarious places, to go under large thick trees, and still more 
dangerous to sleep under them. But this property, thus a source of peril to those 
who are ignorant of it, affords when known and rightly made use of, a mode of 
protection and remedy against the influence of the miasmata. In the territory of 
Guiana, where large trees abound, the settlers live fearlessly, and unhurt, close 
to the most pestiferous marshes, and to leeward of them, provided that a screen 
or belt of trees be interposed. New Amsterdam, in Berbice, lies on the lee side 
of an immense swampy forest, in the direct tract of a strong trade-wind that blows 
night and day, and pollutes even the sleeping apartments of the town with the 
stench of the marshes ; yet it brings no fevers. The inhabitants are well aware 
that it would be almost certain death for an European to sleep, or even to remain 
after nightfall, within the verge of the forest. To cut down the trees would not 
only be a perilous operation in itself ; but would let in pestilence to the town. 

This property also of the malaria, as well as the use to which it may be turned, 
was known to Lancisi. He describes the vast increase of agues and remiitent 
fevers in Rome during the summer of 1695, after a great overflowing of the Tiber, 
by which the lower part of the city, and the fields adjacent, had been inundated 
in the preceding winter. The bad effects of this flood were felt throughout the 
wl^ole of Rome, with the exception of one particular quarter, which was protected 
by a belt of trees around it. Lancisi even addressed a remonstrance to the Pope 
against a project which was entertained of felling some wood near the Pontine 
marshes, between them and the city. He endeavours to show that woods and 
groves were first made sacred on account of their conservative influence in this 
way, to prevent their ever being cut down. 

It would appear, from the facts I have just been detailing, that dwellings unfor- 
tunately built in the vicinity of marshes, might sometimes be rendered safe and 
salubrious by encircling them at a little distance by a hedge of trees — or (perhaps) 
even by drawing round them a broad moat of water. Such experiments deserve, 
at least, a fair trial. 

Sixthly, the production and consequently the effects, of the malaria are pre- 
vented, or lessened, by cultivation. It is to this, that the diminution of agues in 
this country is mainly attributable. The fenny lands have been drained ; and 
many of them brought under the plough. Dr. Craigie states that East Lothian, in 
Scotland, was at one time so productive of malaria, that it was quite an expected 
thing that the reapers in harvest should be attacked with ague; but that now, in 
consequence of the perfect tillage, and the numerous tracts of wood with which 
the country is covered, that disorder is quite unknown there. Conversely, in 
regions which have been suffered to fall out of cultivation, intermittent and remit- 
tent fevers multiply. The more thoroughly any country is cultivated, the more 
fully, in general, is it peopled also : and in many places the prevalence of these 
fevers has been observed to diminish and increase with the increase and diminu- 
tion of the population. C set eris paribus, agues are much less common in large 
towns than in country villages. This has been oddly enough accounted for by 
saying that populous cities are so full that there is no room for the malaria. A. 
much more rational and probable explanation is that which ascribes the freedom 
of crowded towns, and thickly inhabited districts, to the number of fires burned 
in them. 

Many instances might be adduced to show that the more any place, naturally 
productive of malaria, is depopulated, the more evident does the power of the 
poison become. The Italians date the introduction of the malaria into the Ma- 
remna, from the great plague in the sixteenth century, since which period the 
inhabitants of that district have never been sufficiently numerous to counteract the 
bad air which increases as population and agriculture diminish. 



MALARIA. 



465 



Bishop Heber, in the narrative I quoted before, bears testimony to facts of the 
same kind with those I have now been stating. He says, "At the foot of the 
lowest hills, a long black level line extends, so black and level, that it might seem 
to have been drawn with ink and a ruler. This is the forest, from which we are 
still removed several coss, though the country already begins to partake of its in- 
salubrity. It is remarkable that this insalubrity is said to have greatly increased 
in the last fifteen years. Before that time, Ruderpoor, where now the soldiers 
and servants of the Police Thanna die off so fast that they can scarcely keep up 
the establishment, was a large and wealthy place, inhabited all the year through, 
without danger or disease. The unfavourable change is imputed by the natives 
themselves to depopulation. The depopulation of these countries arose from the 
invasion of Meer Khan, in 1805. He then laid waste all these Pergunnahs, and 
the population, once so checked, has never recovered itself." 

When persons having intermittent fever are unable to leave the unhealthy 
situation in which they have been exposed to the influence of the malaria — and 
especially when they are placed under unfavourable circumstances in respect to 
food, and clothing, and shelter — the disease is apt to become exceedingly serious, 
leading to disorder of the sensorium, and great disturbance of the abdominal vis- 
cera, even in the intermissions; sickness, diarrhoea, dysentery, diseases of the 
liver.* In Zealand, the biliary functions suffer so much during the complaint, that 
it is commonly known among the inhabitants of that country under the name of 
the gall fever. The frequent unnatural concentration of the blood in the internal 
parts may afford a reasonable explanation of these phenomena. When death 
takes place, morbid appearances present themselves such as might be expected : 
hepatic alterations ; inflammation and ulceration of the mucous membrane of the 
alimentary canal : but the most characteristic morbid condition produced by repeated 
attacks of intermittent fever consists in enlargement of the spleen; with or with- 
out induration of its substance. That viscus is sometimes enormously increased 
in bulk, so as to he felt, and even its outline seen through the integuments of the 
abdomen. It has been known to weigh nearly eleven pounds. So common is this 
state of the spleen, that it is familiar to the observation of the vulgar, who have 
even given it a name: it is called among the inhabitants of the fenny parts of this 
country, the ague cake. I believe that whenever the abdominal circulation is 
much embarrassed, and the abdominal veins gorged, as they must be during the 
cold stage of an intermittent, the spleen in particular becomes distended with blood. 
Constantly we see this happen when the passage of the blood through the portal 
vessels is impeded by disease of the liver. Now this distension may not tho- 
roughly subside perhaps at once. If the paroxysms of ague be frequently repeated, 
we may understand how the spleen may become fuller of blood on each succes- 
sive occasion. It may be that a portion of the blood coagulates ; or that inflam- 
mation of a slow kind is set up in the stretched covering of that organ. At all 
events, this is a very common sequel of ague: and it can scarcely be doubted that 
the repeated congestions of the internal vessels and viscera are the determining 
causes of the ague cake. 

Independently of the paroxysm of ague, there is ample evidence to show the 
injurious influence of the malarious districts upon the general health. In this 

* [Dr. S. A Cartwright, of Natchez, asserts, that the jussieuagrandijlora, or floating plant 
of the bayous and lakes of lower Louisiana, has the power of preventing the development 
of malaria in regions particularly adapted to its generation. He affirms, also, that "it puri- 
fies all stagnant water in which it grows— that of the lakes and bayous inhabited by it, 
being as pure to the sight, taste, and smell, as if it had just fallen from the clouds." He 
ascribes to the presence of and the peculiar "hygienic or health preserving properties of 
this plant," the remarkable exemption of the inhabitants of lower Louisiana from " mala- 
rious or miasmatic diseases." "The fact," he remarks, " that the region of country in 
which this aquatic plant abounds, is exceedingly healthy, can be established beyond cavil or 
dispute; it nevertheless contains more stagnant water and swamps than any other inhabited 
district, of the same extent, in the United States." — C] 
30 



466 



INTERMITTENT FEVER. 



country such effects are not much seen ; but in places where the malaria is more 
constantly and abundantly present, the race of inhabitants deteriorates. Their 
stature is small; their complexion sallow and yellowish; they are prematurely 
old and wrinkled; even the children early acquire an aged aspect; and the spirits 
and intellects of those who dwell in these unhealthy spots are low and feeble, and 
partake of the degeneration of their bodily qualities. 

It is therefore strange that a notion should ever have prevailed, of the salutife- 
rous effects of an attack of ague. But such a notion may be traced from very 
nearly our own times up to the earliest records of physic. "The late Dr. James 
Sims, who was a physician of some note in this town, felt convinced, at the 
commencement of the illness which terminated his life, that he should recover if 
he could catch an ague : and he went down into one of the marshy districts ex- 
pressly for that purpose ; but returned to London without having succeeded, 
complaining that the country had been spoiled by draining, and that there were 
no agues to catch. The superstitious Louis XI. entertained a similar opinion, and 
prayed to the Lady of Selles that she would confer upon him a quartan ague. 
Our monarch, James the First, had more sensible notions on that score. There 
is an old English proverb which says, ' An ague in the spring, is physic for a 
king;' and when this was repeated to him by his courtiers, he, being then ill of 
that disease, answered that the adage might be applicable to a young man, but 
that it would not do for an old one like him. In fact, as I mentioned before, he 
died of his ague. The same doctrine has, however, been handed down to us by 
the father of physic himself. Hippocrates says, in the fifty-seventh Aphorism of 

Ilis fourth Section, vrto Grtati/xov, t\ titavov svox'kov^vccii rcvpsfog srtiysvofxsvog %vsi to 

yovsvjixa. And Celsus, in his capital digest of the medical knowledge of his time, 
preserves the same opinion, with some apparent astonishment that it should be 
true. 'Denique ipsa febris, quod maxirne mirum videri potest, saepe praesidio 
est." I recollect hearing Dr. Graham, the professor of botany in Edinburgh, 
relate the following anecdote in one of his clinical lectures. — His brother was 
intimate with the professor of natural history at Cremona; and this gentleman 
was resolved to put the truth of the aphorism that I have quoted from Hippocrates 
to the test. Accordingly he sent a patient afflicted with epilepsy, to pass a night 
or two in a marshy place, where the malaria was known to be so abundant, and 
so powerful that few escaped ague, who were there exposed to its influence ; and 
the twofold design succeeded admirably. The patient got an ague, and lost his 
epilepsy. The worthy professor contented himself with moderating and keeping 
in check the new complaint, thus intentionally produced, for a period of six 
months, when he administered its coup de grace in a few doses of Peruvian bark; 
and the epilepsy never returned. If I had believed that this could have been any 
thing more than a mere coincidence, I should have told you of it before, when I 
was speaking of the treatment of epilepsy. I should rather imagine the notion 
thus prevalent for so long a time, that ague had a salutary tendency, and that it 
was wrong to stop it too soon, to have originated in the difficulty which physicians 
found in stopping it, before its cause was so well understood, and the specific for 
it was discovered. They found it obstinate under the feeble and inert methods 
then employed, and therefore they endeavoured to persuade their patients, and 
perhaps themselves, also, that the disease had better proceed a certain length. 

I have very little to say, in addition to what you must have inferred from what 
I have already said, as to the prognosis in intermittent fevers. In cold countries, 
such as ours, it is almost always favourable. Of course it will be modified by the 
previous condition of the patient : if he was beforehand the subject of serious orga- 
nic visceral disease, or if he be very old, or infirm, the supervention of ague may 
destroy him. But to persons of tolerable health and strength prior to the setting 
in of the ague, we may confidently promise a cure. In warm countries intermit- 
tent fevers are much more dangerous : and are sometimes very rapidly fatal. 
They are often accompanied by most severe affections of the head, stupor, deli- 
rium, convulsions; and of the alimentary canal, diarrhoea, sickness, and not 



TREATMENT. 467 



unfrequently the black vomit. They are prone, also, in those climates, to run 
into the remittent or continued form ; and ihis tendency is shown by long pro- 
tracted paroxysms, or by the anticipation or doubling of the paroxysms. In all 
countries quartans are cured with more difficulty than either tertians or quotidians. 
And quartans are most common in the autumn : and accordingly autumnal inter- 
mittents are more pernicious and intractable than the vernal. This fact has passed 
into a proverb in Italy; which proverb has been thus translated into Latin, 
" Febris autumnalis — vel est longa, vel lethalis" The longer intermittents have 
lasted, the more difficult also are they to cure : and certainly there is much more 
danger of visceral disease in those that are of long standing. 

It is probable that agues, such as we see in this country, would generally, 
under favourable circumstances, terminate in spontaneous recovery, provided that 
the patient could be put beyond the further operation of the malaria, protected 
from exposure to wet and cold, and suitably nourished. But possessing as we do 
a specific cure for ague, if there be such a thing as a specific, there would be no 
sense in our allowing the spontaneous recovery to be made : or rather we should 
be inexcusable, knowing as we do that the complaint is the more obstinate the 
longer it has lasted, and that it tends to the establishment of organic visceral dis- 
ease, we should be inexcusable if we did not stop it as quickly as we can. The 
disease is always distressing to the patient, and always debilitating. It may be 
dangerous, even in these climates, to weak or old persons : and it is dangerous to 
all persons in hot climates. "If the first fit (says the wise and observant Heber- 
den) has been marked so clearly as to leave no doubt of its being a genuine 
intermittent, the remedy should be immediately given in such a manner as to pre- 
vent, if possible, a second." There needs very little preparation of the patient 
before administering the specific substance which is to cure him ; and which every 
one here knows before he hears me say so, is the celebrated Peruvian bark, or its 
active principle as presented by the salts of quina. The old practice was to wait 
a few returns of the fits, either till some hypothetical ferment had taken place, or 
until supposed morbid matter had been expelled by vomiting or purging. There 
is, however, one very simple and short preparative which I am in the habit of 

using, and which I learned at Cambridge. You are aware that Cambridge is Shu- 
ts 7 © o 

ated on the very edge of the fenny country which extends along that part of the 
east coast of the island. Numerous patients afflicted with ague come in from the 
surrounding villages ; and Dr. Haviland found that many of these had taken quina 
before they applied for assistance as out-patients at the hospital ; but with very 
poor success. Now these cases readily gave way — the patient remaining in all 
other circumstances as before — after the operation of a calomel purge. I have 
adopted this practice, therefore, upon his recommendation ; but it does not delay 
the specific treatment. I generally prescribe three grains of calomel with six or 
eight grains of rhubarb at bed-time, and commence with the quina the next morn- 
ing. Very lately, in perusing the late Dr. Baillie's posthumous volume, I met 
with the following passage : — " I have known a good many cases in which bark 
alone would not cure an ague. In all these cases, as far as I now recollect, when 
a grain of calomel was given every night for eight or ten nights, bark cured the 
ague in the course of a few days. This practice I learnt from my friend Dr. 
David Pitcaim." 

I believe that calomel given once in a purgative dose is enough. 

But first of all what is to be done for the patient while he is in the fit ? I con- 
fess to you that I seldom give myself much concern on that head. In ague, as 
we see it in this country, nature generally prompts the patient what to do; to 
cover himself up in bed, and apply warmth to his feet, and to take some hot drink 
during the rigors ; to adopt a cooler regimen during tbe hot stage ; to wipe his 
skin dry, if the sweating should be very profuse or protracted. But in hot coun- 
tries, and in severer forms of intermittent, the patient really requires some help; 
and therefore I must consider shortly in the next lecture the management of the 
paroxysm ; and I am the more bound to do so, because certain measures which I 



468 INTERMITTENT FEVER. 

do not think necessary or judicious, at any rate for the complaint as we see it 
here, have lately been strongly recommended during the ague fit. 



LECTURE XLII. 

Treatment of Intermittent Fever ; during the paroxysm ; during the intermis- 
sions. Prophylaxis. 

I was about, when we last separated, to consider the treatment of ague : first, 
during the paroxysm ; secondly, during the intermissions. 

In this climate we need not, I say, encumber a patient in an ague-fit with too 
much help. But in hot countries, where the disorder is apt to run into the remit- 
tent, or even the continued form, and where, during its violent and rapid course, 
internal organs are liable to sustain serious damage, the best and indeed almost 
the only time for the effectual interference of the physician is in the first assault 
or paroxysm of the disease. 

The objects of treatment during the paroxysm are, to alleviate the uneasy sen- 
sations of the patient: to abridge, if possible, their duration, by shortening the 
fit; and to avert the danger which, under certain circumstances, may arise from 
intense internal congestion long continued, or from the severity of particular symp- 
toms. 

Now in the cold stage of ague, diluent drinks have been recommended, and 
cordials, and external warmth, and opium, and emetics, and blood-letting. One 
would suppose that if some of these expedients were useful, others could scarcely 
be so too. The diluent drinks are very proper : and I should allow the patient 
to use his own discretion in the choice of them. It was customary, formerly, to 
prescribe medicated drinks of this kind ; and one pleasant, but neglected ptisan 
still lingers in our Pharmacopoeia, the decoction hordei compositum. Now-a-days 
we are contented with the simple barley-water, toast and water, weak tea, gruel, 
and the like. These diluents should be taken warm, and for persons who are 
very feeble or exhausted, they may be made gently cordial; weak negus, for 
example, or white wine whey, may be given. 

External ivarmth, being what nature and common sense would suggest, is cer- 
tainly advisable and beneficial in the cold fit ; even the warm bath, if it can be 
procured. In some places it is the custom to await an expected fit in the warm 
bath. When this cannot so conveniently be obtained, the pediluvium may be 
employed; or the patient may be put into a warmed bed, and have bags of hot 
salt or bran applied to his epigastrium ; and a hot bottle, or a hot brick, wrapped 
up in flannel, to his feet. Or, what perhaps is best of all, he may have a hot air 
bath applied to him, as he lies in bed. This may be very easily done, by means 
of a semi-cylinder or cradle of wicker work, closed at one extremity by a board. 
This is laid over the patient, and then covered with blankets. Through a hole 
in the centre of the board one end of a curved iron tube is passed ; the other end, 
expanded into a bell, looks downwards: and a spirit lamp being placed beneath 
it, the air between the wicker work and the sick person is soon made very hot. 
This apparatus was constructed many years ago, by Dr. Gower, when he was 
physician to the Middlesex Hospital ; where its utility has been fully proved. 
External warmth applied in some one of these ways, affords singular comfort 
oftentimes, and contributes to shorten the eold stage. And the same may be said 
of friction, with stimulating liniments, along the course of the spine. Lind found 
that, in children, rubbing the spine with an embrocation composed of equal parts 
of soap liniment and laudanum, at the approach of the cold stage, often prevented 
the paroxysm. 

Opium has often been exhibited in the cold stage, with the view of cutting 



TREATMENT. 



469 



short the fit ; and not without some success. The strongest evidence of its use- 
fulness in that stage of the paroxysm is furnished by Dr. Trotter, in his Medicina 
Nautica . Agues being very frequent among the crew of the Vengeance, he 
resolved to try the full effect of opium in preventing the fit. At its first approach 
a dose of laudanum (never less than thirty drops) was given ; if this did not bring 
on some warmth within ten or fifteen minutes, from twelve to twenty drops more 
were administered. In most cases, "in a few minutes an exhilaration of spirits 
was perceived; the pulse from being weak, quick, and sometimes irregular, be- 
came less frequent, full, and equal; an agreeable warmth was diffused over the 
whole frame, and every unpleasant feeling vanished, sometimes in a quarter of an 
hour. The patients were themselves surprised at the sudden change in their 
sensations." Dr. Trotter speaks of these as being the completest cures that ever 
came under his observation. If, at the next period, the paroxysm threatened to 
recur, the opiate was repeated always with the same success. ",Few instances 
were met with where any indisposition indicated a third attack, at the expected 
period of accession." Notwithstanding this testimony, it appears that opium is 
still better adapted to another stage of the paroxysm. 

Emetics were formerly much prescribed in the cold stage, at its earliest ap- 
proach. Cullen recommends them ; and they may sometimes be useful, in spite 
of Chomel's assertion that they are always hurtful. That they have gone so 
much out of fashion is, however, a proof that they cannot be depended upon for 
cutting short the paroxysm. Vomiting is itself no small distress to many per- 
sons ; and for my own part, I should not think of giving an emetic unless some 
indications of a loaded and oppressed state of the stomach were present; such as 
nausea, an ill taste in the mouth, a coated tongue, and foul breath. A scruple of 
ipecacuanha will, even then, be sufficient. The object is to empty the stomach 
effectually, but mildly. I would not give antimony. Irritability of the stomach, 
in the more violent of these fevers, is too apt to arise spontaneously. Sir Gilbert 
Blane tells us that the greatest impediment to the cure of the severer intermittents 
at Walcheren, in their early stages, proceeded from the extreme irritability of 
stomach, which made it difficult to administer the requisite medicines. In hotter 
climates nausea and vomiting are still more common and more urgent ; and we 
have to guard against the risk of inducing or aggravating these symptoms. 
" Emetics (says Dr. Mackintosh, in his Practice of Physic) have been often ex- 
tolled, but I believe every experienced tropical physician will agree with me in 
cautioning young practitioners against their indiscriminate employment. Irrita- 
bility of the stomach is one of the most frequent and troublesome symptoms ; and 
once excited, it is always difficult, and in many cases impossible to restrain it. I 
have seen emetics exhibited, and the vomiting has continued till death, in spite of 
every remedy."* 

Lately, the practice of blood-letting in the cold stage has been revived (for it is 
not a new practice), and strongly recommended by the physician whose name I 
have just mentioned ; and whose opinion carries with it the more weight from its 
having been founded on much personal experience in the treatment of these fevers. 
Dr. Mackintosh affirms that bleeding, performed in the cold stage, will often stop 
at once the paroxysm, and with it the disease: that even when its curative effects 
are less decisive, it will generally stop the cold stage and shorten the paroxysm, 
and mitigate its severity, and afford speedy and great ease to the distressful sensa- 
tions of the patient; and that any subsequent paroxysms which may occur will 
be mild and few. One bleeding, he says, is commonly sufficient; sometimes two 
are required : seldom more than two. The blood is to be suffered to flow till the 

* [We have repeatedly prevented the accession of the chill by administering to the patient, 
just before the period when it was expected, an emetic of ipecacuanha, and after this had 
ceased operating, immersing his feet in hot water, and, as soon as he is placed in bed, giving 
him from 30 to 40 drops of laudanum, or a teaspoonful of the camphorated tincture of 
opium. By this treatment not only is the chill prevented or shortened, but the whole pa- 
roxysm is often rendered milder. — C] 



470 



INTERMITTENT FEVER. 



patient feels relief: which usually consists in liberation from pain of the head and 
loins ; freedom of respiration ; the departure of the painful sensation of cold ; and 
the cessation of the tremors and of the debility. Most of the patients fall asleep 
after the operation. These effects have been produced by the abstraction of an 
ounce and a half of blood; they have sometimes (but rarely) required for their 
production twenty ounces. 

Now this is the piece of practice to which I adverted at the close of yester- 
day's lecture, as being, in my humble opinion, inexpedient and not to be recom- 
mended ; at least in the agues of this country. I have seen a good many cases, 
first and last, and certainly I have never seen one in which I could have thought 
such an heroic remedy necessary, in the cold stage ; if indeed it be, in that 
stage, a remedy at all. But I do not desire to oppose my experience alone, or 
my judgment, to that of Dr. Mackintosh. His method has been tried, since he 
first made it public, by various practitioners in this country. Drs. Townsend 
and Law, of Dublin, found it fail in the majority of cases. In Dr. Stokes's 
hands, the most usual effect of blood-letting in the cold stage was, to check the 
shivering; and, next to this to mitigate its severity, without abridging its dura- 
tion. In most instances, no modification was produced of the hot and of the 
sweating stages. In Dr. Kelly's experience, the general effect was, to shorten 
the cold stage, and to render the hot one milder; but in some cases it seemed to 
aggravate the symptoms. Mr. Gill found that, although the blood-letting might 
cut short the cold stage, it appeared to lengthen the period of febrile disturbance. 
Confining myself, then, to intermittents, as they show themselves in this climate, 
I cannot advise you to adopt the practice introduced by Dr. Mackintosh — of 
bleeding in the cold stage. I object to it because it appears to me quite unne- 
cessary ; because it is not such as the nature of the symptoms would suggest ; 
because it tends to produce subsequent debility, which we should not needlessly 
inflict ; and because the experience of other sober-minded men, who have given 
the method a fair trial, does not bear out the statements made by Dr. Mackintosh 
in respct to its usefulness. 

At the same time, after a careful perusal of nearly a hundred cases adduced by 
Dr. Mackintosh to illustrate the efficacy of this measure, I think it highly pro- 
bable that blood-letting may constitute the most important part of the treatment, 
in the very outset of the severer malarious fevers of hot climates; attended as 
they are with a degree of internal congestion and disturbance which is dangerous 
to the integrity of vital organs.* 

* [Mr. Twining, in his work on the Diseases of Bengal, bears strong testimony in favour 
of bleeding in the cold stage of intermittents. In the greater number of cases he has found 
it to arrest the paroxysm; that is, the occurrence of the hot and sweating stages is pre- 
vented. In the majority of patients, when the bleeding has been preceded by a course of 
mild purgatives, there will be no return of the disease, provided attention is paid to keep 
the body properly clad and to guard against exposure to atmospherical vicissitudes. Ia 
this manner, he remarks, we cut short the fever, and guard against those ulterior visceral 
engorgements and indurations, by which it is too often prolonged, until the constitution is 
completely ruined. 

The only period of the cold stage at which bleeding is proper, Mr. Twining states to be, 
at the very commencement of the rigor, or just when the coldness and shivering are com- 
pletely established. He has found that, in general, it is sufficient to take from an adult 
twelve or fifteen ounces of blood, and in the most robust European he would limit the 
quantity to be taken at one bleeding to twenty ounces. After the arm is tied up the patient 
should be permitted to lie quiet in bed for an hour or two— but not heated by being covered 
with too many bed-clothes ; he should be immediately supplied with a cup of warm tea, 
gruel or thin sago. 

According to Mr. Twining, " the requisites to ensure success from bleeding in the rigor, 
are, 1st, the preliminary course of moderate purging; 2d, that the blood be taken, from a 
large orifice, quite as soon as the coldness and rigor are fairly established ; and 3d, that the 
patient be bled in a recumbent posture, and no more blood be taken than is sufficient to 
arrest the paroxysm." 

In robust plethoric patients, who, during the intervals of the paroxysm, complain of head- 
ache, and morbid tenderness on pressure over the abdomen, and pain or uneasiness in the 



TREATMENT. 



471 



If, in this country, bleeding be requisite at all, it is in the hot stage. But it is 
not requisite at all, except when there appears to be danger of some internal 
inflammation. The best remedy of the hot stage in undoubtedly opium. Dr. 
Lind, who wrote after large experience, says that he never saw a person die in 
the cold fit, but had known several carried off in the hot one, with strong convul- 
sions and delirium. He happened to notice the beneficial effect of an opiate 
given while the patient was very hot and feverish. He determined, therefore, to 
make further trial of opium in the paroxysm, ff Having at that time (says he) 
twenty-five patients labouring under intermitting fevers, I prescribed, an opiate 
for each of them, to be taken immediately after the hot fit, provided the patient 
had then any inquietude, headache, or any such symptom usually subsequent to 
the fever. The consequence was, that nineteen in twenty-two received imme- 
diate relief; the other three had no occasion to take it. 

" Encouraged by this surprising success, I next day ordered the opium to be 
given during the hot fit. In eleven patients out of twelve to whom it was thus 
administered it removed the headache, abated the fever, and produced a profuse 
sweat ; which was soon followed by a perfect intermission. Since that time I 
have prescribed an opiate to upwards of three hundred patients labouring under 
this disease : and I observed, that if taken during the intermission, it had not the 
least effect either in preventing or mitigating the succeeding fit ; when given in 
the cold fit, it once or twice seemed to remove it; but when given half an hour 
after the commencement of the hot fit, it generally gave immediate relief." 

Dr. Lincl goes on to state that he found the influence of opium more uniform 
and constant in intermitting fever than in any other disease ; and more quick and 
sensible than that of any other medicine. 

Very little need be said in regard to the sweating stage. Up to a certain point 
the perspiration is to be promoted and encouraged. When the uneasy feelings 
of the patient have abated, it should be restrained ; not suddenly but with caution. 
Now the sweating may be promoted by diluents ; by keeping the patient in bed, 
and covered with moderately warm clothes ; by sippings of hot gruel or of hot 
chicken broth. On the other hand, when the sweating has continued long 
enough, it may be stopped by drying the patient carefully with towels, changing 
his linen, and getting him up out of bed. 

It is well to bear all this in mind; but I repeat once more that in agues, such as 
you are likely to meet with in this country, it is unnecessary, and therefore 
objectionable, to be over-busy during the paroxysm. "Wherever the disorder 
assumes a distinctly intermitting form, the most important part of the practice is 
that to be employed during the intermissions. Now there are certain general 
remedies advised for adoption in this period; and there are certain specific reme- 
dies. The general remedies are bleeding, emetics, and purgatives. They need 
not detain us a moment. Blood-letting may be used if there be any apparent 
tendency to local inflammation, or any marks of severe topical congestion ; espe- 
cially in young and robust subjects. Barring such circumstances, there can 
be no occasion to bleed your patient in the intermissions. 

An emetic given a short time before the expected paroxysm has been known to 
prevent its accession ; and even has sometimes cured the disease. But we can 
stop the paroxysms by gentler and. better means; so that I should not prescribe 
an emetic unless I saw symptoms of a foul and loaded stomach. 

Purgatives should always be given at the outset. They clear the stomach and 
intestines of hurtful accumulations, which are apt to impede the beneficial opera- 
tion of the quina, or of other drugs given to check the disorder. I mentioned in 
the last lecture my own custom in this matter; viz., to give a couple or three 

chest, the disease will seldom be arrested by the first bleeding; in many cases, they wilt 
have repeated paroxysms in each of which the use of the lancet will be required. Patients, 
also, in whom the paroxysm, more especially the cold. stage, is attended with vomiting, Mr. 
Twining has found to require the repeated abstractions of small quantities of blood during 
the rigors. — C] 



472 



INTERMITTENT FEVER. 



grains of calomel with eight or ten of rhubarb at bed-time ; and to commence with 
the specific remedies the next day. 

Of these specific remedies, bark and arsenic are by far the most certain and im- 
portant; but a multitude of others have been highly praised for possessing similar 
virtues. I shall by and by say a word or two about some of these, because bark 
is dear, and arsenic is scarcely a safe drug to be entrusted to the hands of unpro- 
fessional persons ; and yet it is often expedient, in country places, where agues 
are rife, to provide the poor with remedies which they may have at hand ; and 
which should both be reasonably cheap, and perfectly safe. 

I shall not detain you with any account of the difficulties and objections which 
were thrown in the way of the Peruvian bark, upon its introduction into the 
materia medica about the middle of the seventeenth century. Its use met with 
the most violent opposition, even from physicians of the highest authority. It 
was resisted by Stahl and Hoffman ; and Boerhaave was never quite reconciled to 
it. Sydenham, by his example and recommendation, greatly promoted its adop- 
tion in this country. All this history is sufficiently curious and interesting, but I 
have no time for it: and you will doubtless hear it from one of my colleagues. I 
will merely say that in the Peruvian bark we have one of the very few specifics 
that we can boast of possessing ; and that, unlike most other highly vaunted sub- 
stances, so far from falling off from the accounts first given of its virtues, it has 
acquired in the lapse of time an increase and stability of reputation. 

Neither shall I enter at all into the consideration of the qualities of the several 
species of cinchona; nor of the several principles that may be educed fr.om them ; 
nor of the modes in which the quina even may be best procured. This would 
not belong legitimately to my province. I must suppose that the professors of 
chemistry and of materia medica have furnished you with the sulphate of quina 
which is the only preparation of the bark I intend particularly to notice : and my 
business is to tell you what I know in respect to its employment as a remedy 
for ague. 

I may observe, however, that this is a remedy to which we could never have 
been led by any process of reasoning. It is a matter of pure empiricism. We 
know nothing of the seat or of the essential nature of the disease; we are equally 
in the dark as to the modus operandi of the quina in curing it ; yet our knowledge 
of ague, upon the whole, estimated in reference to its precision and practical bear- 
ing, is more satisfactory than of many other complaints, with the seat and nature 
of which we are much better acquainted. The group of symptoms is so distinct, 
that we have no trouble or doubt as to the diagnosis ; and experience has taught 
us a remedy which is all but infallible. 

The discovery of quina and its salts formed a great era in the history of the 
materia medica. As far as my own experience goes, the sulphate of quina has 
quite superseded the necessity for exhibiting any other form of cinchona for the cure 
of ague. Before quinia was unshrouded by the chemist, the bark in substance was 
the only form in which the remedy could be confidently relied upon : and I am old 
enough to be aware of the infinite superiority of the salt, over the actual bark. To 
obtain the desired efTect, it was often necessary to give it in such quantities as almost 
justified Mr. Abernethy's sarcastic way of speaking of it and of physicians. He 
said the doctors talked of throwing in the bark, as if it were to be pitched into the 
stomach with a shovel. The sulphate of quina lies in a much smaller compass, 
and a more commodious form ; and it does not cause that insupportable nausea 
Which the woody mass of the powdered bark was so apt to occasion. 

I am in the habit of giving two, and sometimes three, grains of the sulphate of 
quina every four or six hours during the intermissions, to those patients whom I 
have occasion to treat for ague. This plan has succeeded so well, that I have never 
been tempted to try any other. I may, indeed, say that I have never known it 
fail to stop an ague ; and to stop it speedily : so that very few paroxysms have 
occurred after the patient has be'gun to take the medicine. You may give it in 
the infusion of roses, which contains a convenient quantity of sulphuric acid, to 



TREATMENT. 



473 



ensure the solution of the sulphate of quina. It changes the colour of the infusion, 
however, and renders it pinker and opaque. Whether the draught be more or 
less elegant on that account, I will not take upon me to say ; I know that the vir- 
tue of the quina is not much interfered with by the change. In private practice, 
I commonly prescribe as many drops of dilute sulphuric acid as there are grains 
of the quina, with a drachm of the tincture of orange peel, and a drachm of the 
syrup of the same ; completing the draught with water. This I find my patients* 
commonly approve of, except in its bitterness, which, in solution, nothing can 
disguise. Or that salt may be administered in the shape of a pill : it is best, how- 
ever, and surest in solution. 

A question has been raised, whether this remedy should be given in repeated 
doses during the intermissions, or whether one very large dose should be given a 
short time before the paroxysm is expected. Dr. Home made some experiments 
on that point in the clinical wards of the Edinburgh Infirmary, some time ago ; 
and he thought that the result was in favour of the plan of giving the bark regu- 
larly at short intervals. I have told you the amount of my own experience, 
which, however, is not very great; nor have 1 had any severe cases to deal with. 
I think it not improbable that my patients would have been cured quite as soon if 
I had given the remedy in half the strength. Dr. Barker, of Dublin, has found 
small doses equally effectual with large ones; and this is very likely to be the 
case with specific remedies. It would appear, however, that in some quartans it 
is better to give large doses before the return of the paroxysm. Dr. Elliotson 
gives large doses just after the paroxysm; and then smaller doses during the 
remainder of the intermission, at regular periods. A great majority of those who 
suffer ague are poor persons. ' Of course, the first object is to make the cure as 
speedy as possible ; the next to make it as cheap as possible. So that it is not a 
matter of indifference, or mere speculative curiosity, to ascertain with how little 
quina you may cure an ague. I repeat that it has not happened to me to be dis- 
appointed, when I have given the medicine in small doses, as already described : 
which amount to about twelve grains in twenty-four hours ; but, then, I suppose 
my cases have been well behaved and submissive. Dr. Elliotson states that he 
is continually obliged to give twenty or thirty grains in the twenty-four hours, 
before he can cure the complaint; sometimes in obstinate quartans, forty-five 
grains ; and he mentions one case in which a scruple of the sulphate of quina, 
with ten minims of the liquor arsenicalis, were given every eight hours in vain, 
but succeeded perfectly when given every six hours. 

It appears also, upon the testimony of careful observers, that in warm climates 
larger doses are required ; and that it takes a larger quantity, upon the whole, 
to repel the complaint. In the aguish tracts of Italy, in the Maremna, small doses 
are said to be inadequate ; and the physicians there are in the habit of giving 
twelve, twenty-four, or even thirty grains at a time : and in one recorded instance, 
the dose, in seven days, was got up to 108 grains, before the ague was arrested. 
The medium dose, in many parts of America, seems to be eight grains. 

It sometimes happens that the irritability of the stomach is so great as to make 
it difficult to introduce a sufficient quantity of the remedy into the system. This 
difficulty was very much felt at Walcheren : it is in a great measure removed since 
the discovery of quina. But even the quina sometimes sits ill on the stomach; 
and it is often very difficult to get children to swallow any preparation of bark, 
on account of its bitter taste. It is an important thing to know, therefore, that it 
has been found scarcely less effectual, in curing the disease, when thrown into 
the rectum. The menstruum in which it is dissolved should not exceed two or 
three ounces, lest the bowel should reject it. Its expulsion may sometimes be 
prevented by adding a few drops of laudanum to the enema.* 

* [The quinia may also be administered endermically ; from 4 to 10 grains being sprin- 
kled upon a blistered surface, once, twice or oftener, according to circumstances, in the 
course of the day. That the remedy will produce its specific effects when thus exhibited 
we know from experience. — C] 



474 



INTERMITTENT FEVER. 



It is said that bark in substance will sometimes cure the disease when quina 
fails. I have never witnessed this: but in obstinate cases I would give the quina 
in the decoction of bark.* 

You must not be satisfied with merely stopping the paroxysms. Patients will 
often be too ready to give up their medicine, as soon as the paroxysm has once 
missed. But the disease is very apt to recur; and it will always be right and 
^prudent to go on with the quina for ten days or a fortnight after the patient seems 
cured, gradually diminishing, after the first week, the amount and the frequency 
of the doses. 

There have been some curious facts observed in regard to the relapses that are 
apt to take place after the bark or the quina has been omitted. Clark, of Do- 
minica, states that if no more of the remedy be taken, in the West Indian ague, 
than is barely sufficient to stop a fit, and then the bark is suspended, a relapse 
may take place on the eighth day, in the case of a quotidian ; on the fourteenth 
or fifteenth in the case of a tertian or double tertian; and on the twenty-first or 
twenty-second in the case of a quartan: thus making (you see) in each type, 
seven periodical revolutions from the time the tit was suppressed to the next 
attack ; and the fit was found to return on the proper day, at the same hour at 
which it would have returned if its course had not been interrupted by the admi- 
nistration of the remedy. All this is very curious, and inexplicable: but it points 
clearly to the propriety of continuing the remedy for some time after the disease 
appears to have vanished.'!" 

Jlrsenic is another substance which has great and unquestionable power over 
ague. It carries with it these marked advantages : it is efficacious ; it is cheap ; 
and it is tasteless. It is well adapted by these qualities for the poor, and for chil- 
dren, and for patients of every age and rank in whom there is much irritability of 
stomach present; but then it has also the serious disadvantage of being an active 
poison. One over-dose may be fatal: and even its long-continued use in minute 
doses leads sometimes to evident and lasting disorder of the health. Arsenic, 
therefore, is an unsafe remedy to be trusted in the hands of the ignorant. It 
should never be administered except under the immediate supervision of a medical 
eye; and even then it requires to be given with much caution. Its bad effects 
may be very certainly prevented, however, by care and attention ; and" it becomes 
a valuable instrument of cure, and should be adopted without scruple, in cases 
where its operation can be watched, and where the quina does not agree with the 
stomach, or fails to stop the disease. I often prescribe arsenic for other com- 
plaints ; but, as I said before, I do not recollect ever having been foiled in remov- 
ing ague by the sulphate of quina. Some persons are of opinion that relapses 
are less frequent after the cure by arsenic than after the cure by bark. It would 
require a large induction of particular facts to make that point clearly out. 

When substances, which even in small quantities prove active poisons, are used 
as remedial agents, it is convenient to have some definite form in which they may 
be administered at all times, and in all places. The liquor potassse arsenitis of the 
London Pharmacopoeia supplies such a form. This is the form in which arsenic 
was recommended to the public by Dr. Fowler: and it is therefore sometimes called 
Foivler's solution. It was founded upon an analysis of the tasteless ague drop, 
which had been in considerable repute in some parts of England. The pharma- 
copceial preparation is an arsenite of potass in solution. There are eighty grains 
of arsenic in the new or imperial pint, and therefore four grains in an ounce of 
the solution. Ten minims two or three times a day are a full dose for an adult: 
and you had better commence with not more than five minims. Ten minims 

* [It is very certain that the quinia, even when given freely and in large closes, will 
occasionally fail in arresting the disease, and that the majority of such cases will be 
promptly cured by the bark in substance. This we have seen repeatedly to occur. — C] 

f [The Quinise Sulphas Impurus of the United Slates Phannacopceia, known in Philadel- 
phia under the name of Extract of Bark, given in pills of from 3 to 5 grains every four 
hours, will seldom fail in preventing the paroxysm of the disease. — C] 



TREATMENT. 



475 



contain one-twelfth of a grain. Twice that quantity has been administered at 
once; but this ought never to be done except when the system has been gradually- 
inured to the arsenic, and thereby enabled to bear such a dose. It is a good pre- 
caution not to give this corrosive substance on an empty stomach. 

The poisonous or hurtful effects that we have to look out for, when arsenic has 
been prescribed, are loss of appetite, nausea, and sometimes vomiting; griping 
pain of the stomach and bowels, and diarrhoea ; and if the medicine be continued, 
fainting is often added. Other symptoms, less constant, perhaps, and less im- 
portant, are painful and hot tumefaction and stiffness of the face and eyelids, or 
even a tingling eruption something like nettle rash. These effects may, I be- 
lieve, be controlled by adding a few drops of laudanum to each dose ; but I would 
rather advise you to suspend the use of the arsenic; or to leave it off altogether. 
When this is done, the unpleasant symptoms will readily yield to mild laxatives, 
followed by opiates.* 

When the paroxysms continue to recur in spite of the bark, it has been recom- 
mended (and I think the plan a good one), to try to stop them by arsenic; and 
then, the periodic recurrence having been broken, to employ sulphate of quina to 
prevent a relapse. 

These, then, quina and arsenic, are the two sheet anchors to which we trust, 
in the cure of ague. A host of other remedies, I say, have had their praises 
sung, I do not intend to enumerate them. But there are a few which I think it 
right to mention, for reasons already assigned. There is strong evidence of the 
efficacy of some of them ; they are cheap, and easily accessible, and above all, 
safe; and, therefore, in aguish districts, they may with much propriety and 
benefit be recommended to the poorer classes, or distributed by Lady Boun- 
tiful s.f 

One of these is willow-bark; in substance, or in decoction. If this does cure 
agues, as it is affirmed to do, it would seem as if Providence had placed the anti- 
dote alongside of the poison ; for these trees, as you know, abound and flourish 
in marshy places. The bark of the willow furnishes an alkaloid substance called 
salicine, in which the febrifuge property is believed to reside. Holly leaves, and 
ilicine derived from them, stand in much the same repute in France, as willow 
bark and salicine here. 

Another curious remedy, said to be very successful, is the web of (he black 
spider, which inhabits barns, stables and cellars. This substance has been tried 
on a tolerably large scale, and the testimony to its influence in curing agues is 
very strong. Dr. Craigie has given this account of it. In the year 1760, a num- 
ber of prisoners from the vanquished squadron of Thurot having been landed 
in the Isle of Man, Dr. Gillespie, who was practising there, found that many of 
the agues which came to prevail both among these prisoners and the inhabitants 
of the island, obstinately resisted bark and such other remedies as he had recourse 
to. He was informed, by an old French physician belonging to the squadron, of 
the alleged efficacy of cobweb, in certain forms of the disease. He therefore 
made trial of cobweb, and found it to answer admirably. He was successful with 
it in more than sixty cases of different types, in the Isle of Man, and he had fur- 
ther experience of its utility subsequently in Ayrshire. 

After this, the same remedy was tested in the West Indies, by Dr. Jackson, to 
whom Dr. Gillespie had recommended it. Dr. Jackson's observations were made 
in the hospital of the army depot, in the West Indies, in 1801. Several cases of 

* [The arsenical solution is a remedy admirably adapted for the cure of intermittent fever 
when it occurs in children, to induce whom to take the quinia in any form will be found 
often impossible. When cautiously administered and its effects are carefully watched, 
we have never known any disagreeable effects to result from the arsenic, and we have 
employed it somewhat extensively. — C] 

T [The ferrocyanuret of iron is certainly a very valuable remedy in cases of intermit- 
tent fever. Stokes places it in efficacy after quinia and the arsenical solution, and perhaps 
he is right in so doing; it will, however, often succeed in preventing the recurrence of the 
paroxysms, given in the dose of six grains every three hours. — C] 



476 



INTERMITTENT FEVER. 



ague, on which bark, arsenic, or mercury, singly or alternately, had made either 
a very temporary impression or none at all, were selected for experiment. In 
four of these cases, two pills, containing each five grains of cobweb, were given 
at intervals of two hours, commencing six hours before the expected time of 
recurrence of the paroxysm. The fit did not return.* On subsequent trials it 
was found not only to arrest the course of agues, but to remove various symptoms, 
such as pain, delirium, vomiting, griping, in ague, and in continued fever, when 
these symptoms were unconnected with inflammation. 

Charcoal is another substance which has been found effectual for the cure of 
intermittent fevers. You may find an account of it in the tenth volume of the 
Edinburgh Medical and Surgical Journal. It would seem to be especially use- 
ful, in those cases in which there is a marked disturbance of the digestive organs ; 
nausea, flatulence, hiccup, diarrhoea, or dysentery. It is said generally to cure 
the complaint by the time two drachms of it have been taken. It may be given 
in doses of ten or twenty grains, in arrow-root; or with a few grains of rhubarb. 
If the power of this substance should be confirmed by future observations, a cheap 
remedy would thus be open to the poor. A clergyman of my acquaintance assur'es 
me that he seldom fails to cure agues among his parishioners by administering to 
them the snuffs of candles, which he takes care to have collected. He does not 
inform them of what his black powder consists. I presume that its virtue may 
proceed from the charcoal it contains ; unless it is derived from the confidence his 
flock is accustomed to place in his specific. The very same remedy, the snuff 
of a candle, is mentioned by Lind. 

Piperine, the crystalline salt of pepper, has obtained a considerable reputation 
of late years, as a remedy for intermittent fever. It was largely tried by an Italian 
physician, Meli ; and Dr. Gordini has repeated Meli's experiments at the hospital 
at Leghorn. The following are the general conclusions at which these physicians 
have arrived:— 1. Piperine, in doses of six or eight grains, cures intermittents. 
2. It is more efficient in powder than in pills. 3. It succeeds in certain cases in 
which the sulphate of quina fails. And 4. It is more effectual in preventing 
relapses. I have seen letters from some practitioners in this country, bearing 
testimony to the power of the piperine. That pepper will cure ague, has long 
been the vulgar belief; and a very popular remedy for the disease is a teaspoonful 
of pepper in a glass of gin. 

1 presume that the efficacy of chamomile flowers in the removal of intermittent 
fever is to be attributed to the piperine which they have been ascertained to con- 
tain. These flowers had been long in use for the treatment of ague, before the 
Peruvian bark was discovered ; and they are said to have accomplished a cure, 
since that time, after the bark had failed ; but this was before the quina had been 
educed from it. Heberden advises us to have recourse to chamomile flowers, if 
the bark should disappoint us. I am always willing to embrace an opportunity 
of referring to his commentaries, for the exact observations they contain, but 
above all for the beautiful Latinity of which the whole book is an example. I 
recommend it strongly to you, as being next to Celsus, the best model you can 
study for good medical Latin. In reference to the point before us he says, 
" Cortex, quanquam rite sumtus, interdum parum efficaxest ; quo in casu suspicio 
erit ventriculum sordibus onustum vin remedii impedire. Itaque vomere oportet; 
quo facto, febris raro non cedit. Quod si redire perseveret, confugiendum est ad 
flores chamaemeli, quorum contritorum scrupulus dandus est loco drachmae cin- 
chonas, et ad idem praescriptum repetendus. Hos flores, sic sumtos, semel atque 
iterum profecisse expertus sum." 

Several mineral substitutes for the bark, or for arsenic, have been tried and 
found useful. Preparations of iron and of zinc. From 5 to 10 grains of the sul- 
phate of zinc have been given several times a day; or 3 grains of the oxide of zinc 

* [We have employed the spider's web in this manner in a number of cases, and in 
many of them found it very promptly to suspend the paroxysms — as effectually, certainly, 
as the quinia ; in a few cases, however, it failed. — C.j 



TREATMENT. 



477 



every three hours. Sir Gilbert Blane says that both in the West Indies and in 
London, intermittents have been cured by the use of this oxide, when they had 
previously resisted the bark. Sir James Mac Grigor speaks of it also in terms 
of praise ; from what he saw of its effects in tht agues of the Peninsula during 
the war. 

Some of the remedies of this mysterious disorder operate upon the mind, or 
rather upon the nervous system, through the mind. Hence it becomes probable 
that the drugs which have such power over the disease, act also on the nervous 
system, through the body. And hence also we derive a confirmation of the 
opinion, that the disease itself is essentially a disease of the same nervous system. 
Ague has often been cured by the agency of strong mental emotion, such as sud- 
den and great joy, anger, terror, or eager expectation. Thus we read that Quin- 
tus Fabius Maximus was cured of an old quartan on the day of a great battle. 
Strong impressions upon the imagination, producing feelings of disgust and horror, 
have had the same effect: such as those caused by drinking blood, swallowing a 
spider gently bruised, and wrapped up in a raisin, or spread upon bread and but- 
ter; keeping a spider suspended from the patient's neck in a nutshell, till it dies ; 
and the like. The undoubted success, in many cases, of charms, must be referred 
to the principle of faith. The patient recovers, because he firmly believes in your 
power to cure him. Dr. Gregory used to relate the case of a patient in the clini- 
cal wards in Edinburgh, who, with sundry ceremonies, swallowed some word, 
written on a slip of paper: the result was, that he had not another paroxysm. 
And I perfectly recollect having a great awe, when I was quite a child, of my 
maternal grandmother, because she was reputed to have the power of curing agues 
by means of some charm. I believe all that she did was to assure the poor peo- 
ple who came to be relieved from their ague, that they should have no more of it 
after such a day ; and their implicit reliance upon this prophecy brought about 
its fulfilment. There seems to be this general principle observable in respect to 
agues, and to most other diseases which occur in paroxysms, viz., that after they 
have continued for some time, their further continuance depends more upon the 
effect of habit than any thing else: and this habit may be broken by strong im- 
pressions made upon the nervous system ; and the cure of one paroxysm is often 
thus the cure of the disease. We have seen examples of the existence of this 
morbid habit in hysteria, and in some cases of epilepsy. Cseteris paribus, that 
physician will be the most successful in these disorders, who is best able to ac- 
quire the confidence of his patient, and to gain a powerful influence over his mind. 

There is no disease in which the prophylaxis is of more importance; but this 
you will have gathered from the facts which were stated in the two preceding 
lectures. The disposition to relapse is strongest soon after the disease has been 
removed ; but it generally continues long, perhaps even for life. The late Dr. 
Macmichael caught an ague many years before his death, by sleeping on a rock 
somewhere in Greece ; and he was ever after subject to occasional attacks of 
periodic headache, and other aguish symptoms, for which he was obliged to have 
recourse to bark or arsenic. Of course one essential point in the prophylaxis is 
the withdrawal of the patient from the influence of the exciting cause ; taking him 
away from the malarious locality. But this cannot always be done ; and when it 
cannot, we must impress upon him those cautions which arise out of the facts 
ascertained in regard to the operation of the malaria upon the human body. Per- 
sons who have been exposed to the exciting cause, or who have once had the 
fever, should, in whatever place they may happen to be, avoid over fatigue, and 
exhaustion of all kinds; sudden exposure to cold or heat; and the neglect of 
changing wet clothes ; wet shoes and stockings, for instance. In a malarious dis- 
trict persons should bear in mind the facts, that the miasmata are much more viru- 
lent in the night-time than in the day ; and close to the surface of the earth, than 
in a higher part of the atmosphere. They should refrain, therefore, from going 
out late in the evening, or early in the morning ; and they should rather select 
the attic than any other floor for their bed-chamber. They who are obliged to go 



478 



EPISTAXIS. 



out la the morning in countries where agues are rife, should take care not to go 
out fasting; a good hot breakfast should be first taken, or at any rate some mode- 
rate stimulus. A crust of bread and a glass of wine, or a small quantity of ardent 
spirit, will fortify the system against the pestilential miasma. Measures of this 
kind have been found extremely beneficial in the navy : the giving, for instance, 
the men a warm breakfast before going out in the morning on malarious shores in 
boats, whatever the hour of starling might be. Generous diet, and a fair allow- 
ance of fermented liquor, are proper also for all persons in aguish countries. The 
late Dr. James Gregory used to mention in his lectures an anecdote in point, told 
him by his father. The elder Dr. Gregory studied at Leyden, under Boerhaave ; 
and twenty-four other English students were living there at the same time: that 
is, they were called English, on account of their common language, but they were 
in fact composed of English, Irish, Scotch, West Indians, and American. The 
celebrated John Wilkes and Charles Tow.nsend were among the number. These 
twenty-five students lived a good deal together ; in truth they -were cut, as the 
phrase is, by the Dutch, for some raffish behaviour on their parts. However, of 
the twenty-five, only one was a water-drinker. The other twenty-four drank 
each a bottle of claret daily ; and the water-drinker,*and he alone, fell ill of ague 
there. 

Persons who have recently become residents in aguish districts, or who even 
happen to be traveling through them, would do well to take moderate doses of 
quina by way of safeguard. And in regulating the bowels, which, of course, is 
of much importance, warm stomachic laxatives should be made use of, rather than 
cold aperients, such as the neutral salts. 

There is just one more expedient which I would suggest as not unlikely to 
afford complete protection to those who are of necessity exposed to the malaria; 
and it is, that they should wear an orinasal respirator. It is possible that as a 
breeze is filtered of the poison which was mingled with it, by passing through a 
dense mass of foliage, so, on a smaller scale, the air inspired in breathing may be 
strained and purified, and rendered harmless, in its transit through the sieve-like 
structure of Mr. Jeffreys' ingenious instrument. The principle of the suggestion 
is not new ; but this mode of applying it has not, so far as I know, hitherto been 
tried. It is said that by surrounding the head with a gauze veil, or conopeum, 
the action of malaria is prevented ; and that thus it is possible even to sleep in the 
most pernicious parts of Italy without hazard of fever. Dr. Macculloch says that 
in Malta, and elsewhere, this belief is universal: and hence the popular practice 
of covering the mouth and nose with a handkerchief in the morning on going out, 
or in other suspicious circumstances : a practice (he observes) the efficacy of 
which is attested, as far as popular belief can attest any thing. Can it be the 
moisture which accumulates upon the handkerchief from the breath, that confers 
the protection? 



LECTURE XLIII. 

Epistaxis. Bronchocele; Cretinism: their Phenomena and probable Causes. 
Medical and Surgical Treatment of Bronchocele. 

I yesterday finished what I had to say respecting intermittent fever; its symp- 
toms; its cause; and its cure. The subtle poison which produces it is thickly 
distributed over the fairest portions of the habitable globe : blighting human health, 
and shortening human life, more often, and to afar greater numerical amount, than 
any other single cause whatever. Known only by its noxious effects, holding 
out no signal of its presence, this unseen and treacherous enemy of our race has 
yet been tracked to its haunts and lurking places, and detected in some of its 



EPISTAXIS, 



479 



habits. It was necessary, therefore, that I should enter somewhat fully into the 
history of the malaria, and show how it may sometimes be shunned, sometimes 
be averted ; how, also, in this climate at least, the effects it has already produced 
upon the human body may be successfully combated. But I shall not pursue 
in further detail, the ravages committed by this invisible agent, and the remedies 
they require, in hotter and less favoured regions than our own. Of these, per- 
sonally, I know nothing; and I must refer you, for information on such diseases, 
to authors who have seen and treated them : particularly to Drs. Lind, Jackson, 
Bancroft, Johnson, and Sir William Burnett. 

It is customary, with writers and lecturers, to pass from the consideration of 
ague to that of continued fever. A paroxysm of ague has been regarded as exhi- 
biting a paradigm or sample of fever in general. But this has always appeared to 
me rather an ingenious refinement than a useful matter of fact. Practically, I 
see nothing to be gained by the association. Intermittent fever, it is true, does 
often run, in hot climates, into the remittent, and the remittent into the continued 
form. But these are very different disorders from the continued fever with which, 
in these climates, and in this country, we have to do. Intermittent fever, and 
continued fever, as toe see them, differ in their phenomena, in their course, and 
in their treatment. They are alike, inasmuch as they both are called fever, and 
both are attended, in some part or other of their course, with pyrexia; but, in 
esseniial symptoms, I have known many a compound fracture more like continued 
fever than any ague we are likely to witness. I shall take up the subject of con- 
tinued fever, then, in connection with the eruptive febrile diseases, with which it 
has many strong links of analogy; and I resume the consideration of the disorders 
that come within the province of the physician, according to their anatomical seat. 

After what was stated of hemorrhage in general, in an earlier part of the course, 
I hardly know whether epistaxis needs or deserves any formal notice. There 
are, however, some points relating to this simple, and commonly harmless hemor- 
rhage, which it may be worth while very briefly to touch upon. Sometimes it 
is a remedy; sometimes a warning; sometimes really in itself a disease. The 
readiness with which the mucous lining of the nasal passages pours forth blood 
is familiar to the experience of every schoolboy, who "often wipes a bloody 
nose." A slight blow, brisk exercise, a strong bodily effort, a fit of sneezing, or 
the summer heat, is sufficient, in many boys, to make the nose bleed; and this 
facility of hemorrhage furnishes, often, an index of some unnatural state of the 
circulation: and especially of undue fullness of the vessels of the head. But the 
import of this symptom is not always the same. Epistaxis may, indeed, be taken 
as affording an epitome of the various forms of hemorrhage by exhalation. In 
childhood and early youth it is idiopathic, dependent upon active congestion, and 
probably arterial. It is nature's favourite mode of blood-letting at that period of 
life. In old age it is symptomatic, the result of passive or mechanical congestion, 
and probably venous. In some adult persons it happens periodically, and is 
habitual : and its suspension, rather tfyan its occurrence, becomes a token of dis- 
ease or of danger. In young women it is not seldom vicarious of suspended 
menstruation : in men it is apt to take the place of hemorrhois. Lastly, it may 
proceed from disease in the nares themselves ; or form a part of a more general 
hemorrhagic disorder. 

It is unnecessary to go at length into the phenomena of epistaxis. The main 
phenomenon becomes obvious at once both to the patient and to those around 
him: and the accessory and incidental circumstances are easily discoverable when 
the attention is aroused to them by the sight of the blood. Usually the blood 
flows guttatim ; in a succession of drops: but these may follow each other so 
fast as to constitute a little stream. Sometimes a few drops only fall; sometimes 
several pints are lost. A moderate hemorrhage of this kind is generally succeeded 
by a sense of relief and refreshment. A large efflux of blood may cause pallor, 
faintness, debility, exhaustion, even death. 



480 



EPISTAXIS. 



Active idiopathic epistaxis, as it occurs in children, is almost always salutary, 
and may be left* to work its own cure. When it runs into excess, or is too often 
repeated, it may be checked by applying cold water to the forehead and to the 
bridge of the nose. The sudden contact of some cold substance with a distant 
part of the surface of the body will often have the effect of restraining the hemor- 
rhage : apparently by producing a general and sympathetic constriction of the 
superficial blood-vessels. This is doubtless a reflex phenomenon. The nursery 
remedy is to slip a cold key down the child's neck, between its back and its 
clothes. The aspersion of cold water is still better. Besides these external 
appliances, cooling laxatives should be given : and if the bleeding proves obstinate, 
some astringent internal remedy may be thought proper. I have, myself, hitherto 
found none so efficacious as the acetate of lead. But I have been recently informed 
by Dr. Latham that his experience has led him to trust much to mercury in the 
management of epistaxis; and that the same indications have governed him, in 
adapting its use to this form of hemorrhage, as serve to guide him in cases of in- 
flammation. Thus, when the hemorrhage has been profuse and frequent, and 
moderate depletion by blood-letting, or by purgatives, has not arrested it, he has 
brought the constitution rapidly under the influence of mercury; and as soon as 
the mouth became sore, the hemorrhage has ceased, not a drop more of blood has 
been lost. Again, when the epistaxis has been, not copious, but habitual or fre- 
quently recurring, without any excess of vascular action, or any other apparent 
ailment in the constitution at large, Dr. Latham has often cured his patient by a 
moderate salivation, gradually induced, and continued for a few weeks. 

In conversing with Dr. Southey on the same subject, I find that he also has 
been taught by experience to rely upon mercury as almost a specific remedy for 
obstinate hemorrhage, occurring under similar conditions, from whatever organ of 
the body it may proceed. 

This plan of treatment it is therefore my purpose to prove, as future opportu- 
nity may permit. 

When epistaxis begins to show itself in advanced life, it is a symptom which 
cannot safely be neglected : for it indicates that the veins of the head are loaded. 
It implies a morbid condition that requires to be redressed. You will look for 
disease of the heart — or for threatenings of apoplexy — and take your measures 
accordingly. The blood-vessels which ramify upon and beneath the pituitary 
membrane, communicate by indirect inosculation with the veins and sinuses of 
the skull, as well as with the jugular veins. You see, therefore, how it is that 
hemorrhage from this membrane may perform the office of a safety-valve, and 
protect the important organ within the cranium from impending mischief. 

On the other hand, when epistaxis, which is known to have been habitual, fails 
to recur at or about the usual periods, you will look, with a jealous care, into 
your patient's state, and watch for and obviate any tendency to plethora capitis. 

When epistaxis forms a part of more general hemorrhagic disease — as when it 
occurs among other symptoms of purpura — its treatment merges in that of the 
whole malady. 

In any case, if the flow of blood be excessive, and cannot be restrained by the 
ordinary remedies, but is exhausting the patient's strength, it becomes an absolute 
disease : and it will be requisite to staunch the blood by manual expedients. 

These consist in stopping the bleeding orifices mechanically: which is most 
effectually to be done by plugging the cavity. A dossiNof lint must be carefully 
inserted into the bleeding nostril. Its mechanical effect, which is pressure, may 
be chemically aided by first wetting the lint with a saturated solution of alum. 
The mode of introducing these plugs it is the business of the surgeon — and not 
mine — to teach. The operation is not a very comfortable one either to bear or 
to perform. 

A very simple mechanical remedy has been lately announced by Dr. Negrier, 
of Angiers ; who discovered it (he says) by mere accident. The patient is to 
raise one or both of his arms above his head, and to hold them for some little time 



BRONCHOCELE. 



481 



in that position. Dr. Negrier declares that during an experience of three years 
he has never known this method fail to arrest the bleeding. His explanation of 
its modus operandi is not very satisfactory. The expedient itself is however so 
easy, so prompt, and even if unsuccessful so harmless, that its real value deserves 
to be tested — and will soon probably be settled — by an ampler trial.* 

Before we trace this mucous membrane downwards, through the mouth, to the 
inside of the throat, let me turn your attention to a singular disorder which may 
be deemed external, for it is scarcely more than skin deep: I mean that enlarged 
state of the thyreoid gland to which the name of bronchocele has been given. 
This word is not merely derived from the Greek, but was used by the Greek 
writers in the same sense in which we now employ it. In Switzerland, where 
it is very common, and in France, the complaint is called goitre ; a corruption, 
it is believed, of the Latin "guttur," the throat. It is known in England as the 
Derbyshire neck; from its frequent occurrence in that county. 

The term bronchocele has been sometimes applied indiscriminately to all pro- 
tuberances or swellings in front of the throat; or at any rate, to all enlargements 
of the thyreoid gland; whereas it should be restricted to hypertrophy of that part: 
an exaggeration of its natural structure, with augmentation of its volume. The 
texture of the gland becomes coarser; its blood-vessels grow larger and more 
numerous; its cells are magnified, and filled with a thick, viscid secretion. It 
usually presents a soft, smooth, elastic tumour, which is neither painful, nor ten- 
der, nor discoloured. The lobes of the gland become more obvious. Sometimes 
the whole tumour is irregularly tabulated: sometimes the exact form and relative 
proportions of the gland are preserved, each lobe and portion being equally 
increased in size. Occasionally there is a soft uniform or irregular swelling, 
without much distinction of parts. Alibert states that the right lobe is more fre- 
quently enlarged than the left. Mr. Rickwood found it so in every instance of 
bronchocele that came under his notice in the neighbourhood of Horsham. 

Unless the tumour be very large, it follows all the motions of the larynx: and 
this is a point of considerable importance whenever the diagnosis is at all doubtful. 
It is just possible that an enlarged lymphatic gland, or an encysted tumour in the 
neighbourhood of the larynx, or even a collection of pus thereabouts, might, in 
some degree, embarrass the diagnosis. But, by placing the head and neck in 
different successive positions, swellings of this accidental kind may, in general, 
be ascertained to be unconnected with the larynx: and they do not follow its up 
and down movements when the act of deglutition is performed. 

It is of importance to know, also, that the gland itself is subject to different 
kinds of enlargement. It may swell from inflammation, chronic or acute: and 
then it will be hard, and tender, and painful. But it does not seem very prone 
to inflame; and probably Dr. Copland is right in his opinion that inflammation 
occurs spontaneously in this organ in scrofulous persons only. Baillie and Alibert. 
speak of it as being occasionally the seat of cancer: but that must be very rare. 
Sometimes cartilaginous or ossific deposits take place in the gland. It is neces- 
sary, I say, to be aware of these circumstances, and to distinguish one kind of 
thyreoid tumour from another: for some of the morbid changes just referred to 
are clearly beyond the power of any medicine to remove; and if all forms of 
enlargement incidental to this part are lumped together under one common name 
of bronchocele, we shall be liable to arrive at false conclusions concerning the 
power of remedies over that disease. 

Bronchocele is not, in itself, a painful disorder: nor does it taint the system, 
or affect the constitution in any way.. It has no character of malignancv about it. 
It is always, however, a deformity ; and, by its mechanical effects, that is, by its 
weight when large, and by the pressure it exercises on contiguous parts, it mav 

* [In cases of frequently recurring or long-continued epistaxis, blisters to the nape of the 
neck will be found, in general, a very effectual remedy. — C.j 

31 



482 



BRONCHOCELE. 



occasion great distress, and suffering, and even death itself. The size, and the 
effects, of the tumour both vary much in different cases; but its injurious effects 
are not always, though they are generally, in proportion to its bulk. Sometimes 
there is no more than a slight fullness of the throat, which some persons, I be- 
lieve, think rather graceful than otherwise. Now and then, the swelling, after its 
first commencement, develops itself with great rapidity ; but its ordinary progress 
is slow. It often continues for months, or years, without reaching any extreme 
or very troublesome magnitude. Sometimes it remains stationary for a consider- 
able time, and then suddenly increases without any apparent cause. The worst 
effects of bronchocele are its interference with the circulation, and with respira- 
tion. By its pressure it may obstruct the free descent of the blood through the 
veins of the neck, and give rise to headache, giddiness, noises in the ears, confu- 
sion of thought, and a turgid condition of the head and face. Or, by pressing 
upon the wind-pipe, it may cause hoarseness, wheezing, and dyspnoea. It may 
even impede deglutition. But these effects, I say, do not depend altogether on 
the actual size of the tumour. A very large goitre may produce no other incon- 
venience than what results from its weight and its unseemly appearance. It may 
surround all the front and sides of the neck like a thick collar, and rise as high as 
the ears ; or it may hang down, in a pendulous lump, and be supported upon the 
chest. Nay, the tumour is said to descend, in some rare instances, so low as to 
be in contact with the abdomen: and Alibert mentions one case in which the 
swelling was of a tapering cylindrical shape, and reached to the middle of the 
thigh. On the other hand, a small tumour, not bigger than one's fist, especially 
if it happens to occupy the central portion, or what is called the isthmus, of the 
gland, may so press inwards upon the trachea as materially to hinder the breath- 
ing, and even Kb threaten suffocation. A pupil now attending the hospital has 
informed me of a case, which he himself saw, of death produced by the encroach- 
ment of a bronchocele ; not so much, however, from suffocation as from starva- 
tion : for the swelling encircled the trachea, and came at last to press so much 
upon the woman's oesophagus, that she could not get food into her stomach. I 
suppose that the reason of these differences may be sometimes found in the man- 
ner in which the tumour grows, and in its relative situations. When it is bound 
down by the muscles of the neck, it presses, as it continues to enlarge, upon the 
parts behind it. When it is not so confined, the skin readily yields, and the 
entire growth of the tumour takes place anteriorly. 

This disease is much more common in women than in men. Indeed we 
seldom see it, in this country, except in females. Yet I happen to have an 
example of it now (December, 1837) in a male among my patients in the 
hospital. Dr. Andrew Crawford states that forty-nine eases were admitted 
into the Hampshire County Hospital, in ten years, and forty-eight of these 
were in women. Of seventy patients treated in the Chichester Infirmary 
in nine years, two only were males, and they were boys of a very feeble 
and feminine habit, and backward for their years. Among one hundred and 
sixteen patients of Dr. Manson, fifteen were men. Taking an average from 
these three lists, we have one male for twelve females. It is well to bear in 
mind that our fashion of dress renders a small bronchocele much more noticeable, 
much less easily concealed, in women than in men. In the former the swelling 
has been known to come on, or at any rate to increase rapidly, during their con- 
finement in child-bed: and it is frequently observed to undergo a temporary en- 
largement at the menstrual period. Dr. Copland has seldom met with an instance 
in the female, unconnected with some kind of irregularity in the calamenial dis- 
charge, or disorder of the uterine functions ; and he never saw a case in which 
the disease made its appearance before the period of commencing puberty. In 
Switzerland, and in some parts of India, where the complaint is much more pre- 
valent than here, the proportion of males affected is greater; and it begins, often, 
prior to the age of puberty, in both sexes. It seldom shows itself earlier than 
the age of eight or ten. Dr. Elliotson states, indeed, that he himself, when in 



CRETINISM. 



483 



Switzerland, saw goitre in a little boy only four years old ; and the natives told 
him that it rarely made its appearance before the age of six. But children have 
been born goitrous. M. Godelle, physician to the hospital at Soissons^iad a 
preparation of the body of an infant, which only lived a few hours, and which 
came into the world with a goitre ; the mother being affected with the same dis- 
ease. A case is mentioned in the London Medical Repository of a child born in 
Derbyshire with bronchocele of considerable size. The disease, therefore, un- 
doubtedly may be congenital; and one of the facts I have just mentioned points 
to the question of its being hereditary. It is said to be so ; and there is much 
probability in favour of that opinion. Children born of goitrous parents often 
have goitre. But that, you will say, may depend upon their being in the same 
place, and exposed to the same causes, which produced bronchocele in the mother 
or father. Dr. Crawford states, however, that he knew a woman, with goitre, 
whose grandmother, father, paternal aunt, and cousins, also had it, although they 
did not all live in the same place, and no other person in their respective neigh- 
bourhoods was affected by the disease. 

Admitting what seems probable, that the disease may sometimes be hereditary 
in the sense in which I formerly explained that term, there can be no doubt that 
it is often acquired. 

In the first place, bronchocele is endemic — prevalent in certain localities, and 
scarcely occurring elsewhere. And persons who, being previously well, go to 
live in those localities, often become affected with the complaint: and persons 
who migrate from those localities, having the complaint upon them, sometimes 
get rid of it by the mere change of residence. The physical circumstances of 
the places thus selected by the disease have been studied with the natural hope 
of discovering what the cause may be of an effect so singular. Some morbific 
quality of the air was long suspected. The habitats of the unknown cause of 
bronchocele appeared at first sight to be very much like those of the malaria. 
Goitre abounds in the hollows of many mountainous districts ; among the Alps, 
for example, and in the Pyrenees. This was notorious to the ancients. Juvenal 
asks — 

Quis tumidum guttur miratur in Alpibusl 
And it is in the deep, close, and humid valleys of Switzerland, which lie at the 
feet of, and between, high mountains, that bronchocele is most common. Several 
writers, who have personally investigated this subject in places where goitre is 
rife, concur in the belief that it depends upon insalubrity of the air, arising from 
the peculiarities of the situation. They affirm that it is most frequent in low, 
damp, confined spots, where the stagnant atmosphere is seldom stirred by whole- 
some breezes ; and where the sun, in summer, has great power. Dr. James 
Johnson remarks, *« We find in the Valais (one of the Swiss cantons) and in the 
lower gorges or ravines that open on its sides, both cretinism and bronchocele in 
the most intense degrees. As we ascend the neighbouring mountains, cretinism 
disappears, and goitre only is observed. And when we get to a certain altitude, 
both maladies vanish." Dr. Reeve, again, states that all the cretins he saw were 
in adjoining houses in the little village called La Batia, situated in a narrow 
corner of the valley, the houses being built up under ledges of the rocks, and all 
of them very filthy, very close, very hot and miserable habitations. In villages 
situated higher up the mountains, no cretins are to be seen." 

The cretinism mentioned in these quotations is a strange and melancholy dis- 
ease : a sort of idiocy, accompanied by (and doubtless dependent upon) deformity 
and imperfection of the bodily organs. The mental affection exists in all degrees, 
from mere obtuseness of thought and purpose, to the complete obliteration of 
intelligence. Many of the cretins are incapable of articulate speech ; some are 
blind, some deaf, and others labour under all these privations. They are mostly 
dwarfish in stature, with large heads, wide vacant features, and goggle eyes, short 
crooked limbs, flabby muscles, and tumid bellies. The worst of them are 
insensible to the decencies of nature, and obey, without shame or self-restraint, 



484 CRETINISM. 

every animal impulse. In no other class of mortals is the impress of humanity 
so pitiably defaeed. 

Mote recent and extensive observation of the localities infested by goitre have 
rendered it improbable that the disease derives its origin from any deleterious 
properties of the air. Certainly it is not owing to any thing that is common to all 
mountainous countries. Some parts of Switzerland are free from it. So are the 
Highlands of Scotland. It is met with also in flat situations — as in Norfolk. I 
have seen several cases of it in Cambridgeshire, which is a very flat country. 
In one viljage in particular, about five miles from Cambridge, it is extremely 
common. There are some striking facts collected by the celebrated and philo- 
sophic Humboldt, which go to show that the prevalence of .bronchocele does not 
depend on any particular configuration of the surface of the earth, nor on any 
peculiar condition of the atmosphere. He tells us that in South America bron- 
chocele is met with, both in the upper and the lower course of the Magdalen 
river ; and in the flat high country of Bogota, 6000 feet above the bed of the 
stream. The first of these regions is a thick forest; while the second and 
third present a soil destitute of vegetation. The first and third are exceedingly 
damp; the second peculiarly dry. In the first the air is stagnant: in the second 
and third the winds are impetuous. In the first two the thermometer keeps 
up all the year at 22 or 23 degrees of the Centigrade scale : in the third it 
ranges between 4 degrees and 17. 

The researches of Mr. M'Clelland, in India, lead to the same conclusion. He 
found goitre extremely frequent in one portion of the district which he surveyed, 
while the other portion was almost exempt from the complaint, " although an 
equality of moral as well as physical circumstances appeared to affect the whole. 
The external Alpine characters of the province are the same in every part; the 
inhabitants all belong to the same tribes of Hindoos, and are subject to fewer 
irregularities in their mode of life than any other people in the world." 

The different localities of the villages, in the portion where goitre was not pre- 
valent, he describes as being as diverse as can well be imagined. "Some are 
erected on narrow ridges, others in deep valleys, surrounded by abrupt and lofty 
mountains; others on rugged declivities between lofty peaks on one side, and deep 
ravines on the other, into some of which the sun can scarcely penetrate. The 
different altitudes of these villages vary from 2000 to 6000 feet." 

Facts of this kind have turned the attention of scientific inquirers towards the 
only other obvious source to which the disorder could, with probability, be attri- 
buted, viz., the quality of the water used for drinking. Wherever goitre prevails, 
the popular belief assigns it to the water, as a cause : and the more accurately the 
search is prosecuted, the more strength and likelihood does this supposition acquire. 
Its very universality is a presumption in its favour. The disease was formerly 
ascribed to the use of snow water : a notion which originated, I imagine, in its 
frequent occurrence in Alpine regions. But the people in almost all the valleys 
of Switzerland drink the water that comes from the Glaciers: while bronchocele 
is known in some of the valleys only. It prevails also in certain spots where 
pump water is used, and there the people accuse the pump water of producing it. 
Besides, goitre occurs in other countries, where the snow never lies long, as in 
Derbyshire; and even in Sumatra, where there is no snow. Dr. Bally, a native 
of a goitrous district in "Switzerland, believes that bronchocele is caused by certain 
waters, which issue from the hollows of rocks, trickle along crevices of the moun- 
tains, or rise from the bowels of the earth. And in support of that opinion he 
refers to some fountains in his own neighbourhood, the drinking of the waters of 
which will produce, or augment^ goitrous swellings, in eight or ten days. Such of 
the inhabitants as avoid these waters are free, he says, from goitre and cretinism. In 
Captain Franklin's narrative of his expedition to the shores of the Polar sea, there 
is the following statement, made by his fellow traveler Dr. Richardson : — " Bron- 
chocele or goitre is a common disorder at Edmonton. I examined several of the 
inhabitants afflicted with it, and endeavoured to obtain every information on the 



CRETINISM. 



485 



subject from the most authentic sources. The following facts may be depended 
upon : — The disorder attacks those only who drink from the ivater of the (Sas- 
katchanan) river. It is, indeed, in its worst state, confined almost entirely to 
the half-bred women and children why reside constantly at the fort, and make use 
of river water, drawn in winter, through a hole made in the ice. The men, from 
being often from home on their journeys through the plain, where their drink is 
melted snow, are less affected: and if any of them exhibit during the winter some 
incipient symptoms of the complaint, the annual summer voyage to the sea-coast 
generally effects a cure. The natives who confine themselves to snow water in 
the winter, and drink of the small rivulets which flow through the plains in the 
summer, are exempt from attacks of this disease. A residence of a single year 
at Edmonton is sufficient to render a family bronchocelous. Many of the goitres 
acquire great size. Burnt sponge has been tried, and found to remove the dis- 
ease: but an exposure to the same cause immediately reproduces it. A great 
proportion of the children of the women who have goitres are born idiots, with 
large heads, and the other distinguishing marks of cretins. I could not learn 
whether it was necessary that both parents should have goitres to produce cretin 
children." 

We are able even to go a step further, and to announce a probable conjecture 
as to the specific quality of the suspected water. Bronchocele is very prevalent 
in Nottingham and its neighbourhood ; and the vulgar there ascribe it (so Dr. 
Manson informs us) to the hardness of the water. You know that the rough 
practical distinction between soft and hard water is that the former dissolves soap, 
while the latter decomposes it. The hardness is generally occasioned by the pre- 
sence either of sulphate of lime, or of carbonate of lime. In the one case the 
remedy is to mix the carbonate of an alkali with the water; in the other you 
simply boil it. Now the well water in and about Nottingham is more or less 
hard, and unfit for the purpose of washing. Dr. Coindet, of Geneva, declares 
that the use of hard or pump water in the lower streets of that town brings on the 
goitre very speedily. At Cluses, on the Arve, numerous cretins and goitrous 
persons are seen in the streets: lofty clifts of limestone tower over the town, and 
through its caverns copious streams of water find a passage. The soil in the 
neighbourhood of Edmonton was found by Dr. Richardson to be calcareous, and 
to contain numerous fragments of magnesian limestone. In a Treatise on En- 
glish Bronchocele, very recently published, Dr. Inglis states his belief that the 
presence of magnesian limestone always implies the co-existence of the disease. 
"Take (he says) that ridge of magnesian limestone running from north to south 
through the centre of Yorkshire, and margining the shires of Derby and Notting- 
ham. All along that line we have goitre to a very great extent ; whereas, on our 
diverging to either side, the disease is found to diminish." 

These scattered indications that the hurtful quality of the water is somehow 
derived from its contact with limestone rocks, receive a powerful corroboration 
from the result of Mr. M'Clelland's minute and valuable inquiries, which were 
carried on in the province of Kemaon, south of the Himalayan mountains. I have 
not been able to obtain his book ; what I am about to tell you I take from a full 
and instructive notice of it in the fifteenth number of the British and Foreign 
Medical Review. Mr. M'Clelland finding goitre very abundant (as I mentioned 
before) in one great section of a district, and almost entirely absent from another 
section, set himself to find out in what other particulars these sections were dis- 
tinguished from each other. He ascertained that they completely agreed " in 
external aspect, altitude, and climatology," but differed remarkably " in their 
geognostic relations ; and this distinction was even traced down to the very vil- 
lages in which the disease is found, with such perfect nicety, as to enable one 
almost to predict, a priori, on examining the rocks of a neighbourhood, whether 
the inhabitants are affected with goitre or not." 

It would be impossible for me to give you even an abstract of Mr. M'Clelland's 
numerous observations ; but I select one or two striking instances in favour of his 



486 



CRETINISM. 



opinion that the endemic prevalence of goitre is connected with the use of water 
impregnated with calcareous salts. 

One extremity of the long village Deota, which occupies half a mile of the foot 
of Durge mountain, is inhabited by Brahmins ; the other by Rajpoots and Domes. 
Of the first caste there are about twenty persons, all of whom are free from goitre. 
There are forty of the second, and two-thirds are affected, more or less. Of the 
third caste, forty-six in number, nearly the whole are goitrous. " To what cause 
can we ascribe the immunity of one caste of the inhabitants of this village, and 
the almost universal affection of the other two castes ? They are all alike well 
fed, and have little toil; their land producing the requisites of life almost without 
labour. Difference of caste does not here imply a difference of pecuniary cir- 
cumstances, and consequently of the comforts of life. In these respects the three 
castes in this village are on perfect equality. Nor will hereditary predisposition 
acquired by intermarriages be sufficient to explain the interesting fact : for the 
affected parties are confined to the Rajpoots and Domes, who cannot intermarry, 
while the Brahmins and Rajpoots may. The village is raised about one hundred 
feet above the level of the valley; and the mountain, at the foot of which it* is 
situated, rises with a gentle slope, and is not in this vicinity at all rugged. It is 
chiefly composed of transition limestone, and the village is erected on a conglo- 
merated rock, composed of calcareous tuff, inclosing fragments of other rocks. 
There is a spring in the valley, about one hundred yards from the village, bearing 
on its first appearance the character of a mineral spring. The water bursts forth 
w r ith strong ebullition, in the quantity of at least forty gallons in a minute, and 
agglutinates the sand and gravel by which it is surrounded, by the deposition of 
calcareous tuff. The temperature and quantity of the water are the same at all 
seasons. The former inhabitants of the village, aware perhaps of the noxious 
effects of this spring, had an aqueduct formed, by which water is conveyed into 
the Brahmin portion of the village from a distant source. The aqueduct having 
been suffered to get out of repair, the quantity of water it transmits is reserved 
exclusively for the Brahmins ; except during the rainy season, when, the water 
being plentiful, the Rajpoots also use that of the aqueduct; but the Domes have 
no alternative at any season but to use the water from the spring." 

The valley of Baribice is elevated 4000 feet above the sea. Its eastern extremity 
is composed of clayslate, and in five villages, containing 152 inhabitants, there is 
not one goitre. The other extremity of the valley is partly composed of lime- 
stone ; and of 192 inhabitants, distributed in six villages, 70 are affected with 
goitre: but Ducygong, one of these villages, supplied with water from clayslate, 
has not a single case of the disease; while Agar, only half a mile distant, and 
containing 50 inhabitants, has no less than 40 ; and of that number 20 are cretins. 
They use the water which issues from an old copper mine in limestone, and which 
contains carbonate of lime, and of soda, but no sulphate. 

Mr. M'Clelland affirms that in the course of his personal inquiries, which 
extended over 1000 square miles, and which were prosecuted without regard to 
any theory, no instance occurred in which goitre prevailed to any extent where 
the villages were not situated on or close to limestone rock.* 

Cretinism has a close, but an ill-understood, connection with goitre. Where- 
ever cretinism is endemic, bronchocele never fails to be abundant. But bron- 
chocele may prevail in a place where there are no cretins. With but few 
exceptions, cretins are goitrous ; whereas many of those who have bron- 
chocele are not affected with cretinism. The two disorders either spring 
from the same cause, requiring for their 4 joint production that this cause should 
be in active operation : or, if they have separate causes, these frequently co- 
exist and act in combination. It is said, I know not with what accuracy, that 

* [In the United States the disease is prevalent in many of the valleys situated in the 
mountainous regions of New Hampshire, Vermont, New York, Pennsylvania and Virginia; 
many of these regions abound in limestone rocks. — C] 



CRETINISM. 



487 



when both parents are goitrous for two generations in succession, the offspring, 
being in the third generation, are sure to be cretins. Certainly cretinism is most 
common where bronchocele is most common, and especially in mountainous* 
places. It occurs in the Pyrenees as well as in the Alps, in the mountains of 
Syria, in the hilly parts of China, and in the Himalayan regions. Yet cretinism 
is confined within much more limited bounds*than goitre. Saussure, Fodere, and 
Dr. Reeve, agree entirely as to the circumstances under which cretinism appears 
to be most commonly engendered in Switzerland. They say that the disease is 
usually met with in valleys which are nearly surrounded by high and steep rocks, 
where there is but little circulation of air, and where the inhabitants are exposed 
to the direct rays of the sun, and to the reflection of them from the rocks ; and 
also to effluvia from marshes. It is in the filthy habitations built in these close, 
hot and humid situations, that cretinism abounds most. The children that are 
taken away from the low valleys, and carried up, when young, into the high 
grounds, escape the disease ; or even get the better of it if removed soon enough. 
And the amendment is said to be perceptible even in a very few days. These 
facts have led many persons to conclude that cretinism, if not bronchocele, de- 
pends on some condition of the 'air. It appears to me probable that the exciting 
cause of both is the same, and that the local circumstances just now mentioned 
operate as predisposing causes only. Cretinism, as well as goitre, was observed, by 
Ramond, in the " open, well- watered, and well-ventilated valleys of the Pyrenees." 

There are some difficulties opposed to the implicit reception of the opinions 
formed by Mr. M'Clelland and by others, respecting the origin of these diseases. 
And the facts upon which those opinions are grounded, are not without apparent 
exceptions. Moreover, the actual substance which exercises or confers the 
noxious power, has yet to be ascertained. This etiological problem, so full of 
interest, is not solved. One step more, and probably one step only, remains to 
be taken. We look to the medical geologist, for its complete solution ; and I 
trust that, now, we have not long to look. The deleterious agent has been traced, 
with tolerable certainty, to water : and hence to some element of the soil washed 
by that water. And if what at present is probable only, shall hereafter be proved, 
— namely, that the hidden cause of goitre and of cretinism lurks in some chemical 
quality of man's natural beverage — it can scarcely be doubted that chemistry will 
be found ready to supply a simple and effectual corrective of the evil.- This hope 
it is which makes it so important that medical men should be accurately possessed 
of the present state and bearings of the question ; and prepared to take advantage 
of every opportunity that may arise from its practical determination. For surely 
it would be a noble achievement of our art, and a signal blessing provided for 
hundreds of human beings yet unborn, thus to prevent the deformity, the discom- 
fort, and sometimes the danger, of bronchocele ; and to forbid, in its very source 
and fountain, the more hideous and loathsome disfigurement of mind as well as 
of body that distinguishes the wretched cretin. 

I ought, perhaps, to tell you, that other causes, many of them very vague and 
unsatisfactory, have, at different times, been assigned. Thus Valentin supposes 
the disease to be more common in women than in men, simply because women 
more frequently have the neck uncovered. It has been affirmed that young 
females who have taken the veil in Catholic countries have lost their goitres in 
consequence of the change then made in their costume ; and a medical man in 
Guatirnala asserts that the same infirmity has sensibly diminished among the 
men in that part of the world, since cravats became fashionable there. These 
views of the matter accord with some whimsical notions entertained by the late 
Sir Anthony Carlisle. He held that the chief purpose of the thyreoid gland was 
to protect the delicate organ of the voice from the injurious influence of cold ; 
and he consequently regarded the tumour of bronchocele as being rather of a 
sanative than of a morbid nature. He looked upon it as an additional greatcoat 
thrown over the important instrument of speech, in circumstances of extraordi- 
nary need. His theory agrees with some of the facts on which other theories, 



488 



CRETINISM. 



not perhaps more plausible, have been founded. Thus, although snow water 
may not be, indeed I may say certainly is not, the cause of bronchocele from any 
• peculiar quality that belongs to it, yet the disorder is confessedly frequent in 
many places where snow water is habitually drunk ; i. e., as Sir Anthony would 
iiave reasoned, where very cold water is frequently drunk; the swelling being a 
provision of nature to obviate the ffurtful effects which might else he produced on 
the larynx by these cold potations. The summer change for the better, described 
by Dr. Richardson, consists also with the same theory; which would suggest 
the covering an incipient bronchocele continually with warm clothing, such as 
flannel, to check its growth, to obviate its necessity, and so gradually to occasion 
its subsidence. And this plan is mentioned, I see, by Bouillaud, among the cura- 
tive indications. 

I mention these theories, not because I have any faith in them myself, but as 
being curious specimens of the manner in which the human mind strives to account 
for obscure phenomena; and as showing how readily facts maybe called and 
pressed into the service of very slender and infirm hypothesis. 

One very important point in the treatment of bronchocele is obvious; the re- 
moval of the patient, if that can be done, from the infested locality. When this 
has been effected, or when the disorder occurs sporadically, as it sometimes does, 
we may administer drugs with belter hope and advantage. Now a great variety 
of empirical remedies have been recommended for the cure of bronchocele, con- 
cerning most of which it would be a waste of time for me to speak at all. The 
remedy which, as an internal medicine, has of late years superseded all others, 
and acquired the reputation of a specific against goitre, is iodine: and it certainly 
has a remarkable influence over the genuine unmixed form of the disease, whether 
endemic or sporadic — the hy pertrophied gland; yet it does not, perhaps, merit 
the title of specific in the same absolute sense as that in which we say that bark 
is a specific for the ague, or sulphur for the itch. Dr. Coindet, of Geneva, was 
the first who made this remedy extensively known. Dr. Straub, however, of 
Hofwyl, has laid claim to the priority of its use. Probably that happened in this 
matter, which has often happened in others, viz., that the state of knowledge was 
ripe for such a discovery, and it was made by each of these physicians independ- 
ently of the other. Dr. Coindet's name, however, has been inseparably con- 
nected with the application of iodine to the cure of bronchocele, in a work which, 
if he had no other claim to be remembered, would immortalize his memory; — I 
mean Sir J. Herschel's profound and beautiful Discourse on the Study of Natural 
Philosophy ; — a book which I should advise those among you who have not 
already read it, to make themselves master of as soon as ihey have leisure to do 
so. He thus strikingly illustrates an observation of his own, that mighty benefits 
often accrue to science from the casual experience of even unscientific or illiterate 
persons. "A soap manufacturer remarks that the residuum of his ley, when 
exhausted of the alkali for which he employs it, produces a corrosion of the cop- 
per boiler, for which he cannot account. He puts it into the hands of a scientific 
chemist for analysis : and the result is the discovery of one of the most singular 
and important chemical elements — iodine. The properties of this being studied, 
are found to occur most appositely in illustration and support of a variety of new, 
curious, and instructive views then gaining ground in chemistry; and thus exer- 
cise a marked influence over the whole body of that science. Curiosity is excited; 
the origin of the new substance is traced to the sea-plants from whose ashes the 
principal ingredient of soap is obtained ; and ultimately to the sea-water itself. It 
is thence hunted through nature, discovered in salt-mines and springs, and pursued 
into all bodies which have a marine origin: among the rest into sponge. A medi- 
cal practitioner, Dr. Coindet, of Geneva, then calls to mind a reputed remedy for 
the cure of one of the most grievous and unsightly disorders to which the human 
species is subject, the goitre; which infests the inhabitants of mountainous districts 
to an extent that, in this favoured land, we have happily no experience of, and which 
was said to have been originally cured by the ashes of burnt sponge. Led by 



TREATMENT. 



489 



this indication, he tries the effect of iodine on that complaint, and the result estab- 
lishes the extraordinary fact that this singular substance, taken as a medicine, acts 
with the utmost promptitude and energy on goitre, dissipating the largest and 
most inveterate in a short time, and acting (of course, like all medicines, even the 
most approved, with occasional failures) as a specific, or natural antagonist, against 
that odious deformity." 

It is curious enough, and marks the accuracy with which the effects of remedies 
may be observed, that not only had burnt sponge been found efficacious in remov- 
ing bronchocele, but the bladderwrack also, the fticus vesiculosus, the plant that, 
with others of the same family, yields the soda wherewith the iodine was found 
combined. Dr. Gairdner, who was the first I believe in this country to write on 
the effects of iodine, accounts for the frequent failure of even large doses of the 
burnt sponge, by showing that it was much adulterated with charcoal. Dr. 
Manson, of Nottingham, has published the following tabular statement of the 
results of the employment of iodine by himself. He had treated one hundred 
and sixteen patients, of whom fifteen were men, and the rest women. Of the 
fifteen men, ten were cured, three were improving and under treatment at the 
time of his publication, one was dismissed for irregular attendance, and one was 
much relieved. Of the one hundred and one women, sixty-six were cured, nine 
much relieved, two received no benefit, ten were discharged for irregular attend- 
ance, and fourteen were improving under treatment. Of the whole one hundred 
and sixteen, therefore, there were seventy-six positive cures, or two-thirds of the 
entire number; and only two positive failures. Dr. Coindet was successful in 
about the same proportion of cases. This is strong evidence of the power of the 
remedy. Dr. Manson found that in some, but not in all individuals, afler the 
preparations of iodine had been given internally for a certain time, they were apt 
to occasion headache, giddiness, sickness of stomach, with some degree of lan- 
guor, and inaptitude for exertion. His plan in such cases was to suspend the use 
of the medicine, or to reduce the dose. The following effects of the iodine are 
stated by Dr. Coindet as having occurred in his practice: — Acceleration of the 
pulse, palpitation, dry cough, watchfulness, marasmus, and prostration of strength. 
Sometimes swelling of the legs, tremors, painful hardness of the bronchocele^ 
diminution of the breasts, or a remarkable increase of appetite supervened; and 
he adds, that in almost all the instances which he had observed, a very rapid 
diminution, or a disappearance more or less complete, took place, during these 
symptoms, of even hard, bulky, and old bronchoceles. His doses varied from 
somewhat less than a grain to somewhat more than a grain and a half. This was 
certainly, as Dr. Manson has suggested, too large a quantity of this powerful 
drug for the generality of patients. The management of the remedy is now better 
understood. I have never seen any of the unpleasant consequences enumerated 
by Dr. Coindet. These practitioners gave the iodine in the form of a tincture. 
But this is a bad mode of exhibiting it : for the tincture is decomposed in any 
aqueous menstruum, and the iodine thrown down to the bottom. Under such 
circumstances the patient may at one time get no iodine at all, and at another time 
a dangerous dose: for you are aware that iodine is an active irritant poison. But 
if you mix iodine with iodide of potassium, it is then held in solution : and this is 
the form in which it is now commonly given. In the last edition of the Pharma- 
copoeia there is a Liquor Potassii Iodidi compositus, made by dissolving five 
grains of iodine, and ten of the iodide of potassium, in a pint of distilled water. 
This will doubtless, in future, be much prescribed. It is a dilute preparation. 
There is one grain of iodine in four ounces of the liquor. An ounce would, there- 
fore, be a very safe dose, but you may begin with a couple of drachms, and increase 
the quantity, if need be, gradually: for not only Dr. Manson, but Dr. Copland 
also, who states that the remedy has been very successful in his hands, advocates 
small, unirritating, what are sometimes called alterative doses. Simple friction 
is said to have had the effect of diminishing the tumour; and friction with some 
ointment or liniment containing iodine should be employed whenever the internal 



490 



BRONCHOCELE. 



exhibition of the remedy is contra-indicated: or in addition to its internal £fse% 
There is an authorized form for that purpose also in the Pharmacopesia — the" 
Unguentum Iodini Compositum. A small portion of this may be rubbed epon 
the tumour night and morning. I need not add that besides great care in watching 
for the specific ill effects of the iodine upon the system, no less care is to be taken 
in correcting the state of any other function which may be faulty, and in improving, 
the general health. 

Such is the best medical treatment of bronchocele ; and such is the plan which 
you will always do well to make cautious trial of in the first instance: and with 
respect to surgical treatment I may observe, that so long as the disease is merely 
a deformity, so long as it does not interfere with any of the important functions of 
the body, nor produce serious discomfort — does not distress the respiration by 
pressing upon the trachea, nor impede deglutition by pressing upon the oesophagus, 
nor derange to any great degree the circulation through the head by pressing upon 
the great blood-vessels of the neck, nor grievously encumber the patient by its 
weight — we should not be justified (in my opinion) in performing or advising any 
surgical operation for the removal or the diminution of the tumour. Of such 
operations the three principal are, extirpation of the whole gland ; the passing a 
seton through the tumour, and so exciting suppuration in it, whereby its substance 
is broken down and destroyed ; and, tying the arteries which supply it with blood. 
The first of these methods, extirpation, has been performed when the wen was 
small; but few patients under such circumstances would consent to the operation ; 
and few surgeons would now-a-days, I presume, advise or undertake it; and in 
cases where it might seem more expedient, that is, where the swelling is large, 
and suffocation is threatened by its pressure on the trachea, the execution of this 
measure would be exceedingly difficult and dangerous ; for the arteries are so much 
dilated in these cases that perilous hemorrhage might be expected from their divi- 
sion, especially when their close vicinity to the carotids is considered. Such 
large goitres come to involve also, by their lateral extension, very important nerves 
there situated. In one case where excision was attempted, the hemorrhage was 
so alarming that the surgeon was obliged to desist in the middle of his task ; and 
the patient actually died of hemorrhage a few days afterwards. I believe that this 
operation may be considered as wholly abandoned by surgeons in the present day. 

The introduction of a seton into the tumour has been more successful. This 
practice was revived somewhat more than twenty years ago by Dr. Quadri, of 
Naples ; who supposed, indeed, that he had been the first to devise it. You will 
find an account of his mode of proceeding in the tenth volume of the Medico-Chi- 
rurgical Transactions, by Dr. Somerville. The seton is passed through the 
substance of the gland, and retained there a considerable time ; the chief caution 
necessary is to avoid the enlarged blood-vessels. Dr. Quadri affirms that the 
larger trunks of the thyreoid arteries will not be endangered unless the seton 
needle be passed so deeply as almost to touch the thyreoid cartilage ; and that 
hemorrhage from any of the branches of those arteries that may be wounded 
when the seton is inserted more superficially, will not be attended with hazard. 
This plan was followed in one case by ulceration and sloughing, and the patient 
died. An example of the success of this treatment occurred in the practice of Mr. 
James, of Exeter; the tumour was almost entirely removed, and the patient was 
for some time in London for the purpose of showing himself to the medical men 
here. But he also had passed through a good deal of suffering and peril. 

The expedient of tying one or more of the thyreoideal arteries, and so starving 
the tumour, has been attended with varied success. It has been done on the con- 
tinent; and several times in this country : there is a case of it by Mr. Coates, of 
Salisbury, in the same volume of the Medico- Chirurgical Transactions. His 
patient was much relieved for a time, and supposed herself cured. But the tumour 
gradually returned, and caused her death by suffocation. Sir B. Brodie has also 
performed a similar operation ; and I have myself seen one very satisfactory 
instance of the same thing, the operation having been done by the late Mr. Earle, 



CYNANCHE PAROTIDJEA. 



491 



in St. Bartholomew's Hospital. The patient was a young woman with an im- 
mense bronchocele, which for some time previously had obstructed her breathing, 
and of which the effect on the trachea seemed to be everyday increasing. There 
was loud wheezing, and great difficulty of respiration, and congh, and extreme 
emaciation : and it was plain that the girl must soon die suffocated if nothing 
were done for her relief. One of the arteries, I think the superior thyreoidal, was 
tied, without much difficulty, on one side. After the operation, the tumour on 
that side shrunk considerably; the distress of breathing was removed; and the 
patient presently recovered so much of her former strength, and flesh, and com- 
fort, that she was unwilling to have any thing more attempted, and left the hospital. 
After some time, however, she came back again of her own accord, and requested 
that the artery on the other side might be tied also. This was accordingly done, 
and a further reduction of the tumour took place. The shrinking, however, if I 
remember rightly, was not so striking or complete after the second operation as 
after the first: but the patient was certainly rescued, upon the whole, from im- 
minent death, and put into a condition of ease and at least temporary safety ; 
the tumour that remained constituting merely a deformity. I never heard of her 
afterwards. In a case very similar to this, related by Mr. Crawford in the 
Cyclopaedia of Practical Medicine, Mr. Wickham, of Winchester, tied one of the 
arteries, with much immediate, but no ultimate benefit. The goitre gradually 
diminished for about six weeks, and then (in consequence, I presume, of the 
establishment of a collateral arterial circulation) it as gradually enlarged again till 
it was as big as ever. 

Of these surgical expedients there is not one, of which the average results have 
been sufficiently prosperous to warrant its repetition, except in cases where life is 
put in jeopardy or made miserable by the swelling; and where other methods, 
and particularly the treatment by iodine, have been tried, and have failed. One 
exception, perhaps, I should here make. The tumour sometimes evidently con- 
tains a quantity of fluid, either in one of its enlarged cells, or in a distinct cyst. 
Now the cell, or cyst, may in such cases be punctured, and the contained fluid 
let out, without much risk. This was done in one instance by my colleague, 
Mr. Arnott. He kept the orifice open ; and the cyst shrank, and was at last ob- 
literated, and the woman was much gratified by this diminution of her load. 



LECTURE XLIV. 

Cynanche Farotidasa. Spontaneous Salivation. Jlphthse. Cynanche Ton- 
sillaris. 

The Greek writers on medicine apply the terms ewtvyzq anc ^ xwwyzy to inflam- 
matory affections occurring about the throat, and more or less interfering with 
the functions of respiration and deglutition: and the Latins employed the word 
angina in nearly the same sense. Cullen, in his Nosology, has made a genus 
of Cynanche, although the diseases which he has included in that genus have but 
little connection, except that the parts they occupy lie near to each other. Some 
of them, indeed, have their seat in different, though almost contiguous, portions 
of the same membrane; and are apt, sometimes, on that account, to pass one into 
the other. In general they are allied rather by proximity of situation than by 
community of symptoms. 

I mention these things, because their being a great disposition in the present 
day to re-name diseases, and to affect a more precise and scientific nomenclature 
than sufficed for Cullen, if I adopted the more modern appellations without 
adverting to the old ones, which have been current so many years, you might 
experience some difficulty in your reading, in determining what disease was 



492 



CYNANCHE PAROTIDiEA. 



intended, when it was merely named. For my own part, I think there is much 
inconvenience in altering the established nomenclature ; and especially in changing 
such arbitrary terms as, though they may not be scientific, are yet definite, and 
convey no erroneous notions respecting the nature of the disorder. I shall give 
you, however, in most cases, both the old and the new denominations. 

Now one of the maladies in Dr. Cullen's genus Cynanche — though not the first 
in the order he follows — is cynanche parotid&a. It is an inflammatory affection 
of the salivary glands, and of the parotid gland in particular. Accordingly it is 
called parotitis now-a-days. It is not, however, mere inflammation of the parotid, 
arising from any cause whatever; and therefore parotitis, unless some epithet be 
added, is less exact than cynanche parotidaea. The vulgar have given it just as 
good an arbitrary name as the learned ; and they call it, in this country, the 
mumps. With the Scotch it is, I believe, the branks. 

The disorder need not detain us long. The parotid swells ; tumefaction takes 
place beneath the ear; and if the submaxillary and sublingual glands are not im- 
plicated in the outset, they soon participate in the tumefaction, in most instances; 
so that the swelling extends from beneath the ear along the neck, towards the 
chin, and the swelled parts are hot and painful, and very tender when touched. 
The aspect of the patient becomes curiously deformed. Sometimes one side only 
is affected; sometimes both sides at once ; but most commonly of all, first one 
side and then the other. These local symptoms are attended with slight fever. 
But the only function that is materially affected is the motion of the lower jaw, 
which is impeded by the swelling. The inflammatory condition almost always 
terminates after a few days, in resolution, under the use of the antiphlogistic regi- 
men, and the application of external warmth. The disease reaches its height in 
about four days, and then begins to decline ; and its whole duration may be stated, 
on an average, at eight or ten days. 

This complaint often prevails epidemically: when it affects one person in a 
family, or school, it usually affects several others, simultaneously or in succes- 
sion. It chiefly attacks children and young persons. There can be no doubt that 
it spreads by contagion ; and it seldom happens that the same person is twice 
affected by the mumps. These are remarkable circumstances, and give the malady 
a peculiar and specific character. I do not dwell upon them now, because they 
belong also to a very interesting group of diseases, which will require to be par- 
ticularly considered hereafter. 

Another curious circumstance connected with the disease, and one which has 
some bearing upon its treatment, is that, in many cases, upon the subsidence of 
the swelling of the neck and throat, and particularly when it subsides quickly, 
the testicles, in the male sex, become swollen and tender, and the mammas in the 
female. It is said, but I do not know whether the observation be constantly true, 
that, the testicle, or the breast, of the same side with the inflamed parotid, suffers. 
Sometimes the testicle wastes away after the swelling recedes; a circumstance 
which is known occasionally to happen when inflammation of that part arises 
from other causes. This, however, is not usual. In general the inflammation 
subsides and ceases in the one gland as it does in the other ; the swelling is neither 
very painful nor long continued. But sometimes a more serious transference 
takes place, from the testicle to the brain : this I have never witnessed ; but then, 
to say the truth, I have not often been called upon to treat the mumps, and my 
personal experience of it is limited. I find it stated that the metastasis to the 
testicle is considered as rather a fortunate circumstance, because it serves as a sort 
of protection against metastasis to the brain; but I suspect this to be a mistake. 
Inflammation of the brain, or of its tnerhbranes, has sometimes occurred on the 
disappearance of the parotid swelling; but it has much oftener supervened, I 
believe, upon the retrocession of the inflammation from the testicle or mamma. 
It is said also that the inflammation sometimes returns from the testicle to the 
parotid, and back again ; oscillating thus two or three times between the two 
glands. Fortunately, the metastasis to the brain is much more rare than that to 
the testicle. 



SPONTANEOUS SALIVATION, 



493 



The treatment of the mumps is simple. It consists in the observance of the 
antiphlogistic regimen; mild diaphoretics; laxative medicines, if the head aches, 
or the bowels are confined ; and warm fomentations, or dry warm flannel, to the 
neck and throat. The tendency observed in this complaint to a change of place 
- — to metastasis to more important organs — forbids us from using very active mea- 
sures to check or subdue the inflammation. Nor are such measures necessary. 
We are not to bleed, nor violently to purge such patients, nor to apply cold to 
reduce the swelling. Luckily, hot applications are not only the most safe and 
proper, but the most grateful also to the feelings of the patient. If suppuration 
should ensue — which is unusual and unlikely, but which sometimes does occur 
from extension of the inflammation to the neighbouring areolar tissue — poultices 
must be substituted for the fomentation. Warm applications, and rest in the 
horizontal posture are to be recommended when the inflammation leaves the sali- 
vary glands, and attacks the testicles ; or if the patient will not, or cannot, lie up, 
the testicle must be supported by a suspensory bandage — a bag truss. If the in- 
flammation of the testicle or mammae be very violeut, we must apply leeches, and 
afterwards poultices ; but this will not often be required, or advisable. Finally, if 
the inflammation should fly to the brain, we must lay aside our previous caution, 
and treat the disease in that active manner which the inflammation of so important 
a part of the body demands. No worse metastasis can occur on the cessation of 
the phrenitis. I have fully spoken heretofore of the treatment to be pursued in that 
disease, and I have nothing to add respecting it now, except that it may be right 
as an auxiliary expedient, to try to reproduce the inflammation in the parotid, or 
testicle, or mamma, by irritating applications — mustard poultices, for example — 
in the hope of thus producing what is called revulsion, and of diverting the dis- 
ease from the brain to the part which it previously occupied. 

You know that there is another specific form of parotitis, which is apt to be 
induced by mercury. Of this I have already spoken. When it is severe, it may 
be treated by leeches, without any dread of such metastasis as occurs in the 
mumps. It is usually, though hot always, accompanied by a profuse discharge 
of the secretion proper to the glands affected ; and it is attended also by spongi- 
ness and swelling of the gums. 

I presume that when inflammation of these salivary glands is not attended with 
ptyalism, the parenchyma of the gland, or the areolar tissue which enters into its 
composition, is principally affected; and that when there is much salivation, the 
membrane lining the secretory and excretory ducts is implicated. We see the 
same distinctions in other analogous organs. 

Profuse ptyalism sometimes occurs without any obvious cause; and is then 
said to be idiopathic, or spontaneous: and this is a circumstance which it con- 
cerns you to be aware of, both as practitioners and as medical jurists. The same 
tenderness and swelling of the salivary glands, the same copious secretion and 
excretion of saliva, nay, even the same fetor, or a smell which can scarcely be 
distinguished from it£-the same collection of symptoms which is familiar to you 
as indicating the specific action of mercury upon the human system — will arise 
sometimes (but very rarely) when not a particle of mercury has been adminis- 
tered. Several other substances are well known to have the occasional effect of 
producing an increased, and even a profuse flow of saliva: preparations, for ex- 
ample, of gold, of copper, of antimony, and of arsenic. The castor oil is said 
to have sometimes the same consequence. Digitalis certainly has ; and the iodide 
of potassium; and sometimes, I believe, opium. Now and then ptyalism is met 
with as a symptom "among others, of pregnancy. Occasionally it results from 
some local irritation within the mouth ; from a decayed or misplaced tooth. But 
what I principally wish to call your attention to is the fact that salivation may 
occur as an idiopathic complaint. In the twenty-sixth volume of the London 
Medical and Physical Journal, there is an instance of it described by Mr. Davies, 
in which two or three pints of saliva were discharged daily for some time. This 
flux at length ceased under the use of laxative medicines. In the second volume 



494 



APHTHAE. 



of the Transactions of the College of Physicians is an extraordinary example of 
the same thing, related by Mr. Power. A young lady, of sixteen, spat from sixteen 
to forty ounces of saliva daily for upwards of two years. Mr. Power believed 
that the ptyalism in this case was originally excited by wool, which he found, 
in a fetid state, in her ears. In the Revue Medicate there is an account given of 
a patient who was cured of a spontaneous ptyalism after spitting nine pints daily 
for nine years and a half. You may see another instance, as related by Dr. Prout, 
in the old series of the Annals of Philosophy. Dr. Pereira states that he has 
seen a dozen such cases; and he describes one which was fatal, not from the 
ptyalism, however, but from sloughing of the cheek: and this is no uncommon 
circumstance. In certain cases of idiopathic inflammation and ulceration of the 
gums or cheeks, from some constitutional unsoundness, there may be extensive 
sloughing ptyalism, and a very offensive odour, much resembling that which mer- 
cury produces. I have met with one example only of well-marked spontaneous 
ptyalism ; and some of its circumstances were so peculiar, that they may be 
worth relating. I was taken out to Bayswater, by a medical friend, in the begin- 
ning of the year 1833, to see a little girl, ten years old, who had been in a state 
of salivation from the 5th of November in the preceding year. Up to that time 
she had been a healthy lively child, with nothing very remarkable about her, 
except that she was habitually subject to profuse perspirations, which had a very 
acict smell; so that the washerwoman was always aware which were her clothes, 
when she came to wash them, by this smell. She then suddenly became indis- 
posed, had a little headache, and began to spit a good deal. This was noticed by 
her mother, and pointed out to her medical attendant, before any medicine was 
given her; and mercury, on that account, was religiously withheld. But in spite 
of all treatment the ptyalism went on increasing. When I saw her she was spit- 
ting three pints of saliva in twelve hours : transparent, rather dark-coloured, and 
with a small quantity of foam on its surface. There was nothing amiss with her 
teeth, or her gums, and no fetor of the breath. She was greatly emaciated, and 
resembled, in some respects, a person worn down by diabetes. From the very 
commencement of the spitting, the acid perspiration had ceased, and even the 
vapour had failed to make her sweat. A great variety of remedies were tried, 
under Dr. Nevison's superintendence, but without the least good effect. At last 
came the visitation of the influenza, in April of that year. "The girl became 
severely affected by that disorder; and thereupon the salivation disappeared, and 
has not returned. I heard to-day that she is in excellent health. 

Should you meet with cases of the same kind, you will search for some cause 
of irritation in the neighbourhood of the salivary glands, and especially in the state 
of the teeth and gums ; and finding none, you will seek further for the cause of 
the salivation in some deviation from the natural condition of one or other of the 
principal functions of the system: and you will regulate your treatment accord- 
ingly. I do not know of any specific plan of cure to be recommended : but it is 
certainly of importance that you should be acquainted with'yhe fact, that ptyalism 
sometimes exists as a separate and independent malady. Astringent washes are 
found, sometimes, of service; a solution of alum, or the infusion of catechu. 

Before I proceed to the diseases pertaining to the interior of the fauces and 
throat, let me take this opportunity of saying a few words in respect to aphthae. 
They form the characteristic symptom of an especial disease of infancy : and they 
are apt to occur in the course of other diseases in adult age ; and are then of some 
importance as guides in forming our prognosis, and even in determining our plan 
of treatment. 

Aphthae consist in small, irregular, but usually roundish white specks, or 
, patches, scattered over the surface of the tongue, and the lining membrane of the 
cavity of the mouth and fauces ; the angles of the lips, the cheeks, the palate, the 
pendulous velum, the tonsils, the pharynx. They look like little drops of tallow, 
or morsels of curd, sprinkled over those parts ; they project a little above the 



APHTHiE, 



495 



surrounding surface ; and, in fact, they are mostly formed by elevated portions of 
the mucous epidermis, covering a small quantity of a serous or gelatinous fluid, 
which separates the epidermis from the subjacent corium. These portions of the 
epidermis detach themselves, and fall off; leaving behind them a reddish raw- 
looking surface, or sometimes a foul and ash-coloured spot: and successive crops 
of these aphthae are apt to be formed. 

Now children in arms who exhibit these aphthae, are said to have the thrush. 
This occurs at an early age; seldom, or never, I believe, after the period of lacta- 
tion is over. The spots occasion some inconvenience in themselves — the mouth, 
is rendered hot and tender by them. The child may be eager enough to take the 
breast, but is observed to do so with pain and wailing whenever the mouth is 
applied to the nipple, and attempts to suck or to swallow are made. 

But these aphtha?, thus occurring in infants, are attended with other symptoms 
of disorder: such as drowsiness, sickness, diarrhoea, and some feverishness. 
And, I believe, a general notion prevails, that the same aphthous condition which 
is visible in the tongue and mouth, pervades, in such cases, the whole of the ali- 
mentary canal. But this must be a mistake. That some morbid condition exists 
throughout that tract is highly probable, but true aphthae can only form on those 
mucous surfaces which are provided with a continuous epidermis. This errone- 
ous notion has been strengthened, perhaps, by the observation of aphthous spots 
on the pharynx and oesophagus. The complaint sometimes appears to be the 
result of improper diet, in children brought up by hand; or of milk of a bud 
quality, from an unhealthy or intemperate nurse. It generally lasts eight or ten 
days. It is not attended with much danger, except in certain cases, when the 
surface is left brown or bluish after the loosening and separation of the crusts. In 
such cases, the local affection is apt to run into a bad kind of gangrenous ulcera- 
tion, and the discharges from the bowels become slimy and shreddy. 

In almost all instances of the thrush in children, there is acidity of stomach 
present. Care, of course, is to be taken to discover and to correct any error of 
diet; and any unwholesomeness in the quality of the food. And antacids are to 
be administered. I know of no form of medicine better adapted to remedy the 
diarrhoea of infants than the pulvis sodse cum hydrargyro of our hospital Phar- 
macopoeia ; composed of two parts of the pulvis cretae compositus, two parts of 
the dried carbonate of soda, and one part of hydrargyrum cum creta. From 
three to five grains of this powder may be given thrice daily: and for the local 
affection of the tongue and mouth, the mel boracis is a capital application. It may 
be painted on the aphthous parts with a camel's hair pencil. 

Aphthae occurring in adults, in the course of other diseases, are often the har- 
bingers of dissolution. They denote considerable debility; and they point out 
the propriety of sustaining the patient's strength, by bark, wine, and nourishing 
food. It is remarkable how treatment of this kind will sometimes tell. I had a 
patient last summer who lived for some months, and in tolerable comfort, after a 
second attack of apoplexy. Every now and then he would have a crop of aphthae 
appear, which was always an admonition to us that he not only would bear, but 
that he required some tonic. A more generous diet, with bark, would dissipate 
them in a day or two. 

Borax is an excellent application for aphthae, whether they occur in adults or 
in infants. I have known it afford great comfort to patients who were in the last 
stage of phthisis, and to whom the aphthous state of the mouth was a source of 
considerable distress. Equal parts of mel boracis, and syrup of poppies, make a 
good form. Or an agreeable as well as useful gargle may be made by mixing 
two drachms of borax, with an ounce of mel rosae, three ounces of decoction of 
quince seeds, and four ounces of water. 

Aphthae seem sometimes to depend upon mere derangement of the stomach. 
A nobleman who is well known as a bon vivant, can never eat shell-fish (so I am 
told by his physician) without finding, within two hours, that his month is full of 



496 



APHTHJE. 



aphthae. Even lobster-sauce will serve him thus. I look upon this as a sort of 
internal urticaria.* 

* [The disease ofthe mouth occurring in infants during the period of suckling, in which 
the tongue, and the inner surface of the lips and cheeks are covered, to a greater or less 
extent, with minute portions of a white matter resembling curd — and which constitutes the 
muguet of the French writers, the thrush or children's sore mouth of nurses, and the aphthae 
hctumina and aphthse infantiksof the older physicians, is evidently a very distinct affection 
from the aphtha which occurs in the adult as well as in the infant. The first depends upon 
an erythematic inflammation of the mucous membrane of the mouth, in which an altered 
secretion, in the form of small and curd-like particles or flocculi, or, as in other diphtheritic 
inflammations, of large patches of a soft pseudo-membranous matter, takes place upon the 
surface of the inflamed membrane. Upon the separation of these morbid exudations, the 
membrane beneath is found to be smooth, and without any solution of continuity. Accord- 
ing to Guersent,the curd-like exudation is deposited beneath the epithelium, and its separa- 
tion is consequent upon the rupture of the latter; Plumbe is of a similar opinion: Guyot 
and Billard, however, never saw it, excepting upon the surface of the epithelium, and this 
accords with our own experience. 

In mild cases, the inflammation of the mouth quickly disappears, the particles of curdy 
matter becoming detached, fall off,and leave the membrane beneath of a smooth and healthy 
appearance. In other cases the inflammation continues for a greater length of time with 
little abatement: the spots of curd-like matter increase in number, and, occasionally, 
form by their union large patches, often of considerable thickness — these patches, sooner 
or later become detached and fall off, and their place is quickly supplied by a new exuda- 
tion: and this separation and renewal of the patches continue as long as the inflammation 
lasts. In some instances, the patches upon the tongue, lips, and cheeks, coalesce, and the 
whole of these parts become coated with a whitish, granulated crust, which not unfre- 
quently extends into the fauces, pharynx, and, occasionally, into the larynx. 

In situations where a number of children are crowded together, in ill-ventilated apart- 
ments, the patches of exudation acquire often a dark colour, the breath of the infant becomes 
fetid — the submaxillary glands enlarged and painful, the face swollen and of a dusky- 
red hue — the lips and gums become tumid and bleed upon the slightest touch, while a 
fetid sanious saliva flows constantly from the mouth. Diarrhoea often attends, the dis- 
charges being dark-coloured and highly offensive. The disease, in its milder forms, is rather 
troublesome than dangerous — and it may be removed very speedily by an appropriate 
treatment; but when it is attended by the symptoms last described, it is very apt to termi- 
nate fatally, death being occasionally preceded by a deep comatose condition. 

There exists some difference of opinion among medical writers as to how far the morbid 
exudation characteristic of this affection extends beyond the mouth and fauces. It is gene- 
rally admitted that, in severe cases, it has been found in the oesophagus, as far down as its 
cardiac orifice: but, while some, including Billard, have asserted that it has been observed 
throughout the whole tract of the alimentary canal, others, with Veron, maintain that, in no 
instance has it been met with beyond the oesophagus — the curd-like crusts, occasionally 
found in the stomach being, as they suppose, conveyed thither from the mouth by degluti- 
tion. Guyot gives a case, in which the disease was detected, after death, throughout nearly 
the whole tract of the intestines. In the few opportunities we have had of examining the 
state of the alimentary canal in infants who have died whilst labouring under this disease, 
we were unable to trace the exudation beyond the oesophagus — a similar statement is made 
by Dew-ees and Eberle. 

We are to recollect that the disease just described is the result of an erythematic 
inflammation of the mucous membrane of the mouth; aphthse, however, are produced by a 
follicular inflammation of the same membrane. This affection is more commonly observed 
about the period of dentition than at an earlier age — it is particularly liable to occur in 
children of a lymphatic temperament, or in whom haematosis has been rendered imperfect, by 
improper or innutritious food, a damp and cold, or impure and stagnant atmosphere, ex- 
clusion from the light, and neglect of cleanliness. It is, also, of very common occurrence 
during most of the chronic affections, especially of the intestinal canal, in persons of all 
ages. 

In the commencement of the disease the mucous membrane of the mouth becomes in- 
creased in redness, and upon the inner surface of the lips and cheeks, on the sides and 
inferior surface of the tongue, and, occasionally, over the greater part of the soft palate, 
there soon appear a number of distinct white specks, which upon examination are found 
to be small transparent vesicles, of a grayish or whitish colour, each being surrounded at 
its base by a raised, hard ring of a red colour more or less decided. These vesicles often 
occur in groups, or they may cover the whole of the lining membrane of the mouth and 
fauces ; extending, in some cas.es, into the oesophagus, and throughout the alimentary canal; 
while in other cases, they penetrate into the pharynx, and. according to some writers, into 



CYNANCHE TONSILLARIS. 



497 



Hard by the salivary glands lie the tonsils: and one of Cullen's species of cy- 
nanche is the cynanche tonsillaris : in more modern language, tonsillitis, or amyg- 
dalitis : or, in the vernacular, quinsy, common inflammatory sore throat: a 
disease which, though internal, is yet within the reach of our sight, and easily 
recognized. 

the larynx and even the trachea. The follicular inflammation will often continue for some 
time, as just described, without making any further progress, and it may often be arrested 
before ulceration ensues. Usually, however, the vesicles enlarge in size, rupture, and give 
discharge to a whitish matter; a superficial ulcer now occurs, with slightly elevated edges, 
and surrounded by a circle of inflammation. These ulcers often secrete a white, curdy 
matter, which adheres, at first, to their surface, but becomes subsequently detached, and is 
either swallowed or ejected with the saliva. It is often succeeded by anew exudation of a 
similar matter, and thus, in protracted cases, the crusts of curdy matter are repeated!}' 
detached and renewed; or only a portion of the crusts are detached, while the general 
layer of curdy matter remains adherent, often for weeks. When the aphthous ulcerations 
are numerous, and in close contact, this curd-like exudation may spread from one to the 
other, and form a layer, often of considerable thickness and extent. Occasionally, the exu- 
dation from the ulcers is mixed with a small portion of blood, it then forms dark-coloured 
crusts, which have, not unfrequently, been mistaken for gangrenous sloughs. 

Upon the subsidence of the inflammation the ulcerated follicles readily cicatrize without 
leaving any permanent scar. 

Occasionally, particularly in children of debilitated habits, and who are deprived of pro- 
per hygienic influences, the aphthous ulcerations become gangrenous, their edges shrink, 
and assume a ragged, flabby appearance ; a brownish slough forms in their centre, which, 
on separating, leaves a granulated surface of a vermilion hue; or, in place of a slough, 
the ulcers become covered with a brown, creamy fluid, that exhales a very decided gan- 
grenous odour. The parts surrounding the ulcers become tumid, soft, and of a violet hue. 
From the half open mouth of the child, is discharged a ropy often fetid saliva. The counte- 
nance becomes pale and puffy; the pulse feeble; and the entire surface of the body pallid, 
and deficient in sensibility: — repeated vomiting, profuse diarrhoea, and a tympanitic condition 
of the abdomen, generally occur; and occasionally, hiccup with frequent eructations, and 
the patient finally dies, according to Billard, without febrile reaction or cerebral excitement. 
(See Condie on Diseases of Children, page 126 et seq.) 

Recently, M. Gruby has attempted to show that, aphthae and muguet are invariably pro- 
duced by the development of a cryptogamic vegetable. 

According to the researches of this gentleman, the affection consists, at first, of small, 
conical, whitish elevations, twenty-five millimetres in diameter, dispersed over the mucous 
membrane of the mouth. These elevations quickly augment in size, and extend rapidly 
over the adjacent surface, until, finally, the whole of the mouth, fauces, and sometimes the 
entire extent of the alimentary canal, appear to be covered with a pseudo-membranou s layer, 
from two to three millimetres thick, and strongly adherent to the subjacent tissue. When 
a portion of this substance was examined under a microscope, M. Gruby found it to be 
composed entirely of a collection of cryptogamic plants, the roots of which, of a cylindrical 
form, transparent, and about one-four hundred and eightieth part of a millimetre in diame- 
ter, are implanted in the cellules of the epithelium. During their development, projections, 
from these roots penetrate the entire series of cellules of which the epithelium is com- 
posed, to arrive at the free surface of the mucous membrane. 

According to M. Gruby, these cryptogamic plants have considerable analogy with the 
sporotrichium described by some botanists. Being very fragile, they become detached by 
the movements of the tongue and lips, and mixing with the food, are carried into the ali- 
mentary canal, a considerable portion of the mucous coat of which they subsequently 
cover. Those children in whom this extension of the disease takes place to any great ex- 
tent, fall into a state of marasmus, and soon die. 

M. Gruby, having never detected in the white substance of aphthae or muguet any thing 
else than the cryptogami just described, and the cellules of the epithelium,— there being, 
in no instance, any product of inflammation present, — considers himself authorized to con- 
clude that aphthse are neither more nor less than a vegetation occurring upon the living 
mucous membrane. Views precisely similar to those of M. Gruby have been advanced 
by Dr. Berg, of Stockholm. 

Dr. Oesterlein has also submitted the matter of aphthae and muguet to microscopic ex- 
amination, and has been able to deteet in it a vegetation similar to that described by the 
observers just named. This vegetation, he has met with, however, only at the period of the 
fullest development of the aphthse or muguet, which latter he considers to be the product 
of an exudation resulting from an inflammatory condition of the mucous membrane; the 
production of the confervas being purely accidental. He attempted, repeatedly, to trans- 
plant them to other animal tissues or fluids, but without success.— C] 
32 



498 



CYNANCHE TONSILLARIS. 



The popular term quinsy is in truth traceable — through the French esquinancie 
— to the scientific term cynanche. 

This common and troublesome disorder occurs with very unequal severity in 
different cases. The differences depend upon the extent of the disease, and upon 
the number and variety of the parts which it involves : for it is seldom limited 
entirely to the tonsils, but spreads to the uvula, the velum palati, the salivary 
glands, the pharynx, and even to the root of the tongue, and the neighbouring 
areolar tissue. When the inflammation is superficial it does not produce any 
great distress, even though it may be diffused. When it penetrates through and 
beyond the mucous membrane, it is apt to end in suppuration, and to harass the 
patient much: the tonsils swell to an enormous size, and at length deep abscesses 
form in them. The disease is worst of all when the back part of the tongue, and 
the muscular and areolar tissue thereabouts, become implicated : it may chance to 
reach even the larynx, and then it is always and extremely perilous. 

Under its more ordinary forms, cynanche tonsillaris generally manifests itself, 
at first, by a slight degree of uneasiness and difficulty in swallowing ; with a con- 
stant dryness and sense of constriction in the fauces, and a feeling as if some 
foreign substance were sticking there. Upon inspecting the throat, more or less 
of inflammatory redness and swelling is seen of one or both of the tonsils. Some- 
times both of them are affected at once. Very frequently one only is first attacked : 
and the swelling begins in the other as it ceases in the first. This is just what 
occurs in many instances also of cynanche parotidsea. The uvula is commonly 
enlarged and elongated, and of a scarlet colour. Sometimes it drags upon the 
back part of the tongue, or dangles into the pharynx, causing the disagreeable 
sensation of a foreign body continually present, and provoking, by its mere con- 
tact, painful and fatiguing acts of deglutition. More frequently the uvula may be 
seen to be adherent to that tonsil which is most swollen. The dryness of the 
fauees soon gives place to a copious secretion of transparent mucus, which is 
frothy and viscid, and sticks to the inflamed surface, so as to be detached with 
difficulty; and the patient is tormented by continual and painful efforts to hawk 
up, or to swallow, this mucus. In an early stage of the disease opaque whitish 
spots appear upon the red tonsil. They are exudations from its surface, or the 
discharged contents of the mucous crypts there situate. It is important that you 
should be aware of this, lest you mistake such specks for ulcerating or sloughing 
points, such as occur in some other affections of the throat, but which are not 
common in the outset at least of this. 

When the inflammation is violent, the submaxillary and parotid glands some- 
times swell, and become tender on pressure; and, less frequently, the patient is 
troubled by profuse ptyalism. In other words, the inflammation spreads from 
the tonsils to the salivary glands, and secondary parotitis occurs; sometimes 
with and sometimes without an augmentation of their natural secretion. Unable, 
or unwilling, to swallow the abundant saliva, the patient allows it to dribble from 
his mouth. 

Now and then, although the act of swallowing is difficult and painful, you per- 
ceive, <m looking into the fauces, no appearance which can account for these 
symptoms. The inflammation is seated lower down in the throat; out of sight. 
This cannot with propriety be called cynanche tonsillaris; indeed, it forms a dis- 
tinct species, the cynanche pharyngea of Cullen. I mention it here because it 
really does not require any separate consideration. 

The pain in cynanche tonsillaris is felt almost solely during the act of degluti- 
tion ; which is difficult also from the mechanical narrowing of the passage by the 
enlarged glands. T^hen both tonsils are affected at once, and much swollen, they 
push forwards the anterior pillars of the velum palati, and project in the shape of 
two great balls of flesh, into the arch of the fauces, so as to leave a very small 
space only between them ; and they sometimes even meet and touch each other, 
and cause ulceration by their mutual pressure. When attempts are made to swal- 
low liquids, they are apt to return through the nose ; the backward passage can 



CYNANCHE TONSILLARIS. 



499 



no longer be shut in consequence of the tumid and fixed condition of the velum 
palati. The patients are unable to swallow even soft solids; indeed the pain of 
swallowing is so great, that they are not easily persuaded to try. In severe cases 
pain shoots from the throat to the ear along the course of the eustachian tube ; 
and this is considered important, as being indicative of suppuration. I believe 
that suppuration does occur in the majority of the cases which are attended with 
this symptom. Sometimes there is tinnitus aurium, and partial deafness, from 
the obstruction produced to the passage of air through the eustachian tube : either 
by closure of its extremity in consequence of the swollen state of the parts about 
it, or by some thickening of its lining membrane from an extension of the inflam- 
mation along its channel. 

When the inflammation is intense, and involves the root of the tongue, the 
patient becomes unable to open his mouth sufficiently to allow the fauces to be 
seen ; and the inflamed parts can be examined only by means of one's finger. In 
some instances the power of separating the jaws is so limited, as not to admit the 
introduction of the finger: and the tongue is incapable of any motion. 

In ordinary cases, however severe the disease may be, there is scarcely any 
affection of the breathing. But the throat is so blocked up, and the free play of 
the velum palati so impeded, that the speech is altered ; becoming thick, guttural, 
and inarticulate. You may often recognize the disease by the peculiar sound of 
the patient's voice, without looking into his throat. When the swelling of the 
tonsils is very great, the breathing does sometimes become impaired ; and it is 
in such cases alone, or nearly in such cases alone, that this disease is at all 
alarming. 

Cynanche tonsillaris is commonly attended, from the very outset of the inflam- 
mation, by smart inflammatory fever: severe headache often, and a rapid pulse, 
rising to 120 beats in the minute, or more. The constitutional disturbance runs 
higher than we might have expected, considering the limited extent of the local 
intlammation, and the comparatively small importance of the part inflamed. At 
the same time there is very little of that debility and anxiety which are observed, 
as we shall see hereafter, in common continued fever. 

The inflammation often terminates by resolution ; but when it is violent or long- 
continued, it very frequently leads to the formation of pus. When the mucous 
secretion increases in quantity, and becomes less viscid, while the difficulty of 
swallowing diminishes, and the febrile symptoms decline, resolution may be 
expected. Suppuration, on the other hand, may be looked for when the inflam- ■ 
mation is unusually intense, when, by the swelling of the tonsils, the breathing is 
impeded, when a pulsating pain is felt, shooting to the ear, when the patient can 
scarcely open his mouth, or protrude or move his tongue, when there is more 
than usual external swelling, and when the symptoms increase, or even fail to 
remit, after five or six days have elapsed. Rigors sometimes accompany and 
announce the suppuration : and afterwards the pus may be often seen shining 
through the membrane covering the tonsils. In many cases, however, it lies so 
deep that it cannot be detected by the most careful examination. At length the 
little abscess bursts ; and the relief thereupon experienced by the patient is sudden 
and striking. All at once the pain ceases : he can swallow, and he feels himself 
well; and often indeed he is well, or nearly so. The matter discharged has 
always a nauseous taste and a remarkably fetid 5mell : and sometimes the fetor, 
or the ill taste, is the only sign, besides the improvement in the symptoms, that 
indicates the rupture of the abscess; the pus being so small in quantity as when 
mixed up with other matters, easily to escape notice, or (what frequency happens), 
passing backwards into the stomach by an involuMary movement of deglutition. 
Suppuration sometimes, but rarely, takes place externally, in the areolar tissue of 
the neck, as well as internally. 

The termination in gangrene is spoken of in hooks \ and it is just possible : but 
it never happens, I imagine, except in unhealt! iv constitutions ; or when tonsil- 
litis occurs as a complication of more general disease, such as scarlet fever. It is 



500 



CYNANCHE TONSILLARIS. 



much more common to see repeated attacks of cynanche tonsillaris produce what 
used to be absurdly called scirrhus, a permanent enlargement and hardening of the 
tonsils. While they are in this state, a low kind of inflammation is very readily 
re-excited in them. The enlarged tonsils are generally irregular, and notched ; 
something like the surface of a walnut shell; and a white or yellow secretion is 
often to be seen lying in the hollows. This appearance may be easily mistaken, 
by an inexperienced eye, for ulceration. 

There is not much risk of your confounding cynanche tonsillaris with any other 
complaint. The various species of cynanche enumerated by Cullen are separated 
each from the others by certain broad lines of distinction: all derived, however, 
from different combinations of two symptoms ; — dyspnoea and dysphagia. Thus, 
in cynanche tonsillaris, deglutition alone is difficult; and when you look into the 
throat you see at once why it is difficult. There is equal difficulty of swallowing, 
and equal freedom of respiration, in cynanche pharyngea; but the cause of the 
dysphagia is not visible. In cynanche trachealis, the respiration is much affected ; 
the facility of swallowing not affected at all. In cynanche laryngea both these 
functions are implicated ; there is difficulty of swallowing as well as difficulty of 
breathing. Cynanche parotidoea is distinguished by the absence of both the 
symptoms; its title to the name of cynanche is therefore equivocal. Many of 
these points will soon come under our notice again. 

Cynanche tonsillaris is supposed to be most frequent among the young and 
plethoric. But it certainly occurs very often also in persons who are pale, and 
spare, and feeble; and in those of middle age. Some individuals appear to have, 
by nature, a strong predisposition to the disease ; and in them its attacks are more 
or less periodical; recurring at particular seasons, and commonly during the 
variable weather of spring and autumn. This peculiarity runs sometimes in 
families. The liability to the complaint is also very much increased by repeti- 
tions of the attacks. 

The only exciting cause worth mentioning, almost the sole cause indeed, is 
exposure to cold. Not unfrequently it assails so many persons at the same time 
as to be epidemic ; and for that reason it has sometimes been thought contagious. 
But it has no contagious property whatever. Although we often see several 
members of the same family affected by it at once, yet we may learn, upon careful 
inquiry, that its commencement in the different cases has been too nearly simul- 
taneous to admit the supposition of its having been communicated from one to 
another. The patients have all been exposed to the same unwholesome influences, 
which operating upon similar constitutions, such as those who are sprung from 
the same parents may be expected to possess, have produced similar effects. 
This prevalence of the disorder at certain times and places, is connected, no doubt, 
with some peculiar conditions of the atmosphere. 

The prognosis is almost always favourable. Not but what deatii may be pro- 
duced by this disease, under peculiar circumstances, and when the inflammation 
is unusually violent and extensive. The late Dr. Gregory, of Edinburgh, used 
to mention in his lectures one instance, the only one he had met with among many 
hundred cases, of death from cynanche tonsillaris. He did not see the patient till 
he was moribund ; and he suspected that it was combined with typhus fever. The 
only fatal case that I ever witnessed occurred some years ago at the Middlesex 
Hospital, in one of my own patients. He was a stout young man, 26 years old, 
a private coachman. The complaint was clearly traced to his having got wet 
through, more than once, a day or two before it came on. Besides the ordinary 
symptoms of cynanche tonsillaris, there was great external swelling on both sides 
of the throat, and the patient was unable either to'open his mouth, or to move his 
tongue. The inflammation involved not the tonsils merely, but the base of the 
tongue, the salivary glands, and the surrounding areolar tissue. At length suppu- 
ration took place. The abscess broke internally, and pointed also externally, just 
below the symphysis of the chin, where it was opened with a lancet. Two days 
after, there was a sudden gush of blood from the mouth. So immovable were his 



CYNANCHE TONSILLARIS. 



501 



jaws that it was impossible to determine from which side the hemorrhage pro- 
ceeded ; it was stopped, however, apparently by the treatment adopted. A fort- 
night later, the bleeding recurred profusely. It was now evident that the blood 
was arterial, and that it came from the left side of the throat. Preparations were 
made for tying the common carotid on the left side ; but just as the operation was 
about to be begun, the patient expired in our presence. His death was shocking, 
but full of pathological interest. He did not sink, as you may have supposed, in 
the way of syncope, from loss of blood ; but by suffocation. The blood passed 
down the trachea and into the lungs ; and he had been so weakened by the pre- 
vious hemorrhage, that he could not expel the blood so introduced, which actually 
choked him. A large clot was afterwards found, filling up the wind-pipe. I felt 
this man's pulse beat firmly and regularly, for a minute perhaps, after his last 
effort to breathe. On examining the body it was discovered that the abscess had 
opened internally behind and below the left tonsil. The lingual branch of the 
carotid artery crossed the site of the abscess ; and had been severed and laid open 
by ulceration. From this vessel the fatal hemorrhage had come. 

It should be borne in mind also, that cynanche tonsillaris does sometimes, by 
extension of the inflammation to the neighbouring parts, superinduce that very 
formidable species of cynanche, of which I am soon to speak, the cynanche 
laryngea. All cases in which the breathing is in any degree affected, should 
excite suspicion, and strict scrutiny ; although the dyspnoea may be produced by 
the mere swelling of the tonsils. 

You will understand, then, that cynanche tonsillaris may, under unusual and 
untoward circumstances, prove a fatal disease ; but that it is so very rarely indeed. 
In almost all cases we may say that the life of the patient is not in danger. 

In the uncomplicated and milder form of the disease, when the inflammation is 
superficial and the fever slight, no great activity of treatment is requisite. The 
patient should be kept within doors, and even in bed : for a troublesome tendency 
to a recurrence of the disorder may be fostered by neglect or imprudence. Cooling 
saline purgatives will be proper, and the antiphlogistic regimen. A strip of flan- 
nel may be put round the neck, and some stimulating embrocation applied to the 
exterior of the throat, beneath the ramus of the jaw : the compound camphor lini- 
ment is well adapted to this purpose. Some such plan as this will generally 
suffice, not indeed to stop the inflammation of a sudden, nor to put an end at once 
to the fever, but to cause the complaint to run its course evenly, and to go on to 
resolution in a few days. Commonly it is not completely over until both the 
tonsils have been attacked in succession. 

When you catch the disorder in its very outset, I believe you may sometimes 
succeed in cutting it short by an emetic: a scruple of ipecacuanha, for example, 
with a grain of tartarized antimony. In all cases it is right to administer a brisk 
purgative. 

A great variety of astringent, acid, and other gargles, have been employed in 
this disease; and their good effects have, I apprehend, been much over-rated. 
Many cases would do quite as well, or better, without them: for in the early 
stages strong astringents, and the straining and movements of the throat that 
accompany their use, may even be hurtful, and increase the pain and the inflam- 
mation. The only gargle which I should consider admissible in the commence- 
ment of the malady is a gargle of warm milk and water. I have known of one 
instance in which quinsy suddenly attacked a gentleman who was extremely 
anxious to use his throat, in public speaking, the next day. He occupied himself 
perpetually, for some hours, in this sort of fomentation of the tonsils with hot 
water ; and with such good effect that on the day following he was able to accom- 
plish his object. Still there are cases in which, at certain stages of the disease, 
detergent gargles are serviceable, by assisting the excretion of the mucus that col- 
lects in the fauces, and by correcting fetor. A weak solution of chlorine in water 
answers well. In more chronic sore-throats, stimulating gargles may often be 
employed with advantage. When the inflammation is violent a slightly stimulant 



502 



CYNANGHE TONSILLARIS, 



linctus is preferable ; it cuts the phlegm as they say, i. e., it promotes its detach- 
ment and removal. Of this kind, currant jelly is one of the best. 

But far better than any thing else, as a local application to the inflamed fauces,, 
is the steam of hot water ; whether we are hoping for resolution of the inflamma- 
tion, or whether we desire to promote and hasten the process of suppuration 
already begun. The inhaler introduced by myself into the Middlesex Hospital, 

and elsewhere, though somewhat clumsy in 
appearance, is the most convenient and effectual 
that I am acquainted with. I show it to yon. 
It was invented in Edinburgh by a friend @f 
mine long since dead, Mr. Hercy. It will standi 
upon a table, or lie upon a pillow ; and a large 
volume of steam is carried inwards against the 
fauces by the mere natural breathings of the pa- 
tient. Most of the inhaling machines that I have 
seen require a sucking effort, like that made in 
smoking a pipe : an effort that is apt to be irk- 
some and fatiguing, especially in pulmonary dis- 
eases ; for some of which this method of apply- 
ing vapour directly to the suffering part is as useful as it is for sore-throats. 

Blistering the outside of the throat is a favourite remedy with many. When 
early applied, a blister often does much good, and probably prevents suppuration 
in some cases. But I have found blisters of uncertain efficacy ; they leave a mark 
which lasts for some time, and which patients of the other sex are apt to com- 
plain of. For these reasons I prefer mere rubefacients ; the liniment I mentioned 
before, or the compound soap liniment, or a mustard poultice folded between two 
layers of thin linen. 

In more severe cases leeches applied to the upper part of the throat, just below 
the angles of the jaw, have been found to give sensible relief: and in the worst 
degrees of the disorder, when there is much outward swelling, and the jaws and 
tongue are fixed, leeches are absolutely requisite. It may be proper to take blood 
from the arm also. The necessity for active depletion must be measured by the 
severity of the local symptoms, the intensity of the fever, and the general strength 
and condition of the patient : and of these things a little experience will teach you 
to judge. 

It is not to be expected that either leeches or blisters will be of much use after 
the process of suppuration has commenced; nay they may sometimes be injuri- 
ous by retarding it. It is frequently a difficult matter to determine whether pus 
has yet formed or not. 

I have already admonished you to make a careful examination of the throat, 
and to watch your patient narrowly, whenever he experiences any difficulty of 
breathing. Dyspnoea may be produced by the mere swelling of the inflamed part: 
and when it concurs with much enlargement of the tonsils you had better pierce 
them with the lancet. If they contain matter, it will be evacuated ; and if not, 
the bleeding produced by the puncture will generally reduce the swelling some- 
what, and relieve the patient. There is an instrument made on purpose for this 
small operation, consisting of a lancet enclosed in a flat silver sheath, from the 
end of which it is made to protrude, to a certain extent only, by pressing upon a 
spring. The instrument should be directed towards the centre of the fauces, and 
not outwards, in order to avoid wounding important vessels or nerves. Dr. Cullen 
indeed says, " this does not require much caution :" but notwithstanding this high 
authority, I must warn you that puncturing or scarifying the tonsils is an opera- 
tion not to be carelessly, or rashly, or wantonly performed. Portal mentions a 
case in which a skilful surgeon in scarifying the tonsil of his patient, wounded as 
he supposes some ramification of the internal carotid, and the patient was presently 
dead. That artery lies, as you know, very near the tonsil ; and only a few years 
ago, in Ireland, it was struck by a surgeon while scarifying a gentleman's tonsil ,* 




CYNANCHE TONSILLARIS. 



503 



and the gentleman died in three minutes. This I was told by the late Dr. Barclay. 
The case I related just now of fatal hemorrhage from the lingual artery points to 
the same danger : and since that case occurred two others involving similar hazard 
have fallen under my own notice, and impressed me with a strong feeling of the 
necessity of caution. A man was brought into the hospital with profuse hemor- 
rhage from the right tonsil or its immediate neighbourhood, the consequence of 
syphilitic ulceration of those parts. He had lost three or four quarts of blood, 
and was nearly dead. His life was saved by Mr. Mayo, who tied the common 
carotid on that side. 

Last February (1838) a boy from Harrow School was placed under my care, 
in whom cynanche tonsillaris came on during convalescence from scarlet fever. 
So much swelling was there of both tonsils that they met, and pushed the uvula 
outwards before them, and the breathing was much impeded. A surgeon who 
was in attendance with me punctured the tonsils. The next day a good deal of 
hemorrage took place ; and this recurred, several times, to a' considerable and even 
an alarming amount. When the clots that formed were wiped away with a sponge, 
the blood could be seen welling out in a little stream, with a pulsating motion, from 
a small incision in the left tonsil. The hemorrhage was ultimately, after much 
trouble and anxiety, arrested, by applying a pencil of lunar caustic freely, within 
the bleeding orifice. Lint, wetted with the muriated tincture of iron, or with a 
saturated solution of alum, is a fit application in similar accidents. 

Mr. Lawrence, who saw this case, told me that he once knew a patient die of 
hemorrhage from the tonsillar artery. 

I ought, perhaps, here to add, that, very recently, Mr. Joseph Bell, of Barr- 
head, has strongly recommended the internal administration of powdered guai- 
acum, in large doses, as being almost specific in the cure of cynanche tonsillaris. 
He gives as much as half a drachm, suspended by means of mucilage, in a 
draught, every six hours. Mr. Bell has no doubt that this remedy, if timely 
administered, will cut the disease short in ninety-nine cases out of a hundred. 
It has been found successful in other hands also. I have never had an oppor- 
tunity of trying it. 

The chronic enlargement of the tonsils, to which I have already adverted, is 
sometimes productive of great inconvenience and distress, and even of danger. 
Its occasional consequences are — an habitual trouble in swallowing': confused and 
inarticulate speech ; deafness in various degrees, from occlusion of the eustachian 
tubes; more or less impediment of breathing; and even spasm of the glottis, 
and impending suffocation. The enlargement may, in such cases, be somewhat 
reduced, I believe, by repeatedly passing a stick of lunar caustic over the surface 
of the tonsils ; but a much readier and better plan is to amputate them, in part at 
least. This may be done by a ligature ; or still better by scissors, or by a sort 
of small guillotine invented for that purpose. It is not a very painful operation. 
Mr. Arnott removed one lately from one of my hospital patients ; and a very few 
days ago (December, 1838) Mr. Mayo brought two, in a piece of paper to the 
hospital. He had just before cut them off for a patient whose respiration they 
had much embarrassed.* 

* [Recently the application to the enlarged tonsils of the iodide of zinc, is said to have the 
effect of causing their rapid absorption. The article is prepared by placing a clean plate 
of zinc over a jar or vial, and sprinkling iodine over it. In a short time the iodine is 
deposited in the vessel, in the form of a semi-fluid deliquescent substance. This is to be 
applied pure, to the surface of the enlarged tonsil, by means of a camel's hair pencil, or a 
piece of sponge, secured to a suitable handle. It is to be held on for a short time, and 
repeated every two or three days, until the object is accomplished. The application is 
followed by a pungent smarting, which lasts for twenty or thirty minutes, but by no other 
inconvenience. Dr. Goddard, of this city, we are informed by Dr. Parrish, in his annual 
Report on Surgery, read to the College of Physicians, has used the remedy extensively, and 
speaks very favourably of its effects. He has found it to possess the property of inducing 
a rapid absorption of the enlarged tonsil, by a sort of shriveling process, without the forma- 
tion of a slough. It does not, like the chloride, of zinc, spread to the surrounding healthy 



504 



ACUTE LARYNGITIS. 



LECTURE XLV. 

Acute Laryngitis. Symptoms. Treatment ; Blood-letting. Tracheotomy, 
Mercury, Antimony. Anatomical Characters of the .Disease. Causes. 
Secondary Laryngitis. (Edema of the Glottis. Chronic affections of the 
Larynx. 

The disease of which I have next to speak is of far more serious character 
than those which were considered in the last lecture. Cynanche laryngea, or 
acute laryngitis, has proved rapidly fatal in a large proportion of the instances in 
which it has been known to occur. Yet, when the patient is seen tolerably early, 
and the nature of the malady is clearly perceived, and the source of peril tho- 
roughly understood, I believe that our art is sufficient, in most cases, to rescue 
the sufferer from the fate that hangs over him. It is of the greatest importance, 
therefore, that you should be able to recognize laryngitis when you meet with it, 
and that you should comprehend the principles according to which it requires to 
be treated. 

What is laryngitis ? It consists, as that term implies, in inflammation of the 
parts composing the larynx ; and especially of the mucous membrane that covers 
the laryngeal cartilages, including the epiglottis. The inflammation may be, and 
sometimes is, exactly limited to the larynx ; but frequently it extends also to the 
posterior fauces, the velum palati, and the tonsils. 

The symptoms of acute inflammation of the larynx are these. The patient 
complains of sore-throat. If you look into his throat you will commonly per- 
ceive some redness of the velum and uvula, and of the fauces generally. But 
there is a degree of restlessness and anxiety about the patient more than propor- 
tionate to the apparent inflammation. Among the earliest of the symptoms that 
bespeak danger, and ought to excite alarm, is difficulty of deglutition, for which 
no adequate cause is visible in the fauces ; and to this is presently added difficulty 
of breathing, for which no adequate cause can be discovered in the thorax. The 
mode and character of the respiration are peculiar; it is attended with a throttling 
noise; the act of inspiring is protracted and wheezing, as though the air was 
drawn in through a dry narrow reed. If you ask the patient what is the seat of 
his distress, where the disease is situated, he points with his finger to the pomum 
Adami. If he coughs, he coughs with a peculiarly harsh, stridulous, husky, 
abortive sound. He either speaks quite hoarsely, or (what is more common) all 
power of audible voice in the larynx is lost, and he speaks by means of his lips 
and tongue only, in a whisper. There is tenderness of the laryngeal cartilages ; 
they are painful when pressed externally. The face is flushed ; the skin hot 
and dry ; the pulse hard. As the disorder advances, the patient's general dis- 
tress increases ; but some of the symptoms alter; his countenance becomes pale 
or livid, anxious and ghastly ; his eyes protrude ; he is miserably unquiet, impa- 
tient for some relief, declares or makes signs that he wants air, and begs that the 
windows may be opened : and if he does not obtain timely relief, he perishes — 
he dies strangled. 

The pathology of this terrible disease is extremely simple. The membrane 
covering the interior surface of the instrument of the voice suffers inflammation. 
One effect of inflammation in mucous membranes is a thickening of those mem- 
branes ; they become turgid and swollen. Another frequent effect is the effusion 
of serous fluid in the subjacent areolar tissue. By such tumid thickening of its 
lining membrane, the chink called the rima glottidis is narrowed : it is still further 

structure, and hence, maybe used without the fear of injury from being swallowed. {Sum- 
mary of the Trans, of the College of Phys., of Philadelphia, No vii, page 191.)— C.J 



ACUTE LARYNGITIS. 



505 



diminished in breadth whenever the membrane Is lifted and protruded by infiltra- 
tion of the tissue beneath it: it is so nearly closed up, that air cannot pass inwards 
insufficient quantity to sustain the vital functions: a small portion only of the 
blood returned to the lungs from the right side of the heart undergoes the requi- 
site change from venous to arterial. The miserable patient grows drowsy and 
delirious, and dies by a slow process of strangulation. If the rima glottidis be- 
comes quite closed up, his sufferings, and his life, are quickly at an end. 

This disease affords a good instance of a truth which was announced in a 
former part of this course of lectures; viz., that the danger of a morbid change 
may depend entirely upon its situation. It is so, eminently, with laryngitis. The 
inflammation is sometimes limited to a spot of membrane not bigger than a square 
inch. If a square inch and no more of the same membrane, a little lower down, 
in the trachea, were inflamed in the same manner and degree, the complaint would 
be quite unimportant. Cynanche laryngea derives all its peril from the circum- 
stance that the inflammation tends to shut up what may well be called the janua 
vitse. The part affected subserves two purposes : it is the organ of speech ; and 
it forms a portion of the channel through which air is conveyed from without into 
the lungs. Both of these purposes are impeded in laryngitis. Now the animal 
function of speech may be entirely and permanently suspended without any dan- 
ger to life. The function of respiration, which, though under the influence of the 
will, is an organic function, will not bear to be suspended, even for a few minutes ; 
and life cannot be long sustained when it is much impeded. 

The difficulty of swallowing is a remarkable symptom, and almost always 
present. Yet it is not absolutely universal; for Mr. Lawrence describes a case 
in which it did not occur. It appears to depend, in some measure, upon the 
tumid and tender condition of the whole membrane which is common to the 
larynx and pharynx, and which is pressed upon as the larynx rises in the act of 
deglutition: but this symptom depends also, and in a greater measure, upon the 
state of the epiglottis, which is often enlarged, and fixed by the swelling in an 
erect position, and unable to execute its natural valvular office; so that when the 
patient makes efforts to swallow, a portion of the food or drink gets into the 
larynx, and a paroxysm of choking dyspnoea ensues. By pressing down the 
back part of the patient's tongue, and getting him at the same moment to make a 
coughing effort, you may sometimes obtain a sight of the tumid, red, and upright 
valve. 

The dyspncea is constant: yet there are pauses of comparative ease and quiet; 
and there are, commonly, periods of severe aggravation and urgent distress. It 
is probable that the permanent narrowing of the chink by the inflammation and its 
consequences is from time to time increased by spasmodic contraction of the 
muscles that close the glottis. 

This is the first disease that has come before us, in which the respiration has 
been primarily impeded. If you call to mind what was stated in one of the early 
lectures respecting death by apncea, you will be at no loss to understand the 
manner in which life is destroyed in laryngitis. 

This formidable malady has always existed ; for you may trace examples of it, 
under various names, even in the writings of the ancients. But it is only in recent 
times that it has been singled out from the rest of the anginae, and made a separate 
object of study. It has numbered some distinguished medical men among its 
victims: Dr. David Pitcairn, Sir John Macnamara Hayes, Sir George Tuthill. 
The celebrated General Washington died of it. When it has caused death it has 
generally run a rapid course, and proved fatal before the fifth day. It has carried 
the patient off in less than twelve hours. 

It is of the utmost consequence to make an accurate diagnosis. Laryngitis 
is easily distinguished from cynanche tonsillaris by the extreme and peculiar 
dyspnoea which attends it. There may be difficulty of breathing in the latter 
disease, from enormous swelling of the tonsils; but then such swelling will mostly 
be visible. In laryngitis the marks of inflammation to be seen on inspection of 



506 



ACUTE LARYNGITIS. 



the fauces are generally slight and trifling, and quite inadequate to explain the 
difficulty of swallowing. Do not, however, forget that laryngitis may supervene 
upon cynanche tonsillaris. Again, cynanche laryngea is readily discriminated 
from cynanche pharyngea ; in which complaint there is great pain and difficulty 
in deglutition; but the breathing is quite free. In cynanche trachealis, or croup, 
which I shall next describe, the breathing is affected, and the swallowing is not. 

What is to be done for a patient labouring under acute laryngitis ? How and 
when are we to employ the great remedy for acute inflammation — blood-letting? 
or are we to employ it at all? These are points concerning which it is quite 
necessary that your minds should be prepared and prompt to decide. If you look 
merely to the results in the recorded cases of this fearful complaint, you will 
scarcely find an answer to the question. In some of them copious bleeding ap- 
peared to save the patients ; in others, it was of no service, but rather seemed to 
accelerate their death. Sir John Macnamara Hayes suffered two attacks of 
cynanche laryngea. In the first he was freely bled. Dr. Roberts, of Bishop 
Stortford, informs us that the first bleeding was attended with considerable relief; 
the second also with manifest advantage ; and by the third, his safety appeared 
to be ensured. Fifteen years afterwards he died of the same disorder, for which 
he was again bled and leeched, under the care of the late Dr. Baillie. Washington 
was largely bled, and died. Again, a Dr. Francis, of New York, recovered from 
acute laryngitis after copious venisection. It is evidently needful to consider and 
determine the circumstances under which we are to use, or to withhold, the lancet. 

Bleeding, to be serviceable, or safe, must be performed early. There is, 
perhaps, no disease in which the xavpog otvs, the fleeting opportunity, is more 
conspicuous than in this. When I say that you must bleed early if at all, I do 
not mean that you are to reckon so many days or hours from the commencement 
of the disorder; but you must ascertain what progress it has made; for it travels 
sometimes at a railroad-pace. You must look to your patient's actual condition; 
and I apprehend that your practice, in respect to blood-letting, may be safely 
guided by the following rules. If there be high inflammatory fever present, and 
the skin is hot, the pulse firm and full, and the cheeks are red, and the lips florid, 
you may bleed your patient with decision and advantage. But if his powers are 
beginning to sink under the poisonous influence of imperfectly aerated blood, if 
his skin be cold, or even cool, his face pale or leaden, his lips blue, his pulse 
small and feeble, his mind wavering — you will do no good by blood-letting: 
nay, you will increase the debility which already exists, and hasten the fatal 
catastrophe. 

With regard to local blood-letting, and to counter-irritation, there is one remark 
made by Dr. Farre of much practical importance. It is a common practice, in 
affections of the throat, to apply leeches over or near the laryngeal cartilages, and 
afterwards to place a blister there. Now serous infiltration of the neighbouring 
parts often follow leech-bites ; and the effect of a blister in producing serous effu- 
sion often extends beyond the skin: and the cartilages of the throat lie very near 
the surface; and it is possible that oedema of the glottis might be produced, or 
augmented, in consequence of these topical remedies. It will be better, therefore, 
when we wish to take blood locally, to take it by cupping from the back part of 
the neck : and when we desire to produce counter-irritation, it will be prudent to 
lay a blister on the upper part of the sternum, rather than to the front of the throat. 

In the advanced stage of the disease, medicine, I fear, can effect but little. 

But surgery may be more successful. 

The danger arises from the mechanical obstacle to the entrance and exit of air 
into and from the lungs ; and this state of peril admits of a mechanical remedy. 
If an artificial opening be made between the obstructed part and the lungs, the air 
is again freely inhaled and freely expelled ; the blood undergoes the vital change 
from purple to scarlet; and the patient is placed in a condition of safety. He 
continues to respire through the hole thus drilled in the trachea, until the in- 
flammation of the larynx has subsided ; the thickening of the membrane disap- 



ACUTE LARYNGITIS o 



507 



peared; the submucous infiltration been re-absorbed; and the vocal instrument 
restored to its natural integrity; and then the aperture in the windpipe may be 
suffered to heal, and the patient will again draw his breath through its natural 
channels. 

This is one of the triumphs of the healing art. It requires a knowledge of the gene- 
ral pathology of the disease, i. e., an acquaintance with the facts that acute inflamma- 
tion may affect the larynx almost exclusively, and that its tendency is to narrow 
the fissure of the glottis, and destroy life by suffocation. It requires a knowledge of 
the symptoms of such inflammation: and it requires an accurate knowledge of all 
the essential circumstances of the particular case. For it is not every case in which 
the transit of air through the slit in the larynx is hindered, that is a fit case for the 
operation of tracheotomy. Some years ago there was brought to me by a surgeon 
a man breathing with considerable labour and constraint, the air passing through 
the larynx with an audible hissing noise. The surgeon wished to know my 
opinion of the propriety of opening the patient's wind-pipe. He had come to the 
conclusion that there was ulceration of the membrane lining the larynx, with 
thickening ; that the cause of the sibilous respiration was partly mechanical, partly 
spasmodic ; the little muscles that close the glottis acting with injurious energy in 
consequence of the neighbouring irritation: and he thought that this mischief in 
the larynx would have a better chance of being repaired, if the functions of the 
organ could be for a time suspended. He was aware, however, of the necessity 
of ascertaining what was the condition of the lungs; and he had not studied aus- 
cultation long enough to trust his own ear in that matter. The patient was pale 
and thin, and emaciated ; and three minutes sufficed to convince me that his lungs 
were extensively disorganized. His respiration was not so difficult as to threaten 
suffocation ; he was not dying of the laryngeal obstruction ; and I recommended 
that he should not be subjected to an operation which might curtail bis existence, 
but could not effect a cure. The man died soon after; and we examined his 
body together. There was, as my friend had supposed, ulceration of the mem- 
brane near the chordae vocales, and the lungs were full of suppurating or softening 
tubercles, I mention this case to show you that it is necessary to ascertain the 
condition of the thorax generally, before we perform or sanction such an operation 
as tracheotomy. Not that there is anything very formidable, or painful, or dan- 
gerous, in the operation itself. But if we cut a hole in a patient's throat, who is 
sure to die soon after of some other incurable complaint, we shall incur the risk 
of being charged with having killed him. Do not misunderstand me, however. 
If a patient's life be threatened by acute laryngitis, or by laryngeal cedema, and 
we are sure of that, and if at the same time we are sure that he carries another 
mortal disease about him, we are not for that reason to let him die, if we can help 
it, of the laryngitis ; any more than it would be lawful for us to administer a 
drachm of prussic acid to a man condemned to be hanged the next morning. But 
we must state the whole of the case plainly to the patient's friends, and propose 
the operation as a mode, not of effecting an absolute cure, but of staving off the 
immediate danger. 

And here let me repair an omission of which I was guilty when speaking just 
now of the diagnosis. My object was to guard you against mistaking laryngitis 
for some other malady: but I must also warn you against the converse error, that 
of mistaking some other malady for acute laryngitis. I can assure you that such 
a mistake has been made; and tracheotomy has been performed, too, when there 
was no disease in the larynx; and the practitioners by whose authority it was 
performed have been ungenerously reproached for their error, although no harm 
beyond the slight pain and inconvenience of the operation resulted from it. The 
cases in which this blunder has been committed have nearly all, I believe, been 
cases of aneurism of the thoracic aorta, which by its pressure on the first divi- 
sions of the air-passages, or on the nerves thereabouts distributed, had caused 
that kind of laboured and stridulous breathing which is characteristic of laryngitis. 
I may venture to say that no person who has had opportunities of educating hi§ 



508 



ACUTE LARYNGITIS. 



ear for the purposes of auscultation, and has made a proper use of those opportu- 
nities, could ever overlook such a complication as this. I have myself seen a 
woman (I mentioned her case before) whose trachea was laid open by a surgeon 
while she was suffering under mere hysteria; so closely did that disease mimic 
laryngitis. 

When you have good evidence that a mechanical obstruction to the passage of 
the air exists in the larynx, and that the tubes beyond the larynx are pervious and 
free ; there are two things which I would urge upon you. First, I would most 
earnestly advise you not to wait too long before you propose or perform trache- 
otomy ; and secondly, never to omit performing it merely because it may appear 
to be then too late. If, in the acute and limited disease, an artificial opening be 
made while the patient's strength is yet entire, and before his whole system is 
poisoned with venous blood, or his lungs are overwhelmed with sanguine conges- 
tion and serous effusion, it will almost infallibly save his life. But if the sinking 
of the vital power has got beyond a certain point, tracheotomy will not, in that 
case, rescue him. It is bad and foolish practice to wait, and try other methods, 
and postpone the operation as a last resource, when the circulation is evidently 
loaded with unarterialized blood. In my own case I should choose to be operated 
on early ; the moment that I found early blood-letting was not telling upon the 
local distress, and that any shade of duskiness became perceptible in the skin; 
just as I should choose to be operated on at once for strangulated hernia, after 
one fair attempt had been made by a skilful hand to return the bowel; without 
waiting till inflammation set in, or had been caused by the taxis. On the other 
hand, if you do not see your patient until his powers are nearly exhausted, do 
not abstain from the operation even though you may feel convinced that it will be 
unsuccessful ; for if it does not save life, it will disarm death of its agony. A 
patient will lie sometimes for hours, painfully labouring for breath in deep and 
strong catches, at considerable intervals from each other: in fact, he is just in the 
condition of a man with a cord round his neck, not pulled quite tight enough to 
suffocate him at once. Besides, it is not always easy to say whether the period 
of possible recovery is yet gone by. I had a female patient in the hospital who 
had suffered one or two attacks of frightful dyspnoea, in which the main difficulty 
was referred to the larynx; but she had rallied from them before any steps could 
be taken for performing tracheotomy. On the next occasion, however, the seizure 
was so sudden and rapid, that although Mr. Arnott was luckily in the hospital at 
the time, the woman was, to all appearance, dead, before he could be found and 
brought to her bedside. Respiration had entirely ceased. This quietude of the 
larynx rendered the operation more easy. Mr. Arnott speedily made an opening 
into the trachea; some air was blown in through the aperture, and then pressed 
out again ; and presently the natural respiration was renewed. The woman 
recovered: the orifice healed up, and she left the hospital. Three or four months 
afterwards word was brought that she had died at her own home after a short 
attack, and when there was no one at hand to open her windpipe. We got per- 
mission to examine the body, and found a large ulcer in the trachea, near the 
larynx; which ulcer by its irritation had occasioned, as we presumed, the spas- 
modic closure of the glottis. A preparation exhibiting the diseased parts is on the 
table before you. You see that there was enlargement of the thyreoid gland. 
This had probably nothing to do with the symptoms. There was also a large 
ulcer in the left bronchus. 

Mr. Goodeve, surgeon to the Clifton Dispensary, operated on a patient in 
whom S* no pulse could be found at the wrist; his face was suffused with blood, 
and his lips livid; and it was hard to say whether he breathed or not:" yet he 
recovered. 

It so happens that there is at present (December 1838) under Dr. Wilson's 
care, in the hospital, a woman named Slack, who was rescued when almost in 
ariiculo mortis, by the same expedient. She had chronic disease of the larynx ; 
but a sudden aggravation of the symptoms occurred ; she became stupid and 



ACUTE LARYNGITIS. 



509 



comatose, her countenance was cadaverous, her skin covered with a cold clammy 
sweat, and her breathing, which had been stridulous and laryngeal, had almost, if 
not quite stopped. She was making short, gasping efforts to respire, not oftener 
than twice in a minute. Her pulse was intermittent, and extremely feeble. In 
this state the house-surgeon (Dr. William Merriman) made a small incision in the 
skin over the cricoid cartilage, and then thrust a large trocar into the windpipe. 
Air rushed through the opening, the respiration returned, the pulse revived, 
and the stupor passed away. This happened on the 10th of October. She is 
still in the ward ; the aperture has closed up; and though she is not well, she is 
living. 

What is the reason, you may ask, of these different and inconsistent results ? 
How is it that tracheotomy shall reanimate one patient, whose last breath, but for 
its help, was already drawn, who was already motionless in apparent death ; and 
yet shall fail to save another patient, who is still alive, and sensible of his danger, 
and struggling with his disease ? The difference depends, I make no doubt, upon 
the time that elapses between the commencement of extreme dyspnoea, and the 
performance of the operation ; upon the slow or the speedy completion of the 
strangling process. And this, again, obviously depends upon the manner and 
degree in which the passage is narrowed. When the obstruction, though con- 
siderable, is incomplete, and does not rapidly augment, the respiration continues 
to be performed, however imperfectly. Meanwhile the brain gets oppressed, the 
circulation tends to stagnate, and, above all, the lungs become gorged with black 
blood, and clogged up by effusion into their cells and substance. Secondary 
causes of apncea are thus established, which do not cease when the primary cause 
is at length removed, by the unbarring of the main channel for the admission of 
air. Whereas when the access of the atmosphere is suddenly or soon shut out, 
the lungs are not thus mortally injured, but remain capable of resuming their 
functions when they are again supplied with air. 

Tracheotomy, then, will be the most likely to succeed, while the patient is still 
lively and strong ; and after that the chance of success will be worse in those cases 
in which the apncea has been slow in its progress, than in those in which it has 
been rapid. I repeat that, in threatening circumstances, the operation should be 
done early ; but that it should not be withheld, through despair, at any period of 
the disease. 

The effect produced upon the condition of the patient by the timely formation 
of an artificial glottis, is very striking. The moment that the scalpel penetrates 
the rings of the trachea, air begins to hiss through the incision ; and when a fair 
opening is established, and a full inspiration is drawn in through the wound, 
several fotcible expirations generally succeed, whereby a considerable quantity of 
mucus is expelled, which could not pass the contracted aperture of the natural 
glottis. Then the breathing soon becomes easy, the anxiety and distress are fol- 
lowed by a perfect calm, and usually the exhausted sufferer sinks into a tranquil 
slumber. This sleep is apt to be from time to time interrupted by the clogging 
up of the orifice with frothy mucus. It is requisite that some intelligent person 
should remain by the patient, to assist him in these emergencies, or he may still 
be throttled, notwithstanding the apparent prosperity of the operation. 

When a sufficient hole has been made in the instrument of the voice, below the 
glottis, the voice of course becomes extinct, or nearly so ; and the patient is as unable 
to utter a cough as he is to use vocal language. Now this it is of some import- 
ance to notice, for he often wants to cough, in order to clear the air-passages of 
mucus, or of blood, by which they may be embarrassed ; and he may be helped 
to do so, or taught to help himself. First he should draw in a full breath, and 
then stop the orifice for a moment with his finger, while he makes the expiratory 
effort. And as the parts within the larynx recover, the patient, by a similar 
manoeuvre, may enable himself to speak aloud. 

As actual examples are more interesting and often more instructive than an 
abstract of results, I will tell you in a summary manner the history of a case of 



510 



ACUTE LARYNGITIS. 



laryngitis, which occurred in one of my hospital patients, in the latter part of the 
year 1832. He was an old man, about sixty. His name was Kent. He was 
brought. to the hospital bloated with anasarca, which was most conspicuous in his 
legs and thighs. His breathing was laborious and difficult, and attended with a 
wheezing noise, audible at some distance. He could not lie down : he had a hard, 
but not full pulse. The dropsical swelling had come on suddenly five or six 
days before; and in the outset his face (he said) was so puffed up that he could 
scarcely see. He had been bled to the amount of a pint and a half, according to 
his own account, on the previous evening. I had a vein opened immediately, 
and twenty-four ounces of blood were drawn ; and eight ounces more were taken, 
from the chest by cupping. He was thoroughly purged with calomel and senna. 
The bleeding gave him very little relief, so far as the respiration was concerned^ 
but the next morning the anasarca had totally disappeared, I found him sitting 
up in bed, breathing with much effort, and with a loud stridulous noise which 
accompanied both inspiration and expiration. He referred all his uneasiness ta 
two points ; one of these was the larynx, the other the ensiform cartilage. He 
swallowed with great pain and difficulty ; and every attempt to do so excited a fit 
of choking cough. There was no morbid appearance visible in the fauces ; everjr 
part of his chest sounded well on percussion, and the murmur of healthy respira- 
tion could everywhere be heard in the lungs, almost drowned, however, in the 
louder laryngeal noise. As his strength was entire I had him again cupped, to 
twelve ounces, at the back of the neck; and prescribed three grains of calomel 
every three hours. He also inhaled the steam of hot water. 

Upon visiting him again the same evening, I found the dyspnoea increased. 
Each act of respiration was attended with a loud croupy noise. His countenance 
was beginning to be anxious and ghastly. He was restless ; and his pulse was 
less firm. Being now firmly convinced that the operation of tracheotomy was the 
only thing that could save him, and that it could not be safely delayed, I sent to 
request that Sir Charles Bell would come and perform it. By the time he arrived 
the restlessness had increased. The patient was shifting perpetually from one 
side of the bed to the other, as if seeking some new point of support: his face had 
become pale; and his lips were turning livid. He spoke with sudden, and as it 
were convulsive efforts ; stating earnestly how thankful he should be to have the 
obstacle to his breathing removed ; and pointing to the larynx as the seat of his 
distress. 

The ordinary operation, under such circumstances, is by no means an easy one 
to perform. Its difficulties were well exemplified in this patient. In the first 
place he was sitting up; he could not bear to be placed in the recumbent position. 
Then the dyspnoea caused him instinctively to elevate his shoulders, ancPsternum, 
and clavicles, to the utmost, so that the trachea was sunk deeply into the thorax; 
and the larynx was in constant and rapid movement up and down with a plunging 
motion, like that of the piston of a steam engine. Sir Charles, after some trouble, 
succeeded in cutting out a piece of the cartilage ; for a mere slit did not suffice : it 
closed tightly during every inspiration, although it was open enough during ex- 
piration. At length, when the air was freely admitted, the breathing became 
gradually easy. I shall never forget the whole spectacle : there sat the poor man 
gasping and fighting for breath ; his face covered with sweat, and wearing the 
most anxious expression. By and by what I have called an artificial glottis is 
opened for him ; and presently afterwards, though half a dozen candles (as Sir 
Charles has himself painted the scene) are held close to his face, to throw light 
upon the wound, and though the surgeons, their hands smeared with blood, are 
still busy about his throat, making arrangements to ensure the patency of the 
orifrce, the patient falls fast asleep. It was necessary to place an assistant behind 
him to prevent his head from nodding forwards, and deranging the apparatus in 
the wound. Nothing can express more strongly than this fact the great distress 
and fatigue which had previously existed, and the perfect relief afforded by the 
operation. 



ACUTE LARYNGITIS. 511 

This man ultimately got quite well ; and he has since shown himself occasion- 
ally at the hospital, in excellent health. There were two or three points about 
the case which I am unwilling to pass over without notice. It was evident that 
after the opening was made in his windpipe, he still breathed in part through the 
rima glottidis also; for the stridulous sound did not wholly cease. The aperture 
was formed as low as the circumstances of the case appeared to permit: the tube 
was perforated in the membranous space between the thyreoid and cricoid carti- 
lages. Strictly speaking, laryngotomy was the operation performed. I do not 
enter into the consideration of the best place for making the opening ; that point 
you will be taught by the professor of surgery : but it was observed in the case 
in question, that the slightest touch of the irritable mucous membrane, with a 
hook or a probe — especially if the touching instrument was turned upwards to- 
wards the glottis — produced a fit of coughing, and a paroxysm of still more labo- 
rious breathing. For some days after the operation, it was noticed that a part of 
whatever liquid he swallowed appeared immediately at the wound. Now this 
proved as plainly as if we could have seen the parts, that the epiglottis was thick- 
ened, and erected, and incapable of performing its protective function to the larynx: 
and it accounted for the paroxysm of choking cough produced by each act of de- 
glutition. At first the lining membrane of the larynx and trachea was so irritable, 
that the patient could not bear to have a metallic tube inserted; and an ingenious 
contrivance was adopted for keeping the orifice from being covered over by the 
lips of the wound. They were held apart by two bent wires, which were tied 
together at the back of his neck. After twenty-four hours had elapsed, the irri- 
tability of the mucous membrane had so far abated that he was able to breathe 
through a canula. 

There cannot be a doubt that this man was snatched from the very jaws of 
death by the intervention of the surgeon. A function indispensable to life was 
nearly suspended ; and a substitute for the faulty organ was provided by art, until 
the interrupting cause was removed. Scarcely a year passes over our heads 
without the occurrence of one or two such events in the hospital. When lectur- 
ing upon this subject last season, I was able to show you a female patient whose 
life had been saved in a similar way. And there is now also (December 11, 
1839), in Pepys' ward, a rescued man, with the tube still in his windpipe. The 
operation was done on the spur of necessity by Mr. Tomes, the present house- 
surgeon, with a trocar. The patient, who was previously in a state of extreme 
distress, said, in a faint whisper, as soon as the opening was effected, "It's all 
right now." 

He had been exposed to rain and cold about a week before ; and had suffered 
pain and tenderness of the larynx. Prior to his admission he had been bled, and 
salwated, and had a blister on the throat which embarrassed the operation. 

Within the last eight years the operation of tracheotomy has been performed 
in the Middlesex Hospital fourteen times. Seven of the patients recovered; seven 
died. In two of the seven fatal cases, the condition of the patients was hopeless 
at the time of the operation. In four at least of the five others much relief from 
suffering was afforded by it, and life apparently prolonged. One of the patients 
was a young child: the opening was made by a trocar; much blood got into the 
air-passages, and the child, which seemed to be sinking previously, died within 
the hour. Life might, I think, have been preserved in this case, by a timely 
operation, properly done. For a trachea so small, the scalpel is preferable to the 
trocar. But in the adult subject I have seen the larynx penetrated so neatly, 
easily, and speedily, both by Mr. Arnott and by Mr. Shaw, with a small curved 
tro<?ar, that I am persuaded of the general superiority of that method over the 
common operation with the knife or scissors. If this be granted, the fit place for 
the opening must be the membranous space between the thyreoid and the cricoid 
cartilages. The superjacent skin is first nicked with a scalpel : the larynx is 
then fixed for a moment by the operator's left hand, while with his right he thrusts 
the instrument steadily inwards and downwards. 



ACUTE LARYNGITIS. 



I have said nothing hitherto about the use of mercury in this acute disorder, 
because I hold it to be of very secondary importance, and because I have been 
anxious not to divert your attention from the two great practical points, bleeding 
and tracheotomy. Mercury may very fitly be given in those cases and circum- 
stances in which blood-letting appears proper; but we cannot depend upon it; 
we cannot reckon upon its influencing the system in time; nor upon any marked 
improvement of the symptoms when it does produce its specific effects. After 
the operation it is, for the most part, unnecessary. 

Nor do I recommend the employment of tartar-emetic, powerful as that drug 
is known to be in subduing inflammation of the mucous tissues. In the swollen 
and unpliant state of the epiglottis it would not be prudent to excite, or to hazard, 
vomiting. The contents of the stomach passing upwards would be apt to enter 
the unprotected larynx, and to cause hurtful, distressing, and even perilous attacks 
of suffocative cough. 

In the examination of fatal cases, sometimes the thickened membrane forming 
the edges of the rima glottidis is found covered with viscid mucus, which had 
formed an additional impediment to the passage of air towards and from the lungs : 
sometimes pus is discovered, lying in the saccnli laryngis, or scattered among the 
cartilages and surrounding muscles: and sometimes the chief morbid condition is 
the infiltration of the submucous areolar tissue. The effect in all cases is the 
same, that of closing up, wholly or partially, the narrow fissure between the 
arytenoid cartilages. The state of the epiglottis I have several times described. 

This very serious disease is a disease of adult age; it is not often known to 
occur in children. They again are almost as exclusively liable to croup: and 
cynanche laryngea has been called the croup of adults. But as the part occupied 
by croup, and the ei r ent of the inflammation, are both different from those of laryn- 
gitis, this name, croup of adults, is objectionable. I may remark, however, that 
sometimes in true croup, the inflammation, besides specially affecting the mem- 
brane of the trachea, extends to that of the larynx also. 

The main exciting cause of laryngitis is exposure to cold, or to cold and wet. 
My hospital patient, Kent, was a seller of small wares in the streets, and must, 
therefore, have been habitually in the way of such causes. The first attack of the 
disease in Sir J. M. Hayes was brought on by exposure at an open window to 
the night air for some time, while he was undressed, and in a profuse state of per- 
spiration, with a strong breeze blowing upon him. Dr. Craigie states that young 
persons from tropical climates, from the West Indies for example, are apt to be 
attacked by laryngitis soon after their arrival in Europe. 

The disease is liable to be produced also by mechanical violence, or chemical 
injury done to the larynx. It has been caused, on several occasions, in children, 
by their attempting to swallow boiling water from the spout of a tea-kettle ; and 
life has been saved in such cases by the performance of tracheotomy. The mine- 
ral acids, taken as poisons, have excited the disease. Fatal laryngitis has fol- 
lowed the incautious application of ammonia to the nostrils, in cases of hysteria, 
and of suspended animation : and I once knew a man nearly killed by the inha- 
lation of the fumes evolved from cinnabar thrown upon a hot iron, in what is 
called fumigation of the throat for venereal ulceration of that part. I am afraid 
that I must confess also to have once seen acute laryngitis produced by a bungling 
attempt to introduce the stomach-pump, in a case of poisoning. 

In all these cases the laryngitis is primitive. But laryngeal inflammation, and 
especially laryngeal oedema, not unfrequently take place, and prove suddenly fatal, 
in the course of other diseases. I have apprised you that in cynanche tonsillaris, 
the inflammation sometimes steals onward to the larynx. I have seen two'or 
three cases of erysipelas of the head, attended, as it almost always is, with sore 
throat, wherein death took place suddenly and unexpectedly, and where the epi- 
glottis, and the edges of the fissure of the glottis, were found to be oedematous : 
the inflammation of the throat had extended to the areolar tissue beneath the 
raucous membrane of those parts, and had led to the effusion of serous fluid there. 



CHRONIC AFFECTIONS. 



513 



The very same thing 1 is apt to happen in other forms of exanthematous disease 
attended with sore throat, and especially in small-pox, measles and scarlet fever. 
I have known a similar condition of inflammatory oedema arise from a mercurial 
sore throat in a broken down constitution. In these cases the laryngeal affection 
is consecutive, and secondary; and in all of them the great remedy is the forma- 
tion of a sufficient aperture beneath the obstructed glottis. In all of them also, 
the essential symptoms, warranting and demanding the operation of tracheotomy, 
are the same. 

A distinction has been made between laryngitis and osdema of the glottis ; 
and it is a just and real distinction. (Edema of the loose areolar tissue subjacent 
to the mucous membrane of the glottis, is, indeed, one common consequence of 
inflammation of that membrane: but it may occur independently of inflammation. 
The lips of the glottis become tumid and dropsical; sometimes, (as I have just 
pointed out,) in consequence of a low inflammatory action in the throat, but 
sometimes also from obstruction of the veins leading from that part. When laryn- 
geal dyspnoea accompanies aneurism of the thoracic aorta, it may, in some in- 
stances, result from local dropsy thus produced ; and then tracheotomy is fully 
justifiable, and indeed demanded. i 

The main practical difference between mere oedema glottidis and acute laryn- 
gitis, is this : that in the former, there being no fever or inflammation, blood-letting 
is not requisite ; and the operation of tracheotomy becomes the sole resource to 
which, in the extremity of danger, we can look for help. Mere oedema glottidb 
is seldomer attended with dysphagia, too, than is laryngitis : yet if the epiglottis 
be involved in the oedematous swelling, and unable to shut over the glottis, the 
act of swallowing will be followed by strangling cough, and increased dyspnoea. 

Besides the affections which I have now described or referred to, the larynx fs 
liable to chronic disease: to chronic inflammation; chronic thickening of the 
membrane; slow ulceration: necrosis of its cartilages. Chronic inflammation 
and ulceration of that part are very common in consumptive patients. It is attended 
first with hoarseness, then with aphonia, a barking or stridulous cough, and all 
the melancholy accompaniments of tubercular phthisis. There has accordingly 
been a species of phthisis spoken of as phthisis laryngea. But in most, if not in 
all cases, this laryngeal affection is only a part of the complaint under which tht 
patient labours ; and what I have further to observe respecting it, I shall postpone 
until we come to the consideration of tubercular consumption. 

Again, the membrane lining the laryngeal cartilages is not unfrequently thick- 
ened and ulcerated in secondary syphilis: giving rise to a hoarse croaking voice, 
and a noisy and painful breathing. In such cases, or in chronic thickening of the 
same parts from common inflammation, you may do great good by gently intro- 
ducing mercury into the system, until the gums rise. I have again and again 
seen the uneasiness about the throat, the noisy respiration, the rough or whisper- 
ing voice, all cease, as if by enchantment, so soon as the specific influence of the 
mercury became manifest. There was a woman who used to apply at the Mid- 
dlesex Hospital for an affection of this kind: whether it was syphilitic or not I 
could not well determine, but she lost it under the employment of mercury, two 
or three times : the complaint returning again after the interval of a few months, 
upon the re-application of some irritating cause. In another female patient, who 
was long under my care in the hospital with similar symptoms, everything failed 
to give permanent relief, till I began to leech the neighbourhood of the larynx 
repeatedly. She had four leeches applied, I think, every night, and then every 
other night, for a fortnight or three weeks ; the hoarseness and difficulty of respi- 
ration gradually diminishing all the time, until at length the perfect use of the 
instrument of the voice was restored. In these cases, while using local depletion, 
or mercury, it is often necessary to uphold the strength of the patient by nourish- 
ing but unstimulating diet : and it is always expedient that the organ should be 
kept, as much as possible, in a state of repose. 
33 



514 



CHRONIC AFFECTIONS. 



It is said that a little practice will enable a person to pass his finger into a 
patient's throat, and to familiarize his sense of touch with the ordinary condition 
of the upper part of the respiratory apparatus, so to be able to detect swelling, or 
irregularity, or thickening about the chink of the glottis. And great advantage is 
said to have been obtained from applying remedies directly to the diseased or 
irritable part. This practice was much followed by the late Mr. Vance, who had 
been for many years a naval surgeon ; and he called it, in naval phrase, swabbing 
the affected organ. A small piece of sponge, secured with a string, or fastened 
to the end of the finger of a glove, is dipped in a strong solution of nitrate of sil- 
ver, and then carried down into the throat, as far as that spasmodic state of the 
muscles which the attempt induces will permit, and pressed downwards against 
the superior surface of the larynx. I believe other stimulating applications are 
sometimes employed in the place of the nitrate of silver. Now of this method of 
cure I do not know much, except by report. I have heard that many cases of 
chronic hoarseness and cough have speedily been cured by it. But I have more 
than once had what seemed satisfactory evidence of the beneficial effect of this 
expedient. The man Kent, whose case I have related, gradually regained the 
power of easy breathing through the natural passage ; and the opening, which 
Sir Charles Bell had made, closed up perfectly. About a week after this took 
place, he began again to respire with a wheeze almost as audible as that which 
existed at the time of his admission : and to speak in a hoarse voice ; and a night 
or two after the return of the wheezing, he had a paroxysm of extreme dyspnoea. 
I began to be afraid that the whole process of laryngotomy and the metallic tube 
would be again requisite. However T got Sir Charles Bell to examine the interior 
of the throat, and we agreed that it would be advisable to swab the epiglottis and 
upper part of the air-passages with a strong solution of lunar caustic. For he had 
no fever, and we thought it probable that the membrane might have been left lax, 
and in a state to be benefited by astringents. Sir Charles applied the sponge with 
very little difficulty; and the next day the breathing was greatly improved, and 
the hoarseness almost gone: and he never had, from that time, any recurrence of 
troublesome dyspnoea. 

Mr. Arnott has twice or thrice, at my request, swabbed the upper part of the 
larynx for intractable hoarseness and aphonia: but with no good, nor any bad 
consequence. 

The lining membrane of the larynx is liable also to warty growths, which im- 
pede the entrance and exit of air, and ultimately destroy life. There are several 
examples of that kind on record. I extract the following from my note book :— 

George Tenon la Font, aged 11, admitted March 4, 1828. He speaks in a 
whisper ; complains of difficult breathing, and of cough. Inspires with a loud 
wheeze. Coughs with a sort of whistling sound, as through a narrow tube. — 
The cough is most troublesome at night. Expectoration mucous, and inconsider- 
able in quantity. 

Has been ill, in this way, all the winter — having had hooping-cough in the 
preceding autumn. There are marks of cupping on his throat. Little can be 
heard in the chest, the loud wheeze of his respiration obscuring all other sounds. 
In about a fortnight his gums were brought under the influence of mercury. No 
perceptible improvement ensued. A careful examination was again made of the 
thorax, and the conclusion arrived at was, that the obstacle to his respiration lay 
in the larynx, or upper part of the trachea, and that the lungs themselves were 
not concerned. After this, a blister to the throat, a seton near the thyreoid car- 
tilage, small doses of ipecacuanha, emetics, and iodine were successively tried — 
but in vain. Towards the end of the month he began to suffer occasional, very 
violent, and apparently spasmodic attacks of extreme dyspnoea. He died during 
the night, two months after his admission. For some days before he had been 
manifestly worse than^usual, was more feeble, wandered somewhat, and complained 
that his vision was imperfect. No noticeable increase had taken place in the 



CYNANCHE TRACHEALIS. 515 

difficulty of breathing, except during the paroxysms of aggravation already men- 
tioned. His death was sudden, and probably took place in one of these paroxysms. 

When the body was examined the lungs were found sound as to structure, but 
copiously infiltered, especially on the left side of the thorax, with serous fluid. 
At the very top of the larynx, involving the base of the epiglottis and the vocal 
cords, was a considerable warty growth, closing the rima glottidis almost entirely. 
The excrescences sprang chiefly from one continuous base, and branched out 
precisely after the manner of what is vulgarly called a seedy wart. There were, 
however, several distinct smaller growths or warts. The main excrescence, 
having several heads, passed upwards from and through the rima, and so came 
to act partly as a valve during inspiration, which was always sensibly more diffi- 
cult than expiration. 

Ought tracheotomy to have been performed in this case ? I now think so. 
But supposing it to have been done, and to have been successful, the boy would 
have been under the necessity of breathing through an artificial tube for the re- 
mainder of his life. 

Therg are two excellent specimens of warty growths in the larynx upon the 
table before you. 

I might'have referred, when speaking of chronic enlargement of the tonsils, in 
the last lecture, to the case of a little boy at present under the care of one of my 
colleagues. He was brought to the hospital on account of great dyspnoea, and a 
hissing respiration, produced apparently by two enormous tonsils. With some 
difficulty (arising from his unmanageable age) a large' part of one of the tonsils 
was cut off with scissors : but after the operation (either from some fresh swelling 
of the parts, or from pressure made by the remaining tonsil, which grew down- 
wards, I understand, into the throat), his difficulty of breathing became extreme ; 
and it was thought necessary to perform tracheotomy, which afforded him signal 
relief. He breathed for some time through the artificial opening in his windpipe. 
At length the other tonsil was partly removed: and the child is now well, and 
about to be discharged. 



LECTURE XLVI. 

Cynanche Trackealis : Symptoms ; Pathology ; Prognosis ; Treatment. 
Child-crowing, or Spurious Croup. 

I proceed this afternoon to another of Dr. Cullen's species of cynanche ; the 
last that I propose to consider in this part of the course : viz., cynanche trachealis 
— tracheitis — croup. 

The essence of this complaint is violent inflammation, affecting the. mucous 
membrane of that portion of the air-passages which lies between the laryngeal 
cartilages and the primary bronchi; in one word, of trachea, or wind-pipe. That 
is the genuine seat of the disease; but the inflammation sometimes ascends into the 
larynx; and not unfrequenlly it dives into the bronchi and into their ramifications.* 

* [In perhaps the majority of cases, the inflammation in croup commences in the mucous 
membrane of the larynx, and from thence extends into the trachea — the disease is therefore, 
strictly speaking, a laryngeo-tracheitis. In many instances, however, we have reason to 
believe that the inflammation commences in the bronchi and from thence extends to the tra- 
chea; but there are, we suspect, very few cases indeed, if any, in which the disease is confined 
to the trachea. In cases of croup thathave terminated rapidly in death, the inflammation and 
pseudo-membranous exudation which form so striking a feature in this disease are found 
only in the larynx and upper portion of the trachea — when death occurs at a later period 
the exudation is often present in the trachea alone, or in the trachea and bronchi; it is never 
found to exist in the latter tubes alone. It has been attempted to be shown by Jurin and 
others, that, in the ordinary form of croup, the disease is, in its first stages, at least, simply 
a tracheitis, and that in the more violent and rapid form, (suffocating croup,) the inflam- 



516 



CYNANCHE TRACHEALIS. 



Cullen makes no distinction between cynanche trachealis and cynanche laryn- 
gea. Yet they are separated from each other by very definite boundaries. They 
differ in anatomical position : they differ in gravity. Both indeed are serious 
diseases ; but croup is the more serious, because it seldom admits of that mecha- 
nical relief which, when rendered in time, deprives cynanche laryngea of its 
dangerous character. The two disorders differ also in respect to the period of 
life at which they occur. Idiopathic laryngitis is seldom met with except in 
adults ; croup seldom after the age of puberty. Cynanche trachealis is indeed a 
very remarkable disease, for it exhibits an event of inflammation which does not. 
usually belong to that process when it affects the mucous tissues. In this too it 
differs from laryngitis. 

I say that croup is peculiarly a disease of early life. The interval that lies 
between the two periods of weaning and puberty, is the time during which its 
visitation is chiefly to be apprehended. Comparatively few cases of it occur 
during the first year of infantile life. There are more in the second year than in 
any other. This, in all probability, is connected with the change that ensues in 
regard to diet, upon the child's being weaned. Dr. Cheyne, whose experience 
of croup was very extensive, says, that the younger children are wli£n weaned, 
the more liable are they, ceteris paribus, to this malady. From the second 
year onwards the number of children affected with croup gradually decreases. 
Of ninety-one instances referred to by Jurin, one only Was after the tenth year. 
But it does occasionally happen subsequently to the period of puberty, and up 
to the twenty-first year ; and even later. A girl of nineteen, one of my hospital 
patients, died of it. Some of the cases recorded of croup in the adult, were 
probably in reality, cases of laryngitis.* 

It is curious that inflammation should thus, at different epochs of life, fix itself 
upon limited portions of the same continuous surface, and lead to consequences 
so diverse. We are unable to give any account of this. 

Cynanche trachealis is frequently preceded by a slighter and more diffused 
affection of the membrane lining the air passages. The child has what is popu- 
larly called a cold ; sneezes, coughs, and is hoarse. Now with respect to this 
last symptom, Dr. Cheyne makes the following practical remark. Hoarseness 
(he says) in very young children, does not usually attend common catarrh. 
When noticed in a district where croup is not unfrequent, it ought to put the 
parents or the medical attendant of the child upon their guard; especially as much 
depends upon the early treatment of the disorder. W 7 ith these symptoms the 
child is feverish and fretful, and does not sleep well. In the course of a day or 
two the signs peculiar to croup begin to show themselves : they are well stated by 
Cullen, in his definition of the complaint. "Cynanche, respiratione difficili, 
inspiratione strepente, voce rauca, tussi clangosa, tumore fere nullo in faucibus 
apparente, deglutitione parum difficili , cum febre synocha." These are the 
phenomena that characterize croup. Difficulty of breathing ; and sonorous 
inspiration. The last is often almost enough, of itself, to identify the disease. 
Hoarseness ; a gruff voice ; sometimes a total loss of the power of vocal speech. 
A very peculiar and distinctive cough, to which the epithet " brassy" has been 

mation is confined to the larynx. Although this is not true, as is shown by the result of 
numerous dissections, yet our observations have shown us, that in cases marked by symp- 
toms of great violence, which are sudden in their onset and rapid in their progress, the 
indications of inflammation are to a much greater extent, and the pseudo-membranous 
exudation more copious about the larynx, glottis, and upper portion of the trachea, than 
in cases in which the disease succeeds to, bronchitis, runs a more protracted course, and 
is attended by symptoms of less violence. For a more detailed account of the pathology 
of croup, the reader is referred to the Editor's Treatise on Diseases of Children, page 301 
et seq. — C] 

* [We have met with the disease most frequently in children between ten months and 
five years old. By numerous writers the occurrence of croup previous to the seventh 
month has been denied; others, however, declare that they have seen it to occur, as a primary 
disease, repeatedly at an earlier period. — C] 



CYNANCHE TRACHEALIS. 



517 



justly applied ; the noise resembling that which would be occasioned by coughing 
through a brazen trumpet. This remarkable sound is always easily recognized 
when it has once been heard. It is a ringing cough ; and the expiration has a 
ringing character ; and either of these, the cough or the expiration, is followed 
by a loud crowing inspiration. Then there is the negative symptom; the absence 
of any difficulty of swallowing; and with all this, inflammatory fever; a* flushed 
face, hot skin, a frequent hard pulse, thirst. 

However, it is by taking the symptoms collectively, that we judge of the 
existence of croup, and by the rapid progress of the disease, rather than by any 
particular or pathognomic sign. Some of the symptoms may occur, separately, 
when there is no croup. The brassy or metallic cough, for instance, has been 
known to accompany some chronic affections of the larynx. Dr. Gregory — the 
late Edinburgh Professor of Physic — knew a man with a venereal disease of the 
throat who coughed so exactly the cough of croup, that he was admitted into the 
clinical wards of the infirmary every session for some years, that the students 
might have the opportunity of hearing this peculiar sound. So also the remark- 
able crowing inspiration may take place, as we shall soon see without croup. 

In the outset, the fever generally runs high ; and it is of importance, as respects 
the diagnosis, to mark the presence or the absence of pyrexia. As the obstruction 
to the passage of air increases, the blood ceases to be duly arterialized ; and then, 
of course, the skin grows dusky, the pulse feeble and irregular, the extremities 
cold. The cough, also, as the malady thus goes on from bad to worse, ceases to 
be loud and clanging, becomes husky, and inaudible at a short distance, and the 
voice sinks into a whisper ; the head is thrown back ; the nostrils, in perpetual 
motion, dilate widely ; the face is pale and livid, and sometimes bloated ; the pupils 
often expand. When these indications of sinking have come on, the case usually 
terminates ill : the bottoms of the feet turn black and hard ; drowsiness supervenes ; 
some tossing of the arms perhaps ; the breathing becomes gasping and interrupted, 
and the child dies after an zVispiration. 

In other cases the croupy symptoms make their attack very suddenly. A child 
shall go to bed apparently well, and in the course of the night have all the worst 
signs of the disease. And it is observable, that whether the attack be altogether 
unexpected or whether it has been preceded by hoarseness, sore-throat, and ca- 
tarrh, it usually comes on in the night. 

Croup resembles laryngitis in this respect, that it runs its course rapidly ; 
proving fatal sometimes within twenty-four, and often within forty-eight hours. 
It may, however, continue for five or six days before it terminates, whether death 
or recovery be the result. Dr. Craigie affirms that it is never protracted beyond 
the eleventh day ; the fatal or the favourable issue having always taken place by 
that time. Life is destroyed, in pure circumscribed tracheitis, by the accumula- 
tion in the windpipe of a concrete mernbrane-like substance, which so frequently 
attends this disease, and is so peculiar to it, that it is called themembrane of croup. 
In cases of recovery this substance has been expectorated in the form of a nearly 
perfect tube, representing a cast of the trachea ; at other times it is coughed up in 
flat or tubular fragments. In fatal cases it is found sometimes lying in close con- 
tact with the mucous membrane, and sometimes quite detached from it; so. that 
it might have been expelled without much forcing or difficulty, if the child could 
have sufficiently inflated its lungs, and the requisite muscular power had remained, 
and spasmodic irritability of the glottis had not opposed. 

But, in many instances, this albuminous exudation is not confined to the trachea. 
It often stretches down to, and enters the ramifications of the bronchi, and reaches 
even to their termination in the pulmonary vesicles. Sometimes also it is found 
clothing the mucous membrane belonging to the laryngeal cartilages. This Dr. 
Craigie denies. But I show you two specimens in which the false membrane, 
besides filling the trachea, evidently extends into the larynx. One of these comes 
from the museum up stairs; the other I have borrowed from the Middlesex Hos- 
pital Museum : it is the larynx and trachea of the young woman whom I men- 



518 



CYNANCHE TRACHEALIS. 



tioned jnst now as having died there of croup, at the age of nineteen. The false 
membrane reached from the tip of the epiglottis to the bifurcation of the trachea. 
You see the same thing represented in this excellent plate of Dr. CarswelPs, pic- 
tured from nature. Usually the adventitious membrane commences just below 
the larynx, where it is thin and soft: about the middle of the windpipe it is more 
dense and firm ; lower down in the trachea, and in the bronchi, it is generally 
looser again, pulpy, and broken : it sometimes, I repeat, penetrates to the very 
air-cells. What are called (absurdly enough) bronchial polypi, branch-like casts 
of the smaller ramifications of the air-tubes, are then apt to be coughed up. And 
even when this concrete substance is not formed, we have other evidence, often, 
of the extension of the inflammation throughout the whole downward course of 
the membrane. 

On the other hand, there are a few cases in which this adventitious membrane 
is not formed at all ; the inner surface of the windpipe is seen to be merely red- 
dened and tumid, and covered with viscid mucus; or perhaps with a shred or two 
of concrete albumen here and there. 

The difficulty of breathing, and the characteristic sounds that accompany it, 
depend, in part, I believe, upon spasmodic contractions of the small muscles of 
the larynx ; for remarkable aggravations of the dyspnoea are apt to occur, and to 
subside again ; and these aggravations are sometimes brought on by sudden causes 
—by the movements of deglutition, for example. 

I shall have to recur to this spasmodic constriction of the glottis : but I may 
here remark, that because it has not been (and cannot be) seen, doubts have been 
expressed by some about its having any thing to do with the dyspnoea. Such 
doubts seem scarcely reasonable. It is easy, at any time, by an effort of the will, 
to close the glottis, and to prevent the passage of air to and from the lungs. This 
is mainly effected by the action of the little muscles that bring together the aryte- 
noid cartilages. But those muscles, like the other muscles concerned in respira- 
tion, act also independently of the will, spasmodically therefore, through the 
reflex function of the spinal cord. And it is by a providential and conservative 
appointment that they do so act, as janitors, admitting, in the healthy state, the 
vivifying air, but barring the door against certain hurtful gases, and against solids 
and liquids which would be injurious to the respiratory apparatus. We know 
that if a drop of water, or a crumb of bread, or a whiff of carbonic acid gas, gets 
past the outer defence, the epiglottis, and into the larynx, spasmodic action of the 
little muscles in question is instantly excited. We cannot see these intruders, 
and voluntarily resist their entrance, but the unsleeping sentinel is there to guard 
the passage. We may well conceive, therefore (and I know not how the suppo- 
sition can be disproved), that the noisy and difficult respiration of croup may be 
caused, in part, by spasm.* 

The presence of the adventitious tubular membrane in the trachea affords a 
plausible explanation of one of the symptoms observed in these little patients ; 
the tendency they show to throw the head back. The cylinder of the membrane is 
kept open in that position ; whereas, if the head were inclined at all towards the 
chest, the membrane would be bent upon itself, and the passage through it ob- 
structed. 

This concrete exudation is often adduced to prove that the mucous membranes 
may exhibit, under certain circumstances, the phenomena of adhesive inflamma- 
tion. Similar films sometimes form upon, or are thrown off by, the mucous 
surfaces of the intestines, and of the uterus. Whether they are to be regarded as 
essentially identical with the layers of coagulable lymph poured forth in inflam- 

* [As further evidence of the correctness of this remark may be adduced those cases in 
which all the diagnostic symptoms of croup are suddenly induced by an irritation seated in 
the stomach, as from indigestible food, &c, and are as suddenly removed the moment the 
cause of irritation is expelled. A medical friend has informed us, that in one of his own 
children, symptoms resembling croup are produced by eating fish, and are immediately 
removed upon the operation of an emetic. — C] 



CYNANCHE TRACHEALIS. 



519 



maiion of the serous and areolar tissues, may be made a- question. There are 
certainly some strong points of distinction between them. The concrete mem- 
brane of croup is more brittle, less fibrous, more decidedly albuminous, than the 
false membranes that cover the inflamed pleura, pericardium, or peritoneum. A 
still more remarkable difference is this, that it is not plastic, in the sense in which 
that term was formerly explained; it never becomes organized, never connects 
itself by blood-vessels with the surface from which it proceeds. On the contrary, 
it is partially detached ; and by degrees, if the patient live long enough, it is com- 
pletely separated from the subjacent parts. 

Hypotheses have been framed to account for the limitation of this product 
of tracheal inflammation to the early periods of life ; and for its variation from the 
usual products of inflammation of the same part. Dr. Stokes thinks that the 
predominance of the white tissues in young subjects may explain the greater 
frequency of croup, with its peculiar membrane, in infants. Dr. C. B. Williams 
starts the very reasonable supposition that the inflammation involves the sub- 
mucous areolar tissue, which is abundant during youth; and that the natural pro- 
duct of this phlegmonous inflammation transudes readily through the thin, simple, 
and delicate mucous membrane proper to that age. 

The formation of this adventitious membrane, and even its renewal, appears to 
be sometimes very rapid. I have here a preparation made by the late Dr. Sweat- 
man, illustrative of this. It now belongs to the Middlesex Hospital Museum. 
Upon a child, on the very brink of suffocation from croup, the operation of tra- 
cheotomy was performed, at one o'clock in the morning, by Mr. Chevalier. A 
tubular portion of membrane, of the shape and size of the trachea, was presently 
forced through the artificial opening. Immediately the child's respiration became 
•easy, and it fell asleep. In the course of the same morning, Dr. Sweatman was 
hastily summoned, and arriving at eight o'clock, found the child dead. It had 
slept six hours, and upwards ; and then the distress of the breathing had returned, 
and was soon fatal. The trachea was found to contain a new tube of lymph, or 
of concrete albumen. The preparation shows that such a membrane may re- 
form in that short space of time ; namely, in from six to seven hours. 

The croup is not contagious ; although, like cynanche tonsillaris, and for the 
same reasons, it is found sometimes existing at the same time, or in quick succes- 
sion, in more than one child of the same family. Thus two twin children of Dr. 
Gregory's were seized with croup on the same night. They had both been walk- 
ing in the evening on the sea-shore during a cold wind. This is in accordance 
with what Dr. Cheyne has stated, that the attack is almost always nocturnal, and 
often when the child has during the preceding day been exposed to the weather. 
It frequently occurs sporadically ; but there are places in which the disease ap- 
pears to be endemic. Dr. Cheyne found it so on the coast of the Frith of Forth. 
Indeed, the first distinct account of it that we possess was drawn up by Dr. Home, 
of Edinburgh, in 1765, from much personal observation of its ravages in Leith 
and Musselburgh. Cold situations* — and damp places, more than such as are 
merely cold — are subject to the prevalence of this disease. It is accordingly 
frequent in the seasons of winter and spring. It is said to be most common near 
the sea-shore, and in the neighbourhood of large bodies of water generally. It 
occurs in low, moist, what are called in Scotland carse districts, more than in 
upland situations that are more exposed to cold winds. It is more common at 
Leith than it is in Edinburgh ; and in Edinburgh, it is most frequent in the lowest 
parts of the town. This I learned from Dr. Alison, who, having long been phy- 
sician to a dispensary there, had had ample means of observing the disease. 
Canal Street and the Cowgate, both low spots, as some of you may know, have 
long been famous, or rather infamous, for cases of croup. Towns situated on the 
banks of rivers are more than commonly visited by it; and it has been observed 
to be particularly frequent among the children of washer-women in such places ; 
and thus evidently connected with exposure to moisture. It has been known to 
prevail epidemically in towns so situated after an inundation. And Dr. Alison has 



520 



CYNANCHE TRACHEALIS. 



made a very curious remark respecting it. He says that it seems to be often pro- 
duced by the child's sitting, or sleeping, in a room newly washed : and that he 
has noticed its frequent occurrence on a Saturday night — the only day in the week 
on which it is customary for the lower orders in Edinburgh to wash their houses. 

Like cynanche tonsillaris, and unlike cynanche parotidaea, the croup is exceed- 
ing apt to recur. Relapses may happen within a few days after apparent recovery ; 
and these are very perilous. But besides this tendency to a renewal of the severer 
symptoms, the little patients are often affected with cough, and hoarseness, and 
even with aphonia, for a long time. And while these relics of the acute attack 
continue, it is easily brought back again. The first seizure is generally, I believe, 
the worst: but to this rule there are numerous exceptions. 

Croup is a disorder which justly excites extreme alarm in the friends and 
parents of the patient: for the prognosis can never be better than doubtful. It is 
said that four children out of five attacked by it used to die: but that now, the 
treatment being better understood than formerly, the number of deaths and the 
number of recoveries are nearly equal. We judge of the probable issue, in a given 
case, by the apparent circumstances and progress of the malady. If we could see 
the interior of the air-tubes, we should know that the chance of escape was small, 
in proportion as the inflammation, and its albuminous product, descended along 
the ramifications of the bronchi. But in these little patients, and amid the tracheal 
noises, it is difficult to ascertain the physical state of the lungs. The prognosis 
is chiefly to be collected from the general condition of the child. If the distress 
of breathing seems to remit, and free expectoration to come on, while the strength 
is yet entire, we venture to hope. On the other hand, we begin to despair when 
the lips are becoming blue, the skin is losing its heat, the pulse is already feeble 
and intermitting, and the little patient is drowsy or comatose: in other words, 
when we perceive the final symptoms of death in the way of apnoea. Some few 
patients die suddenly and unexpectedly without any previous coma. 

The mortality will differ according as the disease is detected early, and treated 
vigorously,— or otherwise. And with respect to treatment, there is no specific 
remedy for this, any more than for any other inflammation. We must put in 
force the general principles upon which the treatment of inflammation is founded; 
adapting them, how r ever, to the malady in question by those particular rules which 
the experience of the best observers has collected for our guidance. 

I need scarcely say that where cough and catarrh, and especially hoarseness or 
loss of voice, are noticed in a young child, he should be narrowly watched, and 
protected against all circumstances likely to excite or to aggravate inflammation : 
he should be kept in the house, and put upon farinaceous diet; and the functions 
of the bowels and of the skin should be attended to. 

The three remedies that most require consideration are blood-letting, tartarized 
antimony, and calomel. 

Bleeding is to be unhesitatingly employed when the patient is strong, and ple- 
thoric, and seen in the outset of the disease. k In judging of its mode, and of its 
amount, we must recollect that what is no more than a topical bleeding in an adult, 
becomes equivalent, in its effects upon the system, to general bleeding, when it 
is used for a very young child. Abstraction of blood, by venesection or cupping 
in the case of older children, and by leeches in the case of infants, should be prac- 
tised whenever the symptoms are violent, and there is much fever, and the patient 
is seen within a few hours after the commencement of the symptoms. The relief 
that is given by this measure, under such circumstances, is often so decided, that 
no doubt can remain of its usefulness and propriety. 

It is impossible to lay down any fixed rules for the quantity of blood that should 
be taken in this complaint. Under two years of age, it should not, says Dr. 
Cheyne, exceed five ounces. I should esteem that a large bleeding, at that age. 
Upon an average, a moderate bleeding will be produced by the application of a 
couple of leeches to an infant in its first year: and an additional leech may be 
employed for every additional year: so that six may be put to a child five years 



CYNANCHE TRACHEALIS. 



521 



old; or eight if he be stout. Dr. Copland estimates the amount of blood which 
these patients may, with safety, bear, to be somewhat more than an ounce, or as 
much as an ounce and a half, for every year of their age. Much, however, must 
depend upon the special circumstances of the case: the quantity of blood extracted 
by a given number of leeches is less in one instance than in another; and then, of 
course, the number must be increased. They should be applied at the upper part 
of the sternum, and not upon the throat itself; for this reason : — that the pressure 
which may be necessary to stop the bleeding, or to regulate its quantity, cannot 
well be borne upon the throat in these cases. 

After one sufficient evacuation of blood, whether by means of the lancet, or of 
leeches, or of cupping-glasses applied between the shoulders, it will always be 
right, before repeating it, to ascertain the effects of other measures ; such as 
emetics and purgatives, the beneficial operation of which in this disorder is often 
very remarkable. 

Full vomiting sometimes affords relief so sudden and complete, as to lead to the 
persuasion that the symptoms had been principally owing to spasm. And even 
when the disease is unequivocally inflammation — sometimes even late, but par- 
ticularly in the early part of its course — the effect of a vomit is often very striking. 
It promotes expectoration; and is not unfrequently followed by the expulsion of 
shreds of the adventitious membrane. When blood-letting is employed, it should 
precede the emetic; or, at any rate, it should precede the act of vomiting. Dr. 
Cheyne recommends that the bleeding should be practised ten minutes after the 
emetic has been swallowed. The loss of blood assists the operation of the emetic, 
and lessens the risk (which is not a fanciful one) of injurious congestion of the 
vessels of the head during the straining efforts of vomiting. 

It is desirable, not simply to excite the act of vomiting, but to produce and to 
prolong a state of nausea and faintness : and so to depress and to keep down the 
increased action of the heart, and to keep empty the capillary vessels of the 
inflamed part. Now the substance best adapted to this purpose is tartarized 
antimony. This medicine, as I have often mentioned before, has great power 
over inflammation of the mucous tissues: and there is one very great advantage 
belonging to it in cases of croup ; namely, that children may be induced to take it 
without their knowing that they are taking medicine; for the solution of it has 
little or no taste: whereas the struggling which is often occasioned by the admi- 
nistration of other emetics may be the cause of much inconvenience, and even of 
much injury to the patient. It should be dissolved in boiling water, in the pro- 
portion of a grain to an ounce ; and the cold solution given. A tea or a dessert- 
spoonful may be repeated every quarter of an hour, till some effect is produced. 
When vomjting is thus excited on the very first appearance of the symptoms, and 
before the disease seems thoroughly formed, it sometimes puts it off : so that no 
other treatment remains necessary beyond the exhibition of some purgative medi- 
cine. But if this perfect relief g!oes not ensue upon the operation of the emetic, 
Dr. Cheyne advises (and this is in conformity with the practice of many other 
persons), that a powder, consisting of two, three, or four grains of calomel, with 
two or three grains of James's powder, should be given at short intervals ; every 
two or three hours, for example. A dose of castor-oil is to be administered occa- 
sionally, to clear the bowels. And another expedient, of great efficacy sometimes, 
and therefore never to be omitted, is the warm bath. This is often properly 
resorted to just after the act of vomiting, particularly if any tendency to perspira- 
tion is apparent. The temperature of the water should not be lower than 98° 
Fahrenheit; and the child should remain in the bath for ten minutes at least. 
When taken out, he should be wiped dry, and put immediately into bed again. 
The change for the better produced by the bath is sometimes so marked and so 
speedy, as to strengthen the conclusion that the most distressing of the symptoms 
had resulted from spasm. 

The usual effect of calomel thus frequently repeated is not, as in adults, that of 
causing salivation, but the discharge of a quantity of green fecal matter, resem- 



522 



CYNANCHE TRACHEALIS. 



bling chopped spinach : and when stools of this kind begin to make their appear- 
ance, there is often a sensible mitigation of the symptoms. The green colour is 
a common consequence of mercury given to young children; and will occur, I 
believe, whatever be the disease, when the full effect of calomel as a purgative is 
obtained. The green matter has been found, after death, in all the intestines, 
small as well as large, up to the duodenum. I presume that the colour is owing 
to some chemical action that takes place between the calomel and the bile. We 
know that calomel does tinge bile green when mixed with it out of the body. It 
may be, however, that the calomel provokes a flow of altered bile. 

Calomel, thus administered, is the purgative that has received the strongest 
recommendations. Its usefulness appears to have been fully borne out by the test 
of experience : and the well-known virtue belonging to mercury, of preventing or 
arresting the effusion of coagulable lymph in other textures, has formed (I con- 
ceive) one cogent reason for its adoption in this disorder, of which the chief peril 
results from the pouring forth of the albuminous part of the blood. But whether 
mercury really has the same power of controlling adhesive inflammation, when 
that process is set up in mucous tissues, which are so commonly exempt from it, 
may be questioned. On the other hand, the effect of full doses of tartar emetic 
in restraining active inflammation of those tissues is well ascertained : and I should 
certainly make use of it in the early stages of this dangerous malady. The system 
can be brought to feel its decided influence with much more certainty, and in a 
much shorter space of time, than that of calomel: and if it fails to make a bene- 
ficial impression, it need not long interfere with the mercurial treatment. Let me 
quote to you the statement of Dr. Cheyne (whose experience of this disease was 
far ampler than mine has been,) respecting the efficacy of tartarized antimony in 
what he calls the second stage of croup. He recommends that half a grain, dis- 
solved in a tablespoonful of water, should be given to a child two or three years 
old, every half hour, till sickness and vomiting ensue. In two hours after the 
last effort of vomiting, the same process is to be recommenced ; and so repeated 
while the symptoms require it, and the strength will permit. This mode of treat- 
ment was suggested to him by the accidental observation of a particular case, in 
which it was remarkably successful. From that time he placed his whole reliance 
on that remedy in the second stage of croup; especially as he had found that 
blood-letting in that stage only accelerated the death of the patient. He noticed 
that the cases were few in which he had known children survive the second stage, 
but in all of these few, they recovered while using a solution of tartarized anti- 
mony. He held that no other medicine was, at that stage of the disorder, entitled 
to confidence. In short, he declared that tartar emetic, so given as to produce 
continued nausea, had been his sheet anchor, in the treatment of croup, since the 
year 1799. This was written in 1801, in a separate work on the pathology of 
the larynx and bronchi ; and Dr. Cheyne recently has affirmed, in the Cyclopaedia 
of Practical Medicine, that he still found reason, to adhere to the same opinions, 
and the same practice. 

Now what is good for the second stage, would, a fortiori, I think, be likely to 
save life, if employed during the earlier stage of the disease. I therefore should 
say, take blood in the very outset* as largely as may seem prudent : then give the 
tartar emetic solution in the way already described. As soon as it causes vomiting, 
and pallor, and a sinking of the pulse, stop ; and suffer the heart to recover itself. 
And if, with the rallying circulation, the difficulty of breathing returns, have 
recourse again to the same remedy. The faintness and collapse are sometimes so 
great as to threaten the extinction of life : the child, with a flying pulse, and a 
clay-cold surface, seems gasping its last. When this happens, a few drops of sal 
volatile, or of brandy, mixed with water, will presently bring the little patient 
round again. If no ground is gained after two or three repetitions of the nauseat- 
ing treatment, then it will be well to make trial of the calomel plan. 

Sometimes the tartar emetic acts severely on the bowels : it may occasionally. 



CYNANCHE TRACHEALIS. 



523 



therefore, be necessary to combine with it a small quantity of syrup of poppies, or 
of laudanum. 

Blisters are often applied in this disease; but with very questionable propriety. 
In the outset they are likely to do harm ; in the advanced periods they are not 
likely to do good. If used at all, they should be placed, not on the throat, but 
across the upper part of the sternum. 

When signs of approaching death have come on — lividity of the lips, coldness 
of the skin, and a tendency to stupor, the question will obtrude itself, whether 
there may not still be a chance of saving the patient by performing tracheotomy. 
In the first place you will consider that the operation is much more difficult to 
execute upon children than upon adults ; and is attended with more perplexing 
hemorrhage. But there is a greater objection than this to tracheotomy in such 
cases ; an objection which you will have anticipated, namely, the existence of the 
preternatural membrane ; which often extends so far down, that air would not be 
admitted into the lungs, even if an aperture in the windpipe were made at the 
lowest possible point. Another consideration, forbidding much hope of success 
from this expedient at any period of the disease, is that the ramifications of the 
bronchi and the ultimate air-cells get filled up with serous, or mucous, or puriform 
matter, or even sometimes with a membranous exudation, whereby suffocation is 
effected in the lungs themselves. The membrane in the trachea, being tubular, 
does not entirely exclude the air from those organs ; but it does not admit it in 
sufficient quantity. Tracheotomy has again and again been practised in this com- 
plaint to no purpose : and I should be inclined to look upon it as absolutely hope- 
less, but for two instances of its successful performance, recorded in the Medico- 
Chirurgical Transactions : the one achieved by Mr. Andre, and related by Dr. 
Farre, in the third volume ; and the other by Mr. Chevalier, in the sixth volume. 
These were both apparently desperate cases. Immediate relief followed the 
operation in both, and the patients recovered perfectly. 

There seem to be just two predicaments in which there is a chance that trache- 
otomy may be useful. They are perhaps rare : yet they have been noticed by 
several observers. The one is where the preternatural membrane extends but a 
very little way down the trachea, and is chiefly confined to the larynx : and the 
other is where there is no preternatural membrane at all, or only a very slight 
coating in some part of the trachea, the impediment to the breathing having arisen 
mainly from the thickening of the mucous membrane. And you will observe 
that an impediment from this cause will always be the greatest at the narrowest 
part of the canal : and therefore incision of the windpipe in such a case may be 
expected to bring relief. The effect produced by the tracheotomy in Mr. Che- 
valier's case was very instructive. Air was fully inspired through the opening, 
then a strong cough took place, by which a large quantity of viscid reddish mucus 
was forced out by the natural channel, through the glottis. It was evident that 
the child could not expectorate before, simply because it could not sufficiently fill 
its lungs with air to drive the collected mucus out. Dr. Farre gives a circum- 
stantial account of a case in which the adventitious membrane did not reach more 
than a finger's breadth below the cricoid cartilage; and the rest of the tube was so 
free that he was convinced the child's life might have been saved by a timely 
opening into the trachea. Unfortunately, we cannot tell, before death, to what 
degree or extent the preternatural membrane exists. All that can be said, I think, 
is, that when dyspnoea and much croup come on suddenly or quickly, the disease 
is probably limited to the larynx and upper part of the windpipe : but that when 
the progress of the disorder is slower, and the croupy symptoms are not so well 
marked, it is more likely that a greater extent of the trachea, below the larynx, 
participates in the mischief. Our expectations of success from tracheotomy will 
vary accordingly. It affords a bad chance at the best ; but it affords also, in many 
cases, the only chance.* 

* [The subject of tracheotomy in croup is one of considerable interest,— That it may, 



524 



CHILD-CROWING, OR 



There is a sort of bastard croup, with which it is quite necessary that you 
should be acquainted, for it is not at all uncommon ; nay, it is far more common, 

in many cases, when timely performed, save the life of the patient, we have the most un- 
questionable evidence. In a statement by M. Trousseau of the result of the operation*, as 
performed by himself, and by others, according to his method, in one hundred and fifty cases, 
the patients were saved in thirty-nine. In the case of his own child, three weeks old, recently 
published by Dr. Scoutetten, the operation was performed on the third day of the disease, 
under circumstances apparently the most desperate, with complete success — the infant 
recovering in a short time from the effects of the operation as well as from every symptom 
of the croup. The class of cases, the period and particular circumstances of the disease 
in which the operation is most likely to afford relief, are questions of no little importance, 
and we believe that much of the want of success, which many practitioners have ex- 
perienced in performing the operation, is to be attributed to its having been resorted to 
under improper circumstances. M. Trousseau, whose experience on this subject has been 
somewhat extensive, has presented the following as a summary of the prognosis of tracheo- 
tomy in croup — 

" 1st. If the commencement of the attack dates several days back, if, consequently, the 
disease has advanced slowly, whatever may be the extent of the false membranes in the 
trachea and bronchi, the children either recover, or live at least several days after the 
operation. 

"2d. But if the disease has been very rapid, even although at the time of the operation, 
we ascertain that the false membranes do not extend beyond the larynx, the children die 
very quickly. 

"3d. If previous to the operation, the false membranes have extended to the nares, or if 
they cover the blistered surfaces; if the child is pale and somewhat bloated, without having 
taken mercury or been bled, or if he has lost much blood, there is little chance of the ope- 
ration succeeding. 

"4th. If previous to the operation, the pulse is moderately frequent, and if, after it, the 
pulse remains calm, hopes may be entertained. 

" 5th. It is a bad sign, if, immediately after the operation, the respiration becomes very 
frequent, without any cough or with very little. 

"6th. More boys than girls are cured. 

" 7th. Children under two, and over six years of age rarely recover. 
"8th. The more deeply the false membranes have extended, the greater, caeteris paribus, 
the danger. 

" 9ih. If the child has been subject to chronic catarrhs, and if he had been suffering from 
a cold for some time when he was attacked with the croup, tracheotomy is more successful. 

" 10th. Even when all is going on favourably, very great frequency of respiration is a 
bad sign. 

" 1 1th. The more rapid and energetic the inflammation which attacks the wound in the 
trachea, the better are the chances of success — a sudden sinking of the wound is a mortal 
sign. 

" 12th. So long as the respiration is silent or the noise is only occasioned by the displace- 
ment of mucosity, there is nothing to fear, but when the respiration becomes saw-like 
(serratique), in other words, when it is attended with a sound like that produced by a saw 
cutting stone, death is certain. 

" 13th. There is no reason to despair of the patient, even if a pneumonic or pleuritic 
attack should supervene. 

" 14th. Agitation and sleeplessness are bad signs. 

" 15th. Should the wound become covered with false membranes ; if, after withdrawing 
the canuia, it remains gaping for a long time, or, if after having become entirely cicatrized 
it reopens largely, the child is in danger. 

" 16th. The sooner after the operation the larynx is disembarrassed, the sooner may we 
remove the canuia, and the more rapid and certain is the cure. 

" 17th. If the croup supervened upon rubeola, scarlatina, variola or pertussis, although 
there is not ordinarily any connection between the malignant angina and these pyrexia 
tracheotomy does not succeed. 

" ISth. If the expectoration becomes mucous and catarrhal by the third day after the opera- 
tion, the children will recover. If there is no expectoration, or it is serous, or like half 
dried portions of gum Arabic, they will die. 

" 19th. If the patients react vigorously under the injections into the trachea of water or 
nitrate of silver, and under the sponging out of the trachea, we should not despair, how- 
ever unfavourable may be the other signs. 

" 20th. Children attacked with convulsions after the operation die, and the younger the 
patients and the more blood they have lost before or during the operation, the more often 
convulsions supervene. 



SPURIOUS CROUP. 



525 



in this place at least, than the real disease. It has received a variety of names, 
which shows that it has been recognized, as a distinct malady, by various observ- 
ers. Yet no doubt can be entertained that it has very often indeed been con- 
founded, — and is still continually confounded,— -with the true croup, with cy- 
nanche trachealis. In their most obvious symptoms the two affections are much 
alike. The broad and essential distinction between them, is the absence, in the 
spurious disorder, of inflammation and of fever — arid consequently of any concrete 
or other effusion from the mucous membrane of the air passages.* The child is 
seized all of a sudden, roused perhaps from its sleep by a catch, or interruption 
of its breathing, more or less complete. It strives and struggles to inspire, but is 
apparently unable to do so ; at length the effort is successful, and the breath is drawn 
in with a shrill whistling or crowing sound, like that which characterizes the in- 
spirations of croup, or of hooping-cough, and depending, no doubt, upon the same 
cause — a narrowing (in this complaint temporary) of the fissure of tfle glottis. 
Spasmodic croup is the most common of its names. It is the thymic asthma of 
the Germans* My late colleague, Dr. Ley, in a volume upon this curious dis- 
order, published a short time before his death, adopts from Dr. Mason Good the 
appellation of laryngismus stridulus. Dr. Gooch called it child- crowing, a home- 
spun term, which I must prefer to the somewhat pedantic and cacophonous title 
bestowed upon it by Dr. Good. The crowing noise, and its concomitant phe- 
nomena, take place in paroxysms, which vary in respect to frequency and severity, 
and which are separated by intervals of easy and natural breathing. 

* When the closure of the chink of the glottis is not perfect, the child struggles 
for its breath : the respiration is hurried ; the countenance generally bluish or 
livid; the eyes staring ; and each inspiration is attended with a crowing noise. 
When the closure is more complete (and this state was found by Dr. Ley, whose 
words I am now quoting, to be much the most frequent at the commencement of 
the paroxysm), the function of respiration is entirely suspended for a while ; there 
is an effectual obstacle to the admission of air. The child makes vehement strug- 
gles, by some termed convulsive, to recover its breath. At varied intervals, from 
a few seconds up to a minute, or upon some occasions nearly two minutes, air is 
at length admitted through the glottis, now partially open ; and this rush of air, 
passing through a very narrow chink, produces the peculiar sound. To these 

"21st. When, after the tenth day, the drinks pass almost entirely from the pharynx into 
the larynx and trachea, even if they are readily rejected, the children most generally die. 

"22d. The increase of the fever after the fourth day, agitation, sinking of the wound, 
and dryness of the trachea, frequency of the respiratory movements, and attempts to cough, 
announce the invasion of pneumonia, which, at first lobular, becomes sometimes pseudo- 
lobar, and is to be treated by the same means as are usually employed in the pneumo- 
nia of children; we should, however, exclude blisters, because they too often become 
covered with false membranes." (See Rilliet and Barthez, Traite des Mai. des Enfans, t. i. 
365-7.— C] 

* [The following comparative diagnostic peculiarities, borrowed partly from M. Valleix, 
and partly from MM. Rilliet and Barthez, will enable us very readily to distinguish the two 
diseases — 

In Croup In Laryngismus stridulus 

There is fever of variable intensity — The symptoms of invasion are slight — 
pseudo-membranous angina, and slight hoarse- there are a slight catarrh, and a cough some- 
ness. what hoarse — the throat is unaffected — some- 

There is a gradual increase of the hoarse- times there are no prodroma. 
ness, and sooner or later a hoarse cough. The attack is sudden — usually at night. 

The fever does not remit; the cough be- Between the paroxysms the patient ap- 
comes hollow and fedble, and the voice faint pears well — the fever disappears or declines 
or extinct. — the voice is rarely extinct. 

The disease is sometimes attended with an There is an expectoration of mucus, 
expectoration of false membrane. The paroxysms of the disease in violence. 

The dyspnoea constantly increases, the 
croupal sound continues during the parox- 
ysms — finally the voice and cough become C.] 
extinct. 



526 



CHILD -CROWING, OR 



symptoms not unfrequently succeed a fit of coughing or crying, which terminates 
the scene: or, if the glottis be not thus partially open, the child, at the end of 
from two to three minutes at the utmost, will die suffocated. Pallid and exhausted, 
it falls lifeless upon its nurse's arms ; and it is then that the child is generally said 
to have died in a fit." 

Sometimes, but not always, with the symptoms now described there is a con- 
tracted state of the flexor muscles of the thumb, fingers, wrist, ankle, and toes ; 
giving to the foot an appearance approaching to that of club-foot. 

Now till very lately most of those persons who had learned not to confound 
this child-crowing with true croup, were of opinion that it depended upon cerebral 
disease or disorder. This was the doctrine of Dr. John Clarke, who has left a 
very good description of the complaint, which he called " a peculiar species of 
convulsions." Dr. Ley doubted the correctness of that notion, and believed that 
the bending of the limbs results rather from feebleness or paralysis of the extensor 
muscles, than from spasmodic contraction of the flexors. It was obviously a great 
point to make out, whether the disorder depends upon pressure within the head 
or not. Our treatment will be regulated by what we know, or believe, in that 
respect. But what is chiefly original, and very interesting, in Dr. Ley's views 
concerning this bastard sort of croup is this, that he attributes the temporary 
closure of the glottis to pressure made by enlarged glands in the neck or chest 
upon the recurrent nerve, or upon some part of the eighth pair; " subverting the 
exact antagonism by which the glottis is automatically and involuntarily kept 
open, and allowing its margins to come together, and to occasion the peculiar kind 
of inspiration so much like that of croup." Dr. Ley looks upon the affection 
altogether as more allied to paralysis than to convulsive movements. This cer- 
tainly is a very original, but, I think, a mistaken view of the matter; I must refer 
you, however, to his book for the facts and reasonings upon which it is founded. 
The important practical fact is, the connection of the child-crowing with tumefac- 
tion of the glands in the neck and chest, and with the entanglement of the pneu- 
mogastric nerve or its branches among these glands. " Scarcely an instance (says 
he) has occurred to me since my attention has been very much directed to the 
subject, in which there has not been the strongest foundation for the belief that 
either the glandulae concatenate of the neck, or the thoracic absorbent glands, had 
become morbidly enlarged." 

Even in the short period that has elapsed since Dr. Ley wrote, this curious and 
intricate knot has been somewhat further (though perhaps it is not yet completely) 
untwisted. Dr. J. Reid has ascertained, by a well-contrived set of experiments, 
that the inferior laryngeal (or recurrent) nerve, is an efferent or motor nerve, by 
which nearly all the movements of the larynx are regulated ; and that the supe- 
rior laryngeal is an afferent or incident nerve. We may easily conceive, there- 
fore, how pressure upon, or irritation of either of these nerves, may affect the 
aperture of the glottis. If the superior laryngeal nerve be implicated, the impres- 
sion is communicated to the spinal cord, and thence reflected, through the recur- 
rent, upon the laryngeal muscles. Irritation of the gastric ramifications of the par 
vagum may have the same result. It is an observation of Dr. John Clarke's, that 
the attacks " very commonly take place after a full meal." Nay, it seems proba- 
ble that not only any of the afferent fibrils of the eighth, pair of nerves, but those 
of the fifth pair also may have a similar exciting power; for a transient crowing 
is readily produced in some children, by exposure of the surface of the face and 
chest to a breeze of wind, or by their being suddenly tossed in the arms of a 
nurse. We must even suppose that the effect produced upon the central cord 
may, by reflexion, influence other muscles, and cause the contractions that are 
sometimes observed in the flexors of the feet and hands. Again, if the recurrent 
nerve itself be pressed upon, or interfered with, undue contraction or paralysis, 
according to the kind and degree of interference, will be likely to ensue of the 
muscles belonging to the glottis. Spasm of those muscles would close the chink, 
and stop the breath. And Dr. Reid has shown that their palsy, except while the 



SPURIOUS CROUP. 



527 



breathing is perfectly quiet and tranquil, sensibly impedes inspiration, and alters 
its character. 

It appears, therefore, that the ingenious view taken by Dr. Ley of the special 
pathology of this child-crowing disorder, or croup-like convulsion, merges in the 
more general principles of reflex function advanced by Dr. Marshall Hall. 

At the same time it is interesting to observe how Dr. Ley's theory harmonizes 
with what has been noticed of the predisposing causes of this crowing inspiration. 
In the first place, it is often manifestly connected with dentition. Now one effect 
of dentition is the production of glandular swellings of the neck ; which happen 
even in the absence of all strumous taint, but with still more certainty if any such 
taint exists. And thus he explains the fact, that the disorder has appeared in the 
most robust as well as in the most delicate infants. Thus also he explains an- 
other well-known fact, viz., that, when child-crowing accompanies painful denti- 
tion the symptoms do not vanish instantaneously, as if by magic, the moment that 
the tooth starts through the gum ; but pass off by degrees. Dr. Ley remarks 
that, " after the gum and enveloping membrane of the tooth have been relieved 
from swelling and inflammation by the free use of the gum-lance, some time is 
still required for the irritation and tumid state of the cervical glands to subside." 
It is not improbable that the gingival irritation alone may sometimes suffice, 
through the channel of the trifacial nerve, to determine the reflex spasm. 

Again, this child-crowing is found to occur in connection with excoriations 
behind the ears, and with inflamed and irritable scalp ; and these complaints very 
frequently lead to enlargement of the absorbent glands of the neck, which enlarge- 
ment may thus form an intermediate link in the chain of events. And upon some 
occasions Dr. Ley has had strong reason to suspect that bronchitis, or other dis- 
ease of the lungs, has occasioned enlargement of the bronchial glands, and so 
given rise to the crowing inspiration. 

I think that Dr. Ley has made out fair grounds for his view of the pathology of 
what is called spasmodic croup. But it is too partial and limited a view. Again, 
the alleged connection between child-growing and cerebral disturbance is not a 
mere fancy, although its bearing may have been sometimes misapprehended. 
The cerebral disturbance is mostly the consequence, and not the cause, of the 
impediment to the function of respiration.* 

The practical fact which you have to remember is, that croupy breathing may 
occur, and return in paroxysms, when there is no croup. And the practical lesson 
which you have to learn is, how to discriminate between these two similar, yet 
different disorders. I have already specified the distinctive characters of cynanche 
trachealis. The complaint that copies it may be known by its sudden accession 
and its sudden departure; by the freedom of breathing in the intervals between 
the paroxysms; by the absence of fever, of preceding or present catarrh, of 
hoarseness, and of any abiding cough. The diagnosis, easily enough reached 
when these points are sufficiently attended to, will be still more sure, if you dis- 
cover enlarged glands in the neck: or hot, tense, and tender gums. 

According to Dr. Clarke, "convulsions of this description seldom, if ever, occur 
after the expiration of the third year of a child's life." 

It must be unnecessary for me to urge the importance of the diagnosis. Those 
active measures which befit the outset of the inflammatory disease, would be mis- 
placed and mischievous in the other. It was the result of Dr. Ley's experience 
that " those children have upon the whole a much better chance of being preserved, 
who are not subjected to very severe discipline, than those who, in compliance 
with the prevailing doctrine, have been treated by very copious bleeding, large 
doses of calomel, and such other remedies as the supposition of the invariable 

* [We doubt the correctness of Dr. Ley's views, as well as the views of those who refer 
the disease to enlargement of the thymus gland. — For an examination of the facts connected 
with the pathology of laryngismus stridulus, the reader is referred to the Editor's Treatise 
on the Diseases of Children, page 311, et seq.—C] 



528 



MSEASES OF 



dependence of the disease upon cerebral tumescence, or excitement, has sug- 
gested." 

Do not, however, imagine, from what I have just been saying, that this dis- 
order, child-crowing, is a trifling disorder, and unattended with danger. It is 
really a perilous, as well as a terrifying condition. The respiration is sometimes 
so long suspended that death takes place in the paroxysm. And each paroxysm 
is accompanied by a tendency to stagnation and congestion of blood, in the brain, 
lungs, and heart: a tendency which, by its frequent repetition, may lay the foun- 
dation of serious and fatal disease in one or other of those vital organs. 

The treatment of this affection must depend a good deal upon the nature of the 
predisposing and exciting causes. To go into it fully would require that I should 
speak of the mode of cure in painful dentition, in eruptive complaints about the 
head, in certain pulmonary and cardiac diseases, and in all those conditions which 
are apt to cause enlargement of the catenated or bronchial glands : or to fret in 
some other way the pneumogastric nerves. 

In addition to the special methods of treatment which these disorders may 
severally need, great care must be taken, in all cases, to regulate the state of the 
bowels, and of the skin. Fresh air also is a powerful adjuvant; and sometimes 
of itself a sufficient remedy. Change of place, therefore, and especially a re- 
moval from the air of a city or town to the pure atmosphere of the country, 
should be urged whenever it is practicable. 

In the paroxysm itself the warm bath might be useful, if it could be got ready • 
in time. The application to the throat of a large sponge from which hot water has 
just been squeezed, is a more accessible, and often a very effectual expedient. 
Sprinkling the face and chest freely with cold water will sometimes unlock the 
spasm, and set the little sufferer free. 

I should have stated, that Dr. Ley's views were amply supported by the re- 
searches that he had made into the morbid anatomy of this affection. Had he 
lived, I should have had it in my power to show you some very beautiful and 
interesting preparations, illustrative of the connection of the disorder with enlarged 
glands, which had come to press upon, or stretch, the par vagum, or its branches. 
As it is, I can only show you the published engraving from some of them, appended 
to his book. 



LECTURE XLVII. 

Diseases of the Thorax. General observations. Dyspnoea. Cough. Methods 
of exploring the physical conditions of the chest, by the senses of sight, touch 
and hearing. 

From the throat— and especially from that part of it with which we were last 
occupied — the transition is natural and immediate to the thorax. Now the inte- 
rior of the chest is the theatre of numerous and most important morbid changes. 
"Within that cavity are lodged two of the three organs most essential to life. The 
heart, lungs, and brain, have been said, by a bold figure of speech, to constitute the 
tripod of life : and the two former are planted in the thorax. In the same division 
of the body lie also the greater blood-vessels, and many other parts of scarcely 
less consequence. With respect to the heart, its alternate swinging movement 
cannot long stop, and the patient continue to live : while three minutes' total in- 
terruption to the play of the lungs would in most cases be irremediably fatal. 
And lesser impediments to the free working of either of these two vital organs 
are productive of much danger and distress; and lead often to consecutive changes 
of a very serious kind, in various other portions of the body. 

These parts, of which the function is so indispensable, and of which the dis- 



THE THORAX. 



529 



orders are so grave and perilous, are encased in such a manner by the ribs and 
other boundaries of the chest, that they can neither be seen nor handled. And 
until a very late period in the history of medicine — until our own times, in fact 
— the diagnosis of the formidable maladies that befal the viscera of the thorax 
was exceedingly uncertain and imperfect. Physicians were able, indeed, by the 
observation of indirect symptoms, manifested through the general system — by 
remarking the presence of inflammatory fever, I mean — to infer that inflamma- 
tion had been somewhere lighted up: and symptoms that denoted disturbed func- 
tion of the respiratory apparatus — cough, difficult breathing, or local pain — might 
suffice to apprize them that the inflammation was situated in the chest. But 
what tissue it affected, where was its exact place, what was its extent, or what 
were its physical consequences — these were points concerning which they had 
no means of obtaining any precise knowledge. " Under the title of pneumonia 
or pneumonic inflammation," says Cullen, "I mean to comprehend the whole of 
the inflammations affecting either the viscera of the thorax, or the membrane 
lining the interior surface of that cavity : for neither do our diagnostics serve to 
ascertain exactly the seat of the disease, nor does the difference in the seat of the 
disease exhibit any considerable variation in the state of the symptoms, nor lead 
to any difference in the method of cure." You will see, as we proceed, how 
very inaccurate this last statement would be, if it were made under our present 
mode of investigating these diseases. " Pneumonic inflammation, (he continues) 
however various in its seat, seems to me to be always known and distinguished by 
the following symptoms: — Pyrexia, difficult breathing, cough and pain in some 
part of the thorax." 

I state these things to you — who do not recollect the time, as I do, when no 
medical man in this country could, with truth and candour, say more of his know- 
ledge of diseases of the chest than Cullen said — that you may the better estimate 
the exceeding value of the discovery of what is called the method of auscultation, 
in the detection and discrimination of disease; and most particularly of thoracie 
disease. In the present day we are able to obtain more exact information respect- 
ing the disorders of the parts contained within the chest, than of any other internal 
and therefore invisible parts of the body. Indeed, in a vast number of instances, 
we can tell, as accurately as if we saw them, the actual condition of the thoracie 
viscera: can follow, step by step, the successive processes of disease, or of repair, 
in which they are involved. We can penetrate beyond the symptoms which 
denote deranged function, and detect and understand those much less fallible symp- 
toms which arise from alterations of structure. And this vast addition to our 
pathological knowledge has been given us by the simple application of one of our 
five senses to the investigation of disease, the sense of hearing, which for so 
many centuries had been (strangely as it now seems) neglected, or but little used. 
By the assistance of the ear it has come to pass that those diseases which, 
besides being the most common and the most destructive, were also the most 
obscure, are now better understood than the diseases of any other internal part 
whatever. 

The direct symptoms which arise out of the changed conditions of the parts 
affected in thoracic complaints, are so mixed up with all that we know or can 
learn of such complaints, that what in other cases is called the morbid anatomy of 
a disease, becomes, here, part of its descriptive history. I shall not say, there- 
fore, — as in regard to many other maladies I am obliged or I find it convenient to 
say — so and so are the symptoms ; and afterwards, so and so are the morbid 
appearances : but I shall describe the morbid conditions in the outset, as the only 
way of rendering the symptoms which result from them intelligible. 

But before I enter upoi#he subject of auscultation, it may be useful to make a 
few remarks upon those symptoms of thoracic disease which were previously 
known, and which depend upon, or rather which express,, derangement of the 
pulmonary functions. 

One of the most constant, and obvious, and distressing, and instructive of these 
34 



530 



DISEASES OF 



symptoms, is embarrassed or laborious breathing: what is technically called 
dyspnoea. You know that by a healthy adult, under ordinary circumstances, the 
act of respiration is performed, unconsciously almost, about eighteen times in a 
minute. There is about one act of respiration for every four beats of the heart. 
In various diseases this proportion is materially altered. The reciprocal move- 
ments, by means of which, in measured succession, air is drawn into and again 
let out of the lungs, are performed with hurry, or effort, or unusual slowness. 
Dyspnoea implies some deviation from the natural manner or rate of alternately 
expanding the thorax, and suffering it to collapse again : of inspiring and expiring: 
in one word, of breathing. The patient himself may, or may not, be conscious 
of this deviation. In most of the cases in which dyspnoea claims to be regarded 
as a symptom, he is conscious of it. Now upon what does this symptom depend ? 
It may ultimately be referred to an altered proportion between the quantity of 
atmospheric air that reaches the lungs, and the quantity of blood that is sent into 
them, from the right side of the heart, to be converted from venous to arterial. 
That, doubtless, is at the bottom of almost every case of dyspnoea. Let me 
remind you that respiration is an automatic movement; subject nevertheless to 
the occasional control of the will. The pulmonary branches of the par vagum 
constitute the principal and constant excitor, as the nerves that supply the muscles 
of respiration are the motor links of the nervous chain by which the automatic 
movements are governed. It is believed that the presence of venous blood in the 
capillary vessels of the lungs forms the natural stimulus to the pulmonary part of 
the par vagum. In the ordinary breathing of a healthy person, this stimulus or 
impression is not felt: perhaps because being slight and habitual, and exactly 
apportioned to the need of the individual, it is not attended to : or, it is at once 
appeased by the admission of air, and the corresponding change in the blood. 
But when that change is not immediately or perfectly accomplished, then arsies 
the distressful sensation which everybody has felt, but which our own language 
has no one word to express. The French call it the besoin de respirer. The 
English phrase, want of breath, denotes the peculiar sensation equally well. It 
calls into exercise, frequently, the voluntary power of performing the mechanical 
acts of breathing-^a power which is superadded to the automatic process. 

Various are the ways in which the natural manner and frequency of the respi- 
ratory movement may be deranged. They were fully considered when I was on 
the subject of death by apnoea. They all operate, ultimately, by destroying the 
just equilibrium between the blood and air which meet to undergo chemical 
changes in the lungs. We have lately been considering certain diseases in which 
the difficulty and distress of breathing is often extreme. In croup, and laryngitis, 
the only inlet for the air is narrowed at its very entrance : there is more blood 
passing through the lungs than can be arterialized under the ordinary motions of 
respiration : instinctive efforts take place to increase the quantity of air: to make 
up by more numerous acts of inspiration for the diminished amount of air intro- 
duced by each single act. For a time these compensatory efforts may suffice. 
But if the access of air be still impeded, blood begins to circulate through the 
arteries but half decarbonized ; and to linger and stagnate in the lungs: the lips 
become livid, and the skin grows dusky. Make, however, a free opening in the 
pipe that should conduct air to the lungs, and the balance being restored between 
the blood in those organs and the air that reaches them, the dyspnoea is soon at 
an end. The quantity of blood being the same then, but the air inspired too little, 
there will be dyspnoea. The very same thing occurs whenever a portion of lung 
from being spongy is rapidly rendered solid. No air can then penetrate it; nor 
perhaps any blood ; but the same quantity of blood as before arrives at the right 
side of the heart, and is transmitted thence through t& pulmonary artery; and 
consequently those portions of the lungs which are pervious to blood and air, are 
supplied with blood in excess, and require air in excess : L e., dyspnoea is neces- 
sitated. And you will perceive that similar consequences may arise from any 
pressure made upon the lung, obliterating in a certain degree its cellular structure; 



THE THORAX. 



531 



as by fluid collected in the pleura; by enlargement of the heart; by aneurism of 
the great vessels ; by tumours, of whatever kind, within the chest ; or by pressure 
upwards against the diaphragm by reason of a distended abdomen, whether the 
distension be occasioned by disease, such as ascites, or by obesity, or by a full 
stomach, or by a gravid uterus. A like disproportion will ensue, if the free ex- 
pansion of the thoracic cavity be prevented by pain, by disease or rigidity of its 
boundaries, or by palsy of its muscles through interruption of the nervous circle 
whereon their contractions depend. 

But on the other hand the balance may be destroyed from the opposite quarter : 
the air admitted during a single ordinary inspiration being the same, the quantity 
of blood requiring to be converted from purple to scarlet may be augmented ; and 
in that case also, in order to maintain the due equilibrium, more numerous acts of 
respiration must be performed : in other words, dyspnoea will arise. This is the 
case under brisk exercise: the pressure of the muscles upon the veins propels 
their contents with greater velocity towards the right side of the heart; the heart 
contracts more frequently in proportion as it is more rapidly filled with blood ; a 
greater quantity than usual is sent through the pulmonary artery to the lungs ; and 
the individual breathes more quickly, to supply this augmented quantity of blood 
with air: he is out of breath, in a state of dyspnoea. But this is not disease. 
Disease, however, will often have the same effect. The quickened circulation in 
fevers, any obstacle to the free passage of the blood from the heart into the arteries, 
will tend to gorge the lungs with blood, to destroy the requisite equilibrium 
between the air and the blood in those organs, and so give rise to dyspnoea. 

Other conditions still may be mentioned, as predisposing to hurry of the breath- 
ing — a peculiar state of the nervous system ; certain qualities of the blood ; — but 
I need not dwell on these at present. 

There are two important corollaries derivable from what I have now been 
stating. In the first place, you must perceive how intimately the functions of the 
heart and lungs are dependent upon each other; and that disease originating in 
either of these vital organs may readily be the cause of consecutive disease in the 
other. We shall have many examples of this before us as we proceed. It would 
afford materials for an interesting essay, this mutual relation between cardiac and 
pulmonary disease. At present I merely glance at it in passing. 

In the second place, what I have said of dyspnoea must have sufficed to show 
you that, taken by itself, it has not much value as a diagnostic symptom. All 
that it tells us is, that the healthy and natural relation between the quantities of 
blood and of air in the lungs is disturbed : but to determine the cause of that dis- 
turbance — to decide whether the heart be in fault, or the lungs, or both, or neither 
— we must have recourse to other sources of information. 

Cough is another of the symptoms, mentioned by Cullen, as denoting disordered 
function of the breathing apparatus. I need scarcely tell you that it is produced by 
closing the glottis, and then making a sudden and strong expiration. Its purpose 
is the dislodgement of mucus which may have collected in excess in the air- pas- 
sages, or of any other source of irritation to the membrane lining those parts. To 
be effectual it requires the admission of a certain quantity of air, and the possession 
of a certain degree of muscular strength. I pointed out to you, in the last lecture, 
a remarkable exemplification of this : the boy whose case is described by Mr. 
Chevalier in the Medico- Chirurgical Transactions, was dying of croup; was on 
the brink of being suffocated by the collection of mucus in his wind-pipe and 
bronchi, which mucus he was unable to expel: and he was unable, not from defect 
of muscular strength, but because he could not sufficiently inflate his lungs beyond 
the collected mucus. When an ample opening was made in his trachea, he drew 
in a strong breath, and coughed the mucus up through the rima glottidis. In 
old and feeble persons labouring under chronic bronchitis with profuse secretion 
from the mucous surface, strength is often wanting to cough the phlegm up ; and 
they die suffocated. 

But the sensation which prompts to the acts of coughing may arise from various 



532 



DISEASES OF 



other causes besides the accumulation of mucus in the air-passages. Any slight 
irritation about the glottis; a long, trailing and tickling uvula; the inspiration of 
irritating vapours; pressure of any kind upon the respiratory organs; may any of 
them produce cough. Nay, it sometimes is provoked by sympathy with other 
parts ; an instance of which we have in what is called a stomach-cough. Some 
morbid condition, some irritation of the stomach exists, which being appeased, the 
cough ceases. You will recollect the name and the functions of the pneumogas- 
trie nerves. We have, in the fact just mentioned, another example, in addition 
to those which I glanced at in a former lecture, of irritation of the sentient extremi- 
ties of one branch of a nerve, declaring itself by uneasy sensations referred to 
other branches of the same nerve. For these reasons, therefore, cough is not 
more diagnostic of particular diseases situated in the thorax, than is dyspnoea. 
There are, indeed, certain varieties of cough, as there are certain modifications of 
the breathing, from which we may obtain very useful information even in respect 
to the nature and seat of some diseases : and these varieties and modifications I 
will point out as I go along. 

Let me admonish you, also, before we come to auscultation, not to fall into an 
error which has been too common ; that of trusting entirely to the ear in the 
investigation of thoracic disease, to the exclusion or neglect of those phenomena 
which are perceptible by the eye, or by the hand ; or of those indirect revelations 
which are furnished by the condition of other parts and functions, or by the pre- 
vious history of the patient. Even before the discoveries of Avenbrugger and 
Laennec, physicians were too remiss (if we may judge from their writings) in 
what may be called the mechanical exploration and notice of the actions of respi- 
ration. A good deal may be learned, sometimes, by merely placing one's hand 
upon the chest, or belly, as I shall explain more particularly by and by : and a 
great deal, also, may be made out, in some cases, by the simple inspection of those 
parts, when they are uncovered. You may see, for example, that the ribs, in 
respiration, scarcely move at all, while the belly rises and falls alternately with 
the descent and ascent of the diaphragm. This is called abdominal respiration. 
It may arise from a painful condition of the intercostal muscles, or of the pleurae, 
rendering the patient unwilling to elevate his ribs ; or it may arise from disease 
of the spinal cord, between the origins of the phrenic nerve and of the intercostal 
nerves, rendering the patient unable to raise them ; or the same inability may 
result from disease of the lungs themselves. The symptom may guide us at once 
to the seat of the malady. Again, the breathing may be entirely thoracic, no 
motion of the abdomen taking place; and this may depend upon an affection of 
the diaphragm, or of the pleura which is reflected over it; or upon disease, ac- 
companied with tenderness, within the abdomen — upon peritonitis, for example; 
or upon mere distension of the abdomen. Or by looking at the naked chest, you 
may see that one side of it moves, and that the other moves less, or does not 
move at all: and the motionless side may be of the natural size as compared with 
the other, or it may be flattened and contracted, or it may be round and bulging; 
and most important conclusions, and most important indications of treatment, will 
flow from a knowledge of these circumstances. The general form of the chest is 
also instructive. Never neglect, then, to examine the thorax, in cases where it 
is supposable that the disease may be seated in that part of the body, by your eye, 
as well as by your ear. The eye needs but little training to enable it to perceive 
and comprehend those signs which are within its sphere : the ear, unfortunately, 
requires to be carefully educated. I will just remark, further, that in the case of 
females no indelicate exposure of the person need be made. In most instances 
the morbid conditions I have been adverting to may be recognized through a thin 
linen covering. 

Auscultation signifies the investigation of internal diseases through the sense of 
hearing: and it is especially applicable, for reasons which I either have stated or 
will state, to the study of thoracic diseases. In its full meaning it includes all 
that we learn by listening to a cough, and all that we gather by striking the chest, 



THE THORAX. 



533 



and attending- to the resulting sound. But in general, the term percussion is used 
to express this last mode of eliciting information, although the information is con- 
veyed through the medium of the ear: and the word auscultation is applied to the 
art of distinguishing diseases by listening to internal sounds, by means of the ear 
placed in apposition with the surface of the body; or by means of some conductor 
of sound interposed between the ear of the listener and the person of the patient. 
In the first of these two modes the auscultation is said to be immediate; in the 
second, mediate. By percussion we ascertain the degree of resonance, or want 
of resonance, of the part struck : by auscultation we learn the qualities and modi- 
fications of the voice, as reflected through the chest; and of the breathing; and of 
the sounds of the heart. The invention of the method of percussion we owe to a 
German, Avenbrugger, who wrote an excellent treatise upon it, which was brought 
into notice by Corvisart, who translated it. For the more brilliant discovery of 
auscultation we are indebted, as every body knows, to Laennec. 

Now it will save us much trouble, and conduce, I hope, to your future progress 
as practical auscultators, if, before I speak of any of the diseases of the chest, I 
premise some general observations respecting these modern methods of examining 
the human body, with the view of detecting and discriminating its diseases. Indeed, 
I could not make myself intelligible unless I did so. 

And first, with respect to percussion, which you will please to recollect is 
nothing else than auscultation of, or listening to, sounds which we ourselves artifi- 
cially and purposely produce. 

You know, every child knows, by daily experience, that different substances, 
when struck, give out very different modifications of sound. If you strike a drum, 
you get one kind of sound ; if you strike a brick wall, you get another. The one 
is loud, trembling as it were, and prolonged ; the other dull, short, and flat. But 
why should I attempt to describe in words things which are familiar to you already ? 
Bodies that are solid, or inelastic, give the dull flat sound in proportion to their 
solid thickness, or their want of elasticity. On the other hand, hollow vessels, 
i.e., vessels containing air, with thin, firm, elastic boundaries, give out a sound 
more or less approaching in its qualities to that of a drum : the sound is called a 
hollow sound from that circumstance. If you have a wooden cask containing air 
only, it is resonant when struck ; fill it half full of water, and the lower part will 
render a flat sound, the upper empty portion a hollow sound; 'less hollow, how- 
ever, than when the vessel contained no water: fill it up with water, and the 
whole is dull on percussion ; pour out the water, and fill it loosely with wool — it 
will still be resonant, though in a different and less clear note than when it held 
air alone. 

Now this experiment may be transferred to the human chest, which is a cavity, 
bounded by firm, thin, tense, and elastic walls, and containing, in its natural state, 
the spongy lungs, which are full of air; and other parts that are solid, whereof 
the heart is the chief. If you strike the surface of the chest (it requires a little 
knack to do it properly), and if the blow falls over a portion of healthy lung, you 
will produce a resonant or hollow sound. If the lung be not there, if it be pushed 
aside, and its place supplied by some more solid or inelastic substance, by fluid 
for example, you will hear a dead sound. So you will if the lung be there, but 
has lost its spongy character, is void of air, and somehow or other solidified. But 
you may have a resonant sound, though the lung is in a state of disease; nay 
though the lung is not there : so that percussion alone cannot always be depended 
upon. I shall tell you, hereafter, how to guard against being misled by it in such 
cases. Again, if you strike over the region of the heart, you will get a positively 
dull sound, or at any rate a much duller sound than in most other parts of the 
chest. 

It is really a singular thing, that this method of searching for indications of 
disease, and of health, should have been so long neglected or overlooked in our 
profession. I am sure that I had a practical acquaintance with the principle of 
percussion long before I knew any thing of physic; and so, I make no doubt, 



534 



DISEASES OF 



have most of you. Many a time, when wishing to know whereabouts I might 
drive a nail firmly into a wall, I have tried with the hammer to find which was 
brickwork, and which was wooden joist; and percussion is an art in daily use 
for similar purposes, with carpenters and bricklayers. Yet it does not appear to 
have been thought of by physicians till the middle of the last century, when Aven- 
brugger, after studying its results for seven years, as he tells us inter tssdia et 
labores, published at Vienna his " Inventum novum, ex percussione thoracis 
humani, ut signo, abstrusos interni pectoris morbos detegendi." This was almost 
totally neglected however, until, as I stated before, Corvisart's work on diseases 
of the heart brought it into general notice. 

Avenbrugger and Corvisart, and indeed every body who used percussion at all, 
until a very few years ago, employed direct percussion : that is, they struck the 
chest with the extremities of the fingers. More recently, mediate percussion has 
been introduced into practice, by M. Piorry. In mediate percussion some solid 
substance is placed upon the spot, the resonance of which is about to be explored, 
and the blow is made upon that substance, which is called a pleximeter — a stroke- 
measurer. A round thin plate of ivory, laid flat upon the surface, is the most 
common sort of pleximeter ; or metal, or wood, or leather, or India rubber, may 
be employed. Many persons, and I am one of them, use no other pleximeter 
than the fingers of the left hand. 

I shall explain, as briefly as I can, the method of employing percussion, and 
the cautions requisite to render it an effectual and a true interpreter of the state 
of the parts beneath the stricken surface. 

The position of the patient is of some consequence. It should be one that is 
convenient to the examiner, and not inconvenient to himself; and it should be 
one calculated to render the part struck as firm and tense as possible. The best 
position of all is a sitting position, on a firm chair. But you may percuss a 
patient very effectually as he sits up in bed, or while he stands, or some parts 
even when he is lying down. A good deal is said, — more, in my opinion, than 
is necessary, — about the effect of curtains, and so forth, in deadening the sound. 
I do not believe they will ever interfere with your conclusions, especially as we 
learn more from comparing the sounds given out upon percussing the correspond- 
ing parts of the opposite sides of the chest, than from the absolute resonance or 
want of resonance of any single part. But there are some exceptions to this ; 
and if your patient can be made to sit on a chair in the middle of the room, so 
much the better. 

Then, if you are about to percuss the front of his chest, make him hook his 
arms over the corners of the back of the chair, and throw his head back. If you 
desire to explore in this way the lateral portion of the thorax, he must place the 
hand of that side upon his head, and lean a little to the opposite side. If you 
would know how the posterior part of the chest sounds, he must lean forwards, 
fold his arms across his breast, and bend down his head. 

Next as to the mode of percussing. For direct percussion, the ends of the 
fingers of the right hand should be brought together, and into a line with each 
other, so that no one of them may project beyond the rest ; and care should be 
taken, first, to compare the sound produced by striking any part of the chest on 
one side, with that produced by striking the corresponding part on the other side. 
It follows from this rule that we should not examine all the points on one side 
before passing to the other, because we should thus lose the remembrance of, and 
the power of accurately comparing, the sounds obtained from corresponding 
points. It is best to strike first on one side of the body, and then on the corre- 
sponding spot of the other. It follows also that we are not to compare the result 
of percussion on one of the ribs, with the result of percussion on one of the in- 
tercostal spaces. The blow should fall upon the rib, and parallel to it. 

A second point requiring attention, is the state of the chest in respect to the 
act of breathing. If one side be percussed after the movement of inspiration, 
and the other after that of expiration, some little difference in the resulting sounds 

•# 



THE THORAX. 535 

will be manifest, even in the healthy condition of the thorax. And this might 
mislead. Let corresponding spots on the two sides be therefore both struck, either 
while the chest is expanded, or while it is collapsed, or while the patient holds 
his breath. 

Thirdly, you must take care to strike the corresponding parts at the same angle, 
and not with the fingers perpendicular to the surface on one side, and inclined 
obliquely to it on the other: also to strike corresponding parts with the same 
degree of force. And the blow should not be hard enough to give the patient 
pain; indeed such a blow would not produce a good sound. It should be smart 
and quick ; the ends of the fingers should not remain on the chest. Under some 
circumstances, however, the patient cannot bear to be percussed at all. 

These latter cautions are most necessary when direct percussion is employed ; 
over which mediate percussion has, however, many advantages. Some of these 
are obvious. In the first place, the space examined by mediate percussion is very 
exactly defined and limited. Secondly, you may strike the pleximeter much more 
forcibly than you could strike the unprotected body, and so produce a more de- 
cided sound. Even when the surface is morbidly sensible, or the patient unusually 
irritable, so that percussion in the ordinary way cannot be performed at all, it may 
generally be done through the pleximeter. A third and very great advantage is, 
that mediate percussion is available when made over certain parts where, even 
although there may be no pain occasioned by it, ordinary immediate percussion 
is attended with no useful result. Parts, I mean, where there is much fat, and 
parts which are fleshy, or cedematous. If the pleximeter be pressed firmly upon 
these parts, even upon the mamma in females, the hollow sound is attainable; 
whereas, if they were struck by the fingers, the sound would be perfectly dull. 
Mediate percussion may be applied also, with effect, through the clothes. 

I say that a convenient way, and one which I find quite sufficient, of employ- 
ing mediate percussion, is by making a pleximeter of the finger or fingers, of the 
left hand ; taking care that they are closely in contact with the subjacent parts, 
and similarly applied to corresponding spots ; and that the backs of the fingers 
be outwards. Piorry declares, indeed, that the resonance produced by this mode 
is scarcely one-tenth part so great as that elicited by using a thin, solid and elastic 
plate. For all practical purposes, however, I am certain that the finger, as it i9 
the readiest, so also it is a very satisfactory and sufficient pleximeter. It has, 
moreover, this positive advantage, that the sound made by striking it is not loud, 
and does not obscure or interfere with that which depends upon the condition of 
the chest. 

It is right that you should be aware of differences of sound which belong to 
the individual. Ceteris paribus, the sound given out on percussion is more reso- 
nant during inspiration than during expiration; in childhood and youth than in 
middle age : in middle age than in old age; in females than in males; in thin per- 
sons than in fat : and, they say, in nervous irritable people than in those of a con- 
trary temperament. 

And it is still more necessary that you should be aware of differences of sound 
given out in health, by different parts of the surface of the thorax, in the same 
individual. And in order to explain this more distinctly, and for the sake of refe- 
rence hereafter, let me here exhibit to you the regions of the thorax, as they have 
been artificially mapped out for the purposes of auscultation. 

It is unnecessary for me to describe particularly the method followed in this 
arbitrary division of the thorax into regions. I will state the names that have 
been commonly applied to them, and the sounds which in health they respectively 
yield, according to their number in the diagram before you. 

The first region is that of the clavicles ; one of course on each side. Upon 
these bones it is immaterial whether direct or mediate percussion be made. The 
sound given out should be very clear at their sternal extremities, dull at their 
humeral extremities, and clear at their middles. The resonance diminishes from 



536 



DISEASES OF 



the sternal towards the acromial end of the clavicle, 
the summits of the lungs. 



These parts correspond to 





The second region is the subclavian. It lies between the clavicle and the fourth 
rib on each side. Beneath this superficial region lies the upper lobe of the lung ; 
and towards the sternum large bronchi are situated. You will understand, there- 
fore, that the sound educed by striking this part ought to be very clear. 

A little lower down, number three, is the mammary region, extending from 
the fourth to the seventh rib on each side, and answering to the middle lobe of the 
lungs. Here also the resonance afforded by percussion is clear; but in the lower 
part of this region, on the left side, we find the heart, which is more or less 
covered by lung: and on the right side the liver begins to mount. The sound is 
somewhat modified and deadened by these deeper-seated viscera. In women we 
can determine the degree of resonance of this region through the mammas, by 
mediate percussion only. \ 

The fourth is the infra-mammary region. It comprehends that part of the 
bony compages of the thorax on each side which lies between the seventh rib and 
the edge of the cartilages of the false ribs. Into this region, on either side, may 
descend the thin anterior margins of the lower lobes of the lungs ; but in the same 
region, on the right side, lies the liver, over which the sound of percussion is dull; 
and on the left side is placed the stomach. Hence, when the stomach is tympa- 
nitic, a preternaturally resonant sound will proceed from this part; and when the 
stomach contains no gas, the sound will be irregularly dull. 

All the regions hitherto described are double. There is still the mesial part of 
the front of the chest to be subdivided, and we may call the three regions there 
situated, and numbered 5, 6, 7, the upper sternal region, the middle sternal, and 
the lower sternal. In all these the sound on percussion ought to be clear, except 
perhaps in the inferior portion of the last, which may be rather dull, or which, 
from its vicinity to the stomach, may be tympanitic. 

The eighth region is the axillary ; the axilla above the fourth rib on each side. 
The ninth is the lateral region, between the fourth and seventh ribs. In both 
these regions the resonance should be distinct and clear. The tenth, which may 
be called the lower lateral region, below the seventh rib at the sides, gives the 
same sounds as the infra-mammary, namely, on the right side a dull sound, on the 
left a sound which at times is preternaturally hollow : on account of the presence 
of the liver in the former case, and of the stomach in the latter. 

But we have yet to look at the hind part of the thorax. Here we have the 



THE THORAX. 



537 



space (region eleven) which forms the top of the shoulder, and lies between the 
clavicle in front, and the superior spine of the scapula behind ; the acromial region. 
Very little can be made out by percussion in this spot; the sound is dull. But 
the depression immediately above the scapula, the supra-spinal fossa, as it is 
called, is a space which affords valuable information to the ear applied over it. 

The twelfth region is the scapular. It comprises the part covered by the 
scapula on either side. It corresponds to the posterior part of the middle lobe of 
the lungs, but yields a dead sound, unless a pleximeter be used. 

The thirteenth region is the intra- scapular. It lies between the inner edge of 
the scapula and the spine on each side. It corresponds to the roots of the lungs, 
and to the middle parts of their lower lobes. You may get a good clear sound 
here, if the patient's arms be crossed, and his head bent forwards, and his back 
arched, so as to stretch and tighten, and make as thin as possible, the superincum- 
bent muscles ; you will find also that the ridge of the spinal column in this part 
gives a hollow sound. 

The last region to be mentioned, number fourteen, the dorsal, is the lowermost 
part of the ribs behind. It answers to the base of the lungs, and gives a clear 
sound : but the liver on the right side is apt to render its inferior portion dull'; and 
the stomach on the left'to make it unduly resonant. 

Now, knowing these circumstances, if you find that a dull sound is yielded on 
percussing a part that should render a hollow sound, you conclude that beneath 
the part struck there is not the natural quantity of air. But whether this arises 
from consolidation of the lung itself, and the obliteration of its cells, or from fluid 
effused into the cavity of the pleura, you cannot, by mere percussion determine. 
So, again, if the sound be unnaturally tympanitic, you cannot say whether that 
results from what is called pneumothorax, or from emphysema of the lung. Per- 
cussion testifies that air is there ; but further this deponent sayeth not. 

The information which the exercise of percussion may leave thus imperfect, 
auscultation of the sounds produced by the acts of breathing, speaking, or cough- 
ing, will in most cases supply. 

If the ear be laid close to the surface of a healthy thorax (or if the instrument 
called the stethoscope be interposed between that surface and the ear), the ear 
will hear the air enter and fill the lungs, and then withdraw and leave them again, 
in perpetual succession. The sound produced by this ingress and egress of air 
has been called the respiratory murmur. I might tell you that this sound, to 
my mind, is rather a rustle than a murmur ; that it is like the sighing of the wind 
in the branches of a tree. I might say, with Laennec, that it resembles the sound 
made in the deep inspiration of a sleeping person ; or, with Dr. Davies, that it 
reminds one of the soft murmur of a pair of bellows, of which the valve does not 
click. But one minute's appliance of your ear to the subclavian region in a child, 
or even in an adult, will give you a clearer notion of the nature and character of 
this sound than any verbal description could convey. Yet, respecting this natural 
respiratory murmur, there are some things of which it is desirable that you should 
be previously informed. 

In the first place, the entrance of the air is much more noisy than the exit: 
which, sometimes can scarcely be heard. You will see, by and by, the import- 
ance of noticing this fact. 

In the next place, the murmur of respiration is not equally audible in all per- 
sons. It may differ much in intensity, though not in kind, in two persons, each 
of whom is in perfect health. Thus it is much more loud and distinct in children 
than in grown persons. So remarkably is this the case, that when we meet with 
an unusually noisy respiratory murmur in an adult, we say that his breathing is 
puerile; it has the character of the respiration of a child. Now, I tell you before- 
hand, that puerile respiration in the lung of an adult is generally a sign of disease ; 
and it is mostly partial; heard in certain parts only of the chest. 

Again, cseteris paribus, the natural murmur of respiration is more clearly audible 
in lean and spare persons than in such as are muscular and fat. Fat and muscle 



538 DISEASES OF 

are bad conductors of sound, and act as dampers. Listening to the breathing 
through a thick layer of adipous tissue, is like listening (as Dr. Latham says) to 
the respiration of a person through his clothes. 

But if you take two healthy men who are alike in respect to leanness and fat- 
ness, you may often find that the respiratory murmur is very loud in the one, and 
very feeble, or almost inaudible, in the other: but in this last it becomes audible 
when he takes a deep and forced inspiration. 

The reason of this difference is not very well understood. The breathing may 
be very indistinct, though the thorax be capacious, and well formed, and healthy. 
Some persons seem to require less effort than others to maintain the due equilib- 
rium between the air in the lungs, and the blood in the lungs : as if they had not 
only pulmonary space enough, but to spare. So that the difference in the manner 
of breathing, and. in the sound occasioned by the passage of the air in an out, de- 
pends, in all probability, upon individual peculiarities of the circulation. At any 
rate, it is very important that you should be aware of the existence of these dif- 
ferences. 

But the sounds which reach the ear applied to the chest of a breathing person 
will differ in different parts, and under different circumstances. The sound 
given out by the air as it passes through the trachea and larger bronchi, differs 
from that which results from its passage into and out of the smaller bronchi 
and air-passages. I am anxious not to refine too much in these matters : and, 
therefore, I pass by minuter points of difference. Place the stethoscope over the 
trachea, and you will hear just such a sound as you might expect to hear: the 
sound of air rushing through a tube of considerable size, a blowing noise. We 
will call that sound, which you will recognize again when you have once heard 
it, bronchial breathing. It accompanies the outward as well as the inward passage 
of the breath. Again, place your ear or your stethoscope upon the right mammary 
region 4 there you shall hear that rustling sound, which I propose to call vesicular 
breathing, and which is chiefly audible during inspiration. We shall find these 
distinctions of much use in the discrimination of disease. We shall find, for ex- 
ample, that the breathing sometimes is bronchial, where it ought to be vesicular. 

Now if in any part of the chest where we should hear breathing, we can hear 
none, this may result from solidification of the subjacent portion of lung; or from 
some obstacle in a large bronchus, preventing the air from entering that part ; or 
from air being in any way shut up and stagnant in that part; or from an effusion 
of liquid into the pleura at that part. And here again percussion comes into play, 
and determines for us which of these possible circumstances is the one really 
present. If the part when struck emits a hollow sound, there is stagnant air 
beneath it, either in the healthy lung, or in the lung altered by disease, or in the 
cavity of the pleura. If a fiat solid sound be given out, there is solid lung beneath, 
or liquid in the pleura, between the ear and the lung. All these points, and the 
conclusions to be deduced from them, will become clear to you, I trust, as we 
proceed. Minuter analysis of the diagnostic signs would be premature. 

A word or two preliminary I must say about the voice. 

The voice passes outwardly through the mouth and nostrils into the surrounding 
air; it passes also inwardly, through the trachea and bronchi into the lungs, and 
it may be heard through the lungs, by the ear laid flat against the chest. But it 
gives quite a different sensation to the ear in different places. If you place the, 
stethoscope on the trachea, the voice will articulate itself into your ear as if it 
came from and through the instrument. This sound, which is natural here, 
would be unnatural, and a mark of disease, if heard beneath the clavicles. When 
heard beyond its natural situation, it is called pectoriloquy. A less degree of this, 
a sound like that of a person talking into a tube, and whose words, for that reason, 
are muffled and indistinct, is called bronchial voice, or bronchophony. When to 
this modification of the voice there is added a twanging vibration, a cracked dis- 
cordant tremor, resembling the squeak of Punchinello, or (as some think) the 
bleating of a goat, oegophbny is said to exist. All these unnatural modifications 



THE THORAX. 



539 



of the voice are indicative of most important changes within the thorax. I merely 
introduce them to you now : you will become better acquainted with them in due 
time. 

What is true of the natural voice, is true, mutatis mutandis, of that unnatural 
vocal sound, cough. The cough may be so modified by the condition of the 
internal parts, as to reveal that condition. 

There are yet other ways in which some information can be gathered respecting 
the interior of the chest. If you give certain patients a sudden smart jog while 
your ear is applied to their thorax, you may hear a splashing sound ; like that 
produced by shaking a barrel or a bottle partly full of water. From this expedient 
you in fact determine that the cavity of the pleura, or perhaps a large excavation 
in the lung, does contain both air and a liquid. This is called the method of 
succussion. It was employed long before the other forms of auscultation were 
thought of. Hippocrates mentions it. 

Again (but that is not auscultation), you may sometimes collect useful informa- 
tion respecting the state of the chest by simply laying your open hand upon it. 
In most persons there is a distinct vibration or thrill produced by their speaking, 
which thrill is very sensibly felt by the hand. Now this thrill may be felt on 
one side of the chest and not on the other. And such a difference is an une- 
quivocal sign of disease. 

The positions which I described before as being the most convenient for the 
performance of percussion, are the most convenient also for the purposes of aus- 
cultation. You may listen with the unassisted ear, or you may listen through 
the stethoscope. This, as you know, is a solid or perforated piece of wood, of 
which one end is adapted to the ear, and the other, which is to be applied to the 
chest, is hollowed out, or expanded, into the shape of a bell, or funnel. The 
object of the instrument is to collect and convey to the ear of the observer the 
vibrating impulse of the air, or of the solid walls of the thorax, occasioned by the 
motions within. The stethoscope is sometimes useful for examining a circum- 
scribed spot in the thoracic cavity. With it we gauge, more nicely than we could 
do with the naked ear, the signs furnished by the patient's voice. We must use 
it also when we would investigate the breathing in parts to which the ear itself 
cannot easily be applied ; and in cases where, from the filth of the patient, or be- 
cause he has some infectious disorder, we desire to avoid any immediate contact 
with his clothes cr person ; and in cases of young or old ladies, to whose breasts 
it might not be seemly or delicate to be putting our faces. But, with these ex- 
ceptions, the stethoscope, in my experience, is rather a hindrance than a help. 
Much, however, depends upon custom. I can best distinguish most of the sounds 
to be heard within the thorax by my unassisted — perhaps I should say my unim- 
peded — ear: and I therefore employ the stethoscope or cylinder in such cases 
only as I have just adverted to. I cannot do without the instrument, but I do 
without it as much as I can. Care should be taken that the end of the stethoscope 
next to the ear be closely and comfortably fitted to that organ ; and that its other 
extremity be blunt, so as not to hurt the patient; and further, that it be uniformly 
and evenly applied to the surface of his chest. If these precautions be attended 
to, the shape and fashion of the instrument are very unimportant 



540 



CATARRH. 



LECTURE XLVIII. 

Catarrh ; its varieties. Acute Bronchitis. Dry sounds attending the Bespira- 
tion ; Rhonchus, and Sibilus ; Moist Sounds ; Large and Smalt Crepitation ; 
how these are produced, and what they denote. Treatment of Acute Bron- 
chitis. Peripneumonia Notha. Sudden Infraction of a large Bronchus. 

In the last lecture I described to you, in a general manner, the method of aus- 
cultation ; or the employment of the sense of hearing in the investigation of 
disease ; and particularly of thoracic disease. I explained, as well as I could, the 
different sounds which result from percussing various parts of the chest; and from 
the entrance and exit of air during the several acts of breathing, speaking, and 
coughing. I mentioned certain conditions in which those natural sounds are 
abolished : but I did not speak, except incidentally and very cursorily, of the 
altered and new sounds to which the presence of disease within the thorax has 
been found to give rise. Nor do I propose to enter now upon any formal account 
of these morbid sounds. I shall endeavour to make you acquainted with their 
characters, and causes, and signification, as they arise in the progress of the sepa- 
rate thoracic diseases which I am about to consider. 

Before you can possibly appreciate the morbid sounds, you must make your- 
selves familiar with the natural and healthy. You must have a standard, by which 
you may measure the numerous deviations from the natural sound, that will reach 
your ear in disease. Listen to the voice and the breathing of healthy children — 
or of some of your friends and fellow students — and you will soon recognize 
those respiratory sounds which accompany the perfect state and working of the 
breath-machine. 

I intend to commence with those diseases of the lungs in which the mucous 
membrane lining the air-passages is primarily or principally involved. This 
membrane is often affected alone. It is much exposed to known causes of disease : 
to alternations of temperature in the air which is constantly passing over it; to 
the irritation produced by acrid or noxious matters, solid or gaseous, which are 
mixed and inhaled with the air. And when disease commences in other parts of 
the lungs, it seldom fails to reach, sooner or later the mucous membrane. In 
diseases also of the heart the same mucous membrane is very liable to be conse- 
cutively affected, by reason of those alterations in the condition of its capillary 
vessels which the disorder of the circulation produces. 

Now I shall first point out the changes to which this mucous membrane is 
liable; and then describe the modifications of the natural sounds that result from 
such changes ; and lastly, consider the different forms of disease which these 
changes constitute, and these altered sounds denote. 

In a former part of the course I gave you some account of the peculiarities 
which differences of texture impress upon the phenomena and process of inflam- 
mation: and among the rest, I spoke of the behaviour of the mucous tissue when 
inflamed. 

The mucous membranes, in the state of health, are perpetually moist. The 
exhalation of this moisture, to a certain amount, and not beyond a certain amount, 
constitutes an essential part of their healthy functions. Now their inflammation 
(for I am about to consider first the inflammatory affections of the membrane of 
the air-passages; some of them indeed I have already discussed), I say the in- 
flammation of these mucous surfaces alters their ordinary secretion. An inflamed 
mucous membrane is in the first instance dry; its secretion is suspended. But 
this is not the only change that takes place in it; it becomes tumid also, swollen, 
thicker than before ; it is redder than natural ; and its sensibility undergoes a per- 
ceptible modification. Pain, in mucous membranes, is not a common phenome- 



CATARRH. 



541 



non : for their texture enables them to expand or dilate freely, so that they escape 
much tension, and the pain which is produced by tension: but their natural sen- 
sations are blunted, and new and uneasy sensations arise in them: sensations of 
heat, fulness, itching. It happens that we can see a portion of the mucous mem- 
brane that belongs to the air-passages; and by noticing the changes produced in 
it by inflammation, we infer those which are apt to take place in the parts we 
cannot see. We have all often experienced in our own persons an inflammatory 
state of the membrane lining the nasal cavities ; the Schneiderian membrane. At 
first the nostril is preternaturally dry : yet though it is dry, you cannot breathe 
through it; it is stuffed up ; not with accumulated mucus, but by the mere swell- 
ing of the membrane : the sense of smell is perverted or lost ; the part is evidently 
red ; it is tender also and irritable ; the contact of atmospheric air a little colder 
or a -little less pure than common, provokes sneezing. The affection extends 
often into the frontal sinuses; and headache and oppression ensue: or it passes 
into and through the lachrymal sac, the conjunctiva participates in the inflamma- 
tion, the puncta lachrymalia become impervious, and the tears flow over the cheek. 
And with all this there is sometimes shivering or chilliness ; and the pulse, espe- 
cially in the evening, becomes a little more frequent than common. There is 
slight fever. After the unusual dryness, the membrane begins to secrete a thin 
serous fluid, having acrid properties ; for it reddens and frets the alae nasi and 
upper lip over which it flows. By degrees, this thin serous fluid becomes thicker, 
and as it becomes thicker it becomes less irritating also, more viscid, opaque and 
yellow: the swelling of the membrane diminishes ; it is less raw and sensitive: 
at length the secretion resumes its natural quality, and is reduced to its natural 
quantity again; and the tumefaction of the membrane entirely disappears. This 
is the course of what is properly called a cold in the head. When the defluxion 
from the nasal membrane is considerable, systematic writers call the complaint 
coryza; when it is attended with much pain and weight about the frontal sinuses, 
it is named gravedo. It is a variety of catarrh. In catarrh, sometimes one part, 
and sometimes the whole, of the mucous membrane of the air-passages suffers 
inflammation. If the disorder goes down into the lungs, it is said to be a cold in 
the chest; or, from one of the most prominent of its symptoms, a cough: in medi- 
cal language, bronchitis. It sometimes travels from one part of the membrane to 
another. Beginning, for»example, in the nose, it gradually creeps down into the 
windpipe and lungs. Sometimes the inflammatory condition passes from the 
throat into the Eustachian tubes, and produces deafness ; or down the gullet and 
to the stomach, causing qualmish or other uneasy sensations, and loss of appetite. 
And occasionally this order appears to be reversed. There are some persons who 
will tell you that whenever any thing disagrees with their stomachs, whenever 
dyspepsia is produced by some error in diet, they are sure to have catarrh. 

Now I have adverted to this cold in the head, or coryza, because the pheno- 
mena which are open to our inspection in the Schneiderian membrane take place 
also, no doubt, in the bronchial. The membrane is first dry, and tumid, and irri- 
table; the uneasy sensations of which it is the seat prompt to the action of cough- 
ing. The chest feels tight, stuffed, constricted. There is some hoarseness, and 
a sense of roughness and soreness in the windpipe ; and a dry cough, which 
seems to arise from some irritation about the glottis. Sometimes, with these 
symptoms, pains in the limbs, like the pains of rheumatism, occur; the appetite 
is impaired ; the patient is thirsty ; and a general lassitude is felt all over the body. 

But what effect has the altered state of the membrane upon the sounds elicited 
by percussion; or heard within the chest, by the ear, during respiration? Why 
it brings us acquainted at once with two remarkable modifications of the natural 
sound of breathing; and these I must describe and explain. 

I will take this opportunity of again recommending yon to read and study the 
little book of lectures recently published by Dr. Latham. It contains a very plain 
and clear account of the auscultatory signs of disease within the chest; and he 
speaks of these signs in more easy and popular language, with less of over re- 



542 



CATARRH. 



finemeiit, and a less subservient adoption of the French mode of thinking and 
writing on these subjects, than any other English author that I know of. I re- 
commend his little volume the rather also, because he uses the nomenclature which 
is the most familiar to myself: in fact, as we some years ago saw and talked of 
these matters together in the wards of St. Bartholomew's, we were likely to 
employ the same terms. 

When you listen, I repeat, to the breathing of a healthy person, you hear, as 
the breath goes in and out, but especially as it goes in, a smooth and gentle rustle 
—the respiratory murmur, or the vesicular breathing. But when the inner 
surface of the bronchial tubes, and of their ramifications, is preternaturally dry, 
and tumid, this sound is altered: you hear a hissing, or wheezing, or whistling, 
as the breath goes in and out; and this is technically called sibilus : or you hear 
a deeper note, a snoring noise, as the patient inspires or expires — a sound like the 
cooing of a pigeon, or the bass note of a violin, or the droning hum of an insect 
in its flight; and this is called rhonchus. These two, in their various modifica- 
tions, constitute the dry sounds of respiration ; and it will be worth while, once 
for all, to reflect upon their cause and nature, and the manner in which they are 
combined, and what they denote. You are aware that when air is propelled 
through a cylindrical tube of a certain size, and when that tube is narrowed in a 
particular way at one or more points, a musical note is produced. Now this is 
what often happens in the larger bronchi ; this is what always happens in them 
when rhonchus is present. Rhonchus belongs to the larger divisions of the 
bronchi exclusively; and as these are often, for a time exclusively affected, so 
rhonchus may exist alone. It will be grave or deep in proportion to the length 
and diameter of the tube in which it is produced. When the sound is grave and 
deep, the hand placed upon the chest may frequently perceive a trembling or thrill 
communicated to its parietes. I believe that rhonchus is mostly occasioned by 
portions of viscid half solid mucus, which adhere to the membrane, and cause a 
virtual constriction of the air-tubes, and act as vibrating tongues while the air 
passes by them. I conclude such to be the case, because it seldom happens that 
the rhonchus cannot be got rid of by a vigorous cough. It will soon begin again, 
perhaps, or it will commence in some other part, but the effort of coughing, which 
detaches and removes the adhering tough mucus, dislodges also, for the time, the 
rhonchus. Yet, rhonchus in a given spot maybe permanent: a tumour, or a 
tubercle, may flatten one of the air-tubes, and convert it into a musical instrument. 
For the most part, you will find what I have told you holds true: you may sus- 
pend the rhonchus by getting the patient to make a hearty cough. Now in the 
natural state of the chest, we do not, except in particular spots, hear the transit of 
the air through the larger bronchi. Whatever sound it makes is damped by the 
spongy lung, or covered by the vesicular breathing. But rhonchus, in its turn, 
may overpower the vesicular murmur, and lender it inaudible. It does not prevent 
it, but it outroars it, as it were. Yet this is seldom the case : you hear the rhon- 
chus, and, if you listen attentively, you may in general hear, mingling with it, 
the vesicular murmur also. Recollect, then, that rhonchus belongs to the larger 
divisions of the air-tubes ; that it denotes their partial narrowing ; that it is a dry 
sound ; and that the condition of which it is expressive implies usually no dan- 
ger: there is no material obstacle to the passage of the air through these larger 
tubes to the vesicular structure beyond them. 

I must further admonish you, that in your earlier essays in auscultation you 
will be apt to deceive yourselves in respect to the exact place in the lung in which 
the rhonchus which you hear is produced. It is so loud a sound, that when it 
proceeds from a single bronchial tube it may be plainly audible over the whole 
of that side of the chest; and sometimes, more obscurely, over the other side 
too. 

When air is driven with a certain degree of velocity through a small pipe, it 
gives rise to a hissing noise. It is by Torcing air through a cylinder perforated by 
a slender tube, that Professor Wheatstone obtains the sound of the letter S in the 



CATARRH. 



543 



talking machine which he has constructed, after Kerapelen ? s model. Precisely 
this condition we have in the smaller bronchial ramifications, when the inflamma- 
tion in catarrh or bronchitis has reached them, and rendered the membrane lining 
them tumid. And sibilus is the result of this change. Now sibilus, like rhon- 
chus, may exist alone ; and, inasmuch as the sibilus proceeds from the smaller 
air-tubes, adjacent to the pulmonary vesicles, it abolishes the natural respiratory 
murmur. It does not, like simple rhonchus, merely drown it, but it takes its 
place. If you hear the respiratory murmur mingling with sibilus, you may be 
sure that some of the lesser air-tubes are narrowed, and some free : you cannot 
have both sounds at once from the same ramifications of the bronchi. Sibilus is 
a sound of more serious import, therefore, than rhonchus ; it bespeaks a condi- 
tion of greater danger. It belongs to the smaller air-tubes and vesicles, and de- 
notes that they are in the first stage of inflammation, which has diminished their 
natural calibre, by rendering the membrane tumid. It is a dry sound, but you 
cannot cough it away. 

I say rhonchus may occur alone, and sibilus may occur alone ; but very often 
indeed they both occur together; and may be heard, in various parts in different 
degrees : causing a strange medley of groaning, and cooing, and chirping, and 
whistling, and hissing, mixed, it may be, here and there, with the natural respi- 
ratory murmur. When you hear sibilus over the entire surface of the chest, the 
mucous membrane is universally affected, and the case is a severe one, and 
attended with considerable hazard. 

It is just possible that a sibilant sound may proceed from a large air-tube, when 
its bore has been narrowed to a very minute slit or orifice; but this possibility 
does not interfere with the general distinctions that I have been endeavouring to 
point out. 

Now in these cases we neither obtain nor require any information from percus- 
sion, except of a negative kind. Supposing the inflammation confined to the 
mucous membrane, the resonance on percussion will not be sensibly diminished ; 
the lung is everywhere spongy still, and air reaches every part of it, though not 
with the usual freedom. 

There is one exception to this. Occasionally, though rarely, a piece of tough 
phlegm may seal up, as it were, the very entrance of one of the principal bronchial 
tubes, and so prevent the air from passing to or from the portion of lung to which 
that tube conducts. When this happens, it is very likely to puzzle the auscultator 
for a time. There is air in the sealed-up portion of lung, therefore percussion 
gives a natural sound ; but the air is at rest, therefore no sound of respiration is 
audible. An isffort of coughing unstops, perhaps, the bronchial tube; and then 
the air is again heard to enter and to depart from that portion of lung. I shall 
advert to this sort of accident again. ' 

Finally, I may remark, that these dry sounds, rhonchus and sibilus, are heard 
during the breathing: they have no relation to the voice or to the cough. 

After a while, the inflamed membrane begins again to pour out fluid ; but it is 
not the thin, bland, moderate exhalation of health ; it is a glairy, saltish, transpa- 
rent liquid, like white of egg somewhat ; and if it be expectorated only after much 
coughing, it will be frothy also, i. e., it will contain many bubbles of air entangled 
in it. It is a stringy tenacious fluid, and the more so in proportion to the intensity 
of the inflammation. With this new condition of the membrane, we have new 
sounds — sounds which result from the passage of air through a liquid; sounds 
which are occasioned by the formation and bursting, in rapid succession, of 
numerous little air-bubbles. These sounds are called crepitations. This process 
may take place in the larger air-tubes, or it may take place in the smaller, or in 
both. In the larger tubes the bubbles will be larger, and the ear can readily dis- 
tinguish this ; we have large crepitation. In the smaller air-tubes, we have, in 
the same way, small crepitation. There is no difference between these sounds, 
except in degree ; and they graduate insensibly into each other. But there is a 
considerable difference in the nature of the intimations which their well-marked 



544 



CATARRH. 



varieties convey. If there be merely large crepitation, without any other morbid 
sound, it is produced in the larger tubes. Air passes, notwithstanding, into the 
vesicular structure beyond the accumulated liquid; and vesicular breathing exists, 
though perhaps it cannot be heard, on account of the crepitation. But the state 
of the patient is not a state of peril. On the other hand, small crepitation has its 
seat in the smaller air-tubes and cells; it supersedes the vesicular breathing, and, 
if extensive, it bespeaks considerable danger. 

Rhonchus and large crepitation are respectively the dry and moist sounds that 
belong to the larger bronchi; sibilus and small crepitation the dry and moist sounds 
of the smaller branches. When the latter sounds are heard over a considerable 
part of the chest, there is, I say, usually a good deal of distress, dyspnoea, and 
cough; and the fever which attends the local inflammation is at its height. By 
and by the expectoration becomes opaque, and more consistent, and of a greenish 
or yellowish colour; it is brought up with more ease; the crepitation, great and 
small, diminishes ; perhaps rhonchus reappears : but at last the parts return to 
their original condition ; and the natural, smooth, equable rustle of the breathing 
is again everywhere audible. 

These are all the morbid sounds to which active and recent inflammation of the 
mucous membrane of the air-passages ever gives rise: rhonchus and sibilus; large 
and small crepitation. Having once described their nature and causes, I need not 
repeat the description if, we find them accompanying other diseases : but their 
import may be different. I may mention here, that as crepitation results from the 
passage of air amongst and through liquid, from the rupture of the little air-bubbles 
so produced, the kind of liquid may vary. If the air in going and returning, 
meets with serum, or with pus, or with blood, it will occasion exactly the same 
bubbling noise. Hence the French term for what I have been calling crepitation, 
viz., mucous rattle, is very objectionable. From the sound itself, we cannot tell 
whether it proceeds from mucus or from some other liquid present in the air- 
passages ; and from this objection the word crepitation, whatever exception may 
be taken against it on other accounts, is free. 

Having thus embraced the occasion of explaining these auscultatory signs, I 
will now resume the history of catarrh. It implies inflammation of the mucous 
membrane of the air-passages; and it receives different appellations, according to 
the district of that membrane which it chiefly plagued: gravedo, in the frontal 
sinuses ; coryza, in the Schneiderian membrane of the nose ; bronchitis in the trachea 
and lungs. 

Catarrh is the commonest of all disorders. Not one man in ten thousand passes 
a winter without having a cold of some sort. And this name point#to its ordinary 
cause: cold somehow applied to the body. It does not always or often result, I 
apprehend, from cold air brought into contact with the membrane itself, in the 
process of breathing; but from cold, and especially from cold and wet, applied to 
the external integument. It is unnecessary for me again to go over the circum- 
stances under which the application of cold is most likely to prove injurious. 
Catarrh is usually a trivial disorder, and runs its course in a few days, if abstinence 
be observed with respect to animal food and stimulating liquor, and if the patient 
remains in an equable temperature, and avoids re-exposure to the cause of his 
malady. I am now speaking of the milder forms of catarrh. We are not often con- 
sulted for this complaint. Every man, in regard to a cold, thinks himself qualified 
to be his own doctor. But if you are consulted, keep your patient in the house, 
or even in bed; let him live upon slops; give him a gentle aperient, and then 
some of those medicines which are esteemed to be diaphoretic : small doses of 
James's powder; three drachms of the liquor ammoniae acetatis, with a drachm of 
the spiritus aetheris nitrici, and an ounce of camphor mixture ; or a saline draught 
with an excess of alkali, and a few grains of nitre, or a little antimonial wine ; 
three or four times a day : and let him take four or five grains of Dover's powder, 
and put his feet and legs into a warm bath, just before he goes to bed. In this 



CATARRH. 



545 



way you may conduce to his recovery ; and he may be simple enough to believe 
that you have cured him. 

Yet I believe catarrhs may sometimes be cured; and the natural recovery from 
them may be, sometimes, accelerated. If you practise the old maxim, which 
says, " venienti occurrite morbo," you may occasionally stop a cold on the 
threshold, as it were, by an opiate. And to persons who are habitually troubled 
with slight catarrhs, this piece of practice may prove of the greatest value. A 
medical man who resides in this neighbourhood, and with whom I was a fellow- 
student, is exceedingly subject to what he calls a sniveling cold. For many 
years he used to bear this as he best might; and that, to say the truth, was very 
ill and impatiently. On one occasion, almost by accident, he took twenty drops 
of laudanum just as one of his colds was beginning to torment him ; and he found 
that the initiatory symptoms ceased. Since that time he has constantly had re- 
course to the opiate under similar circumstances ; and whereas he used formerly 
to be very miserable for three or four days, he now is quite well and comfortable 
in the course of half an hour. And this is not a solitary case. It is worth trying, 
if you experience the feelings of an incipient catarrh, to go to bed, and to take a 
beaker of hot wine negus, with a tablespoonful of the syrup of poppies in it. 
This will not suit every person; but if it fails on the first trial, it need not be 
repeated, and no great harm, beyond an increase of headache, will be done by it. 
I would not recommend this plan, however, to a plethoric person ; nor to any one 
having a tendency to inflammatory disease ; for when it does not cure, it makes 
the complaint worse. 

There is also a period in catarrh which.fiss gone on unchecked, when you may 
accelerate its departure — " speed the going guest" — by a good dinner, and an 
extra glass or two of wine. But this pleasant method is scarcely to be advised 
for persons of delicate habits; or in whom any phthisical tendency is suspected 
to exist; or who are prone to inflammation. And it is not to be tried with any 
one till the fever is over, and the expectoration thick and loose. 

I must not omit to mention the dry plan of cure ; although (I confess it with 
some shame) I have never yet tried it either upon myself or upon others. Dr. 
C. J. B. Williams, who invented it, I believe, has a high opinion of its efficacy. 
It certainly has the merit of simplicity, for it consists merely in abstinence from 
every kind of drink. No liquid, or next to none, is to be swallowed until the 
disorder is gone. The principle here concerned is that of cutting off the supply 
of watery materials to the blood. The wants of the system exhaust, from the 
circulating fluid, all that can be spared for the natural evacuations ; and there is 
nothing left to feed the unnatural secretion from the inflamed mucous membrane. 
Its capillary vessels cease to be congested ; the morbid flux is diverted, and the 
inflammation starved away. Such is the theory. Habitual topers might hold 
the remedy to be worse than the disease; but Dr. Williams assures us that the 
necessary privation is not very hard to bear: and that it achieves a cure, upon an 
average, in forty-eight hours. He allows, without recommending, a tablespoonful 
of tea or milk for the morning and evening meals, and a wine-glass of water at 
bed time. 

One great advantage of this plan is, that it does not require confinement to bed, 
or to the house. The man whose business calls him abroad, may, with appro- 
priate clothing, pursue his customary employment, and his cure is all the while 
going on. In fact, exercise, inasmuch as it promotes perspiration, helps the re- 
covery ; whereas the system of warm djinks and diaphoretics renders the body 
more susceptible to atmospheric vicissitudes ; and, to be effectual, implies restric- 
tions which are oftentimes extremely inconvenient. 

Dr. Williams observes, that while this dry treatment is serviceable in catarrhal 
bronchitis, it is most successful in coryza, the sniveling cold in the head. It 
must be put in force in the very commencement of the disorder. 

You may often do much by way of prevention, for persons who are unusually 
liable to take colds. I have remarked before upon the great value of the shower- 
35 



546 



CATARRH. 



hath for that purpose. I could mention several instances in which persons have 
got rid of the tendency to catch cold by the habitual use of this aspersion. It 
should be begun in the summer, and made tepid at first; but in a short time quite 
cold water may be employed; and being once begun, the practice may be con- 
tinued through the winter. I stated formerly, that the effect of exposure to cold 
was, cseteris paribus, in proportion to the intensity and the duration of the sen- 
sation of cold that it produced. The intensity of the sensation of cold under the 
shower-bath is considerable, but the duration of it is momentary. It operates as 
a prophylactic in this way : it inures the surface to a lower temperature than it is 
likely to be subjected to at any other part of the day. The lesser degrees of 
cold have then no injurious effect, unless they are long protracted. For those 
who cannot procure a shower-bath, or who cannot bear its shock, cold sponging 
will be found exceedingly salutary. 

But inflammation of the membrane lining the air-passages may be, and often 
is, a very acute and dangerous disorder, i. e., the inflammation may be both in- 
tense and diffused ; it may descend into the vesicular texture, and occupy the 
whole surface of the membrane on one side of the chest, and then it may prove 
a very grave disease ; or it may involve the whole lining membrane of both lungs, 
and then it is always attended with considerable peril. 

This inflammation will sometimes, when it is thus general over the whole 
membrane, linger for a considerable period in its first stage ; and it may even, 
after so lingering, subside again without ever passing beyond the first stage. By 
the first stage, I mean the stage of dryness. Very little notice of this modifica- 
tion of bronchitis has been taken by authors. Dr. Latham has given a distinct 
and graphic description of it, to the accuracy of which I can testify from my own 
experience. You will find cases of it detailed in his book. Since they were 
published, some striking instances of this form of the disease have occurred to 
myself. One, which happened lately, I will relate by way of example. I was 
asked by an old pupil of the hospital to see a lady, his patient, in Gordon Square. 
I found her feverish and in a state of extreme dyspnoea, sitting up in bed from 
inability to lie down, labouring for her breath ; her face turgid and rather livid, 
her nostrils working, her shoulders elevated. She could scarcely speak, but 
expressed, in what she did say, a dread of immediate suffocation. She had been 
in nearly the same state for a day or two. On listening at her back I could hear 
the air slowly wheezing and whistling into her lungs everywhere, and then leaving 
them still more slowly, with a prolonged growl, something like that of an angry 
cat. There was no true vesicular breathing ; there was no crepitation ; and 
there was no part into which the air did not, although with difficulty, find its 
way. The chest was everywhere resonant on percussion. There could be no 
doubt that the membrane throughout was tumid and dry, and in the earliest stage 
of inflammation. Depletion had already been employed in this case, and we had 
recourse to the tartar emetic. This was given in free and repeated doses, till it 
produced nausea and sickness. Whenever it did so, the pulse diminished in 
force, the face became blanched, and the breathing much easier; and the medi- 
cine was then suspended until these effects had gone off, when it was repeated in 
the same manner. The disease was not, however, brought at once to an end by 
this treatment; it was kept at bay for a day or two longer, and then a copious 
secretion from the membrane took place, with great relief to all the distressing 
symptoms. Then, of course, crepitation became universally audible. Except 
the debility which it left behind, the patient soon recovered of the bronchial in- 
flammation. 

But in the great majority of instances the inflammation does not thus linger in 
its first stage ; the membrane soon begins to pour forth glairy mucus ; so that we 
do not often meet with sibilus, without finding at the same time, in some part of 
the same lung, that there is also small and large crepitation. It is of some import- 
ance to attend to the characters of the mucus that is expectorated. It is transpa- 
rent and adhesive. If you pour it from one vessel into another, it flows out in 



CATARRH. 



547 



one mass of extreme tenacity ; it will draw out sometimes like melted glass ; and 
the degree of viscosity is a tolerably accurate measure of the degree of the existing 
inflammation. Upon the surface of the viscid mucus there is usually more or less 
froth, the quantity of it depending on the facility or the difficulty with which the 
sputa are brought up. If the patient does not expectorate till after a long fit of 
coughing, during which air has been many times inspired and expired, and has 
thus got intimately mingled with the mucus that fills the air-passages, the expec- 
toration will contain numerous little air-bubbles ; will be very frothy. Sometimes 
also, during this stage of the complaint, the sputa are marked "with streaks of 
blood. 

While the expectoration' possesses the characters I have been describing, the 
inflammation is still intense, and the fever and dyspnoea considerable. This 
correspondence between the general symptoms and the matters spat up was well 
known to the ancients, who said that such expectoration was still crude. But in 
proportion as the inflammation approaches to resolution, the appearance and quali- 
ties of the sputa are changed ; the mucus loses by degrees its transparency, is 
mixed with masses that are opaque, and of a yellow, white or greenish colour : 
and these masses, few at first, increase more and more in number, until they con- 
stitute the whole of the sputa. Such expectoration as this is commonly accom- 
panied by a marked remission in the different symptoms of the bronchial inflam- 
mation ; it announces that the inflammation is terminating in resolution. It is 
such as the ancients spoke of as being concocted, or ripe. However, the charac- 
ters of the opaque sputa expectorated towards the end of an attack of acute bron- 
chitis are subject to much variety. 

It will often happen that the expectoration, after having thus become opaque, 
and parti-coloured, will go back again to its former condition of transparency, and 
stickiness, and froth : and that is a very certain index of a return or increase or 
extension of the inflammation; so that the character of the matter expectorated 
exhibits, in a certain degree, the progress of the inflammation ; and consequently 
constitutes one point of guidance to our treatment. The nature of the expectora- 
tion forms also an important particular in our means of distinguishing bronchitis 
from pneumonia; as I shall further explain when I speak of the latter disease. 

I have described acute bronchitis as it appears when it terminates favourably : 
in such cases the inflammation generally begins to abate, somewhere from the 
fourth to the eighth day of the disease. But acute bronchitis may terminate unfa* 
vourably. When the inflammation is universal and intense, .the fever high, and 
the labour of respiration great — if the symptoms do not yield to the treatment em- 
ployed, or if judicious treatment has not been adopted, or has been too long delayed, 
signs of impending suffocation begin to show themselves : the lips and cheeks, 
and tongue, assume a purplish colour; a livid paleness takes the place of the 
former red flush ; the expression becomes more and more anxious : delirium comes 
on, and rapid sinking. These indicate, you know, the circulation of blood that 
is in a great measure venous through the arteries ; and the venous blood acts as a 
poison when it so circulates. Profuse, cold, clammy sweats ensue ; and the patient 
dies of apncea. His breathing is choked by the morbid secretion which occupies 
the bronchial tubes, small as well as large, and which he has not strength enough 
left to cough up. 

Accordingly, when we examine the thorax after death so produced, we find, in 
the first place, that the lungs do not collapse upon the admission of the pressure 
of the atmosphere to their external surface. We next find the trachea, and bronchi, 
and their ramifications, blocked up by a frothy adhesive mucus, resembling that 
which during life had been expectorated ; and the membrane which lines them is 
red and thickened. 

The treatment proper for these acute and dangerous forms of bronchitis is a 
matter of some nicety. Blood-letting, as I formerly stated to you, has not that 
decided power over inflammation of the mucous tissues which it possesses over 
the adhesive inflammation that takes place in the serous membranes. If there be 



548 ACUTE BRONCHITIS. 

much fever, a hard pulse, and great oppression of the breathing, and particularly 
if these symptoms present themselves in a young, strong, and robust individual, 
we must bleed him from the arm. And you will always find blood-letting relieve 
the symptoms; even when its ultimate effect may be injurious. The patient's 
distress arises from his inability to supply air enough to arlerialize the venous 
blood which is transmitted to his lungs; and by diminishing the quantity of blood 
sent to those organs, you will, pry tanto, mitigate his uneasiness. But a great 
part of the danger to be apprehended in the advanced periods of the disease, is 
that the patient may not have muscular power enough to disembarrass his air- 
passages of the phlegm that overloads them ; to draw a strong breath, and to achieve 
a vigorous cough. We must not bleed therefore to syncope, and again and again, 
as we are often justified in doing in cases of pneumonia. Sixteen ounces will be 
a moderate bleeding at first for an adult, but more or less than that must be taken, 
and the bleeding must be repeated or not, according to the condition of the pulse : 
for the pulse affords a better measure of the propriety of pushing the abstraction 
of blood, than is furnished by the local symptoms. 

Great relief is often obtainable by topical blood-letting; by cupping over the 
surface of the chest, or between the scapulae. If you distinguish sibilus in one 
portion of the lung more than in another, take the blood rather from that part of 
the surface which corresponds to the place of the sibilus. 

After the bowels have been cleared by a mercurial purgative, calomel and jalap, 
for example, you will find the tartar emetic a very valuable medicine in these 
acute cases of bronchitis. It should be given in such doses as will excite nausea: 
and if vomiting be occasioned, you may still go on with the medicine after the 
sickness has subsided. The depression which this substance produces is great, 
but it is temporary, and it is effected without expending blood. With the anti- 
mony — I mean during the same period — mercury may and ought to be given : to 
this combination I should be inclined to trust more than to any other internal 
treatment. 

If symptoms of sinking and debility have begun to show themselves, it will be 
necessary to administer stimulating expectorants. I presume that the carbonate 
of ammonia, which is often extremely useful in such cases, acts as an expectorant, 
by giving a fillip to the muscular power. But it is supposed by some persons to 
exercise some specific influence upon the bronchial membrane. However this 
'may be, five or six grains of it, given in solution every four or six hours, are often 
followed by free expectoration and a marked improvement. 

One of the circumstances of which patients are much disposed to complain, is 
the violent or importunate cough; and another is, the want of sleep and of rest: 
indeed, the one of these is often, in a great measure, the cause of the other:—" 
the urgency or frequency of the cough prevents the patient from sleeping. Now 
there is nothing so well calculated to allay cough, and to procure sleep, as opium ; 
and you will be strongly tempted to give these patients opiates, and you will pro- 
bably be encouraged to do so by the success which will follow that practice in 
many cases. The good effects of a full narcotic at bed-time are sometimes very 
striking. Patients who for previous nights have been perpetually harassed by- 
cough, and who are worn out by the disturbance of their rest, will sleep tranquilly, 
and in the morning expectorate largely and freely, and declare themselves wonder- 
fully the better for their opiate. Yet opium is a ticklish remedy in these cases. 
Many a patient — some within my own knowledge — labouring under general or 
extensive bronchitis, have been put so soundly to sleep by a dose of opium on 
going to bed, that they have not waked again. I believe you may receive it as a 
golden rule in these cases, not to give opium — I mean in a full dose, so as to force 
sleep — if you see any venous blood mingling in the general circulation, — if the 
complexion be dusky, and the lips in any degree blue. The circulation of half- 
arterialized blood through the brain is in itself a powerful cause of coma; and if 
you add the influence of an opiate, the coma may easily be made fatal. While 
the cheeks and lips remain florid, and when the first violence of the disease has 



PERIPNEUMONIA NOTHA. 



549 



abated, an opiate will do capital service. It is a common practice to combine it 
with antimony or some other expectorant. Twenty minims of laudanum, with 
the same quantity of the liquor antimonii tartarizati ; or a third of a grain of the 
acetate of morphia, with a drachm of oxymel of squills; are convenient forms. 

Counter-irritation is frequently of great use, as an auxiliary measure, in the 
treatment of acute bronchitis. Sensible relief of the cough, and of the oppressed 
breathing, often follows the rising of a large blister laid across the front of the 
chest. When the dyspnoea is extreme, and a more speedy counter-irritant is 
required, you may have recourse to the mustard poultice. Inhalation of the steam 
of hot water is also very soothing and useful. It is one of the best expectorants 
I know of when it answers at all; but to some persons it proves irritating, and 
they derive no comfort from it. 

I have been speaking of acute bronchitis, uncombined with any other pulmo- 
nary disease ; and it is curious how little disposed the inflammation often seems 
to be to extend itself from the mucous membrane to the neighbouring tissues. 
The reason, doubtless, is, that this membrane is furnished with a distinct set of 
blood-vessels, the bronchial arteries, and veins : while the substance of the lungs 
is supplied by the pulmonary. We could not tell, merely by attending to the 
general symptoms, whether the inflammation was limited to the inner membrane 
or not; but by making use of the sense of hearing, we are able to determine this. 
If the inflammation should spread- to the parenchymatous texture of the lungs, — 
i.e., if the bronchitis should pass into pneumonia, — this circumstance would be 
disclosed by physical signs, which I shall in due time describe and explain ; and 
it would demand certain modifications of our plan of treatment. 

I shall have to speak of some varieties of chronic bronchitis ; but there is a 
mixed form of pulmonary disease that requires to be noticed, in which acute or 
subacute inflammation engrafts itself upon changes that are chronic and abiding. 
Sydenham calls the disorder to which I now refer peripneumonia notha — bastard 
peripneumony. Catarrhus senilis is another of its names. It may be considered 
as chronic bronchitis, occurring in old persons, and very apt to be converted into 
pneumonia, or to be greatly aggravated in degree during winter, or upon any 
accidental exposure. This is the common complaint of persons advanced in life. 
I mention it here in compliance with the usual custom, and because this is as 
convenient a place for its introduction as any. But it would be an error to regard 
it as exclusively a disease of the mucous membrane of the lungs. An habitually 
congested state of that membrane, marked by some shortness of breath, and some 
expectoration, and by the constant presence of some degree of crepitation in the 
lower parts of the lungs, — these are circumstances which are of daily occurrence 
as consequences of disease of the heart; and it is in persons whose habitual 
health is of this kind, that what is called peripneumonia notha, which implies a 
diffused inflammation of the pulmonary mucous membrane, with sometimes an 
enormous secretion from its surface, is most apt to supervene. Almost all such 
persons will tell you that there are periods at which they experience slight febrile 
attacks, and exacerbations of their complaints: they have pain in the breast or 
side, headache, heat, and thirst; and at these periods the cough and expectoration 
are always aggravated, and continue for some time to be more than commonly 
severe. " The disease (says Cullen, who, following Sydenham, has given a good 
description of its general symptoms) has often the appearance only of a more 
violent catarrh; and after the employment of some remedies, is entirely relieved 
by a free and copious expectoration. In other cases, however, the feverish and 
catarrhal symptoms are at first very moderate, and even slight; but after a few 
days these symptoms suddenly become considerable, and put an end to the pa- 
tient's life, when the indications of danger were before very little evident." 

The truth is, (and we learn the truth by the evidence of auscultation,) that in 
these cases pneumonic inflammation is often suddenly set up. There is no 
security, as Dr. Latham observes, that the portions of lung which yield small 



550 



PERIPNEUMONIA NOTHA. 



crepitation to-day may not be solid and impervious to-morrow. Dr. Latham is of 
opinion that in this disease the inflammation is apt to travel over the bronchial 
membrane from place to place, as erysipelas is seen sometimes to wander over 
the surface of the body. I know not how this may be; but certainly death is 
often produced in these persons by the sudden spoiling of even a moderate portion 
of lung. In their ordinary condition, the patients have just enough, and no more, 
of the respiratory apparatus in an effective state, whereby to subsist; and when a 
fresh part of it is rapidly rendered solid, they quickly perish. But they die also 
from another cause. The nicety of treatment which I spoke of as being required 
in certain stages of acute bronchitis, is still more apparent and necessary here. 
We are placed in this dilemma. If we do not take blood in these attacks, we run 
a risk of losing our patient from the effects of the unchecked inflammation ; and 
if we do bleed, we are in danger of losing him by producing a degree of weak- 
ness which will render him unable to expectorate the effused mucus, and so liable 
to perish by suffocation. Leeches and blisters, and what are called expectorants, 
are the remedies to which we must chiefly trust. Medicines, which are at the 
same time diuretic are also serviceable — the spiritus aetheris nitrici, the prepara- 
tions of squill, and of digitalis. 

Even in younger patients, in whom the bronchitis is idiopathic, not engrafted 
upon any previous disease of the chest, and in whom the disorder had not ap- 
peared severe, extreme" difficulty of breathing will sometimes most unexpectedly 
arise, and sometimes it will rapidly lead to the extinction of life. Now both 
Andral and Laennec have pointed out one cause (to which, indeed, I have already 
adverted in the present lecture) of this sudden change for the worse. It is a cause 
which was not likely to be even guessed at before the discovery of the method of 
auscultation. Occasionally it happens, they say, that during the course of an 
attack of bronchitis, we cease altogether to hear, in a certain extent of the lung, 
either the natural respiratory murmur, or any of the modifications of rhonchus, 
sibilus, or crepitation, that have been mentioned; yet over this same portion of 
lung, in which no sound, healthy or morbid, is heard by the ear applied to the 
thorax, percussion gives the natural hollow sound. At the same time the patient 
becomes affected with urgent dyspnoea. This sudden suspension of all sound of 
respiration they attribute to the temporary, or, in some cases, the permanent, 
obstruction of one of the bronchi, the ramifications whereof are distributed to that 
portion of lung in which the respiration is no longer audible. In such cases it 
generally happens that at the end of a strong fit of coughing — the effect of which 
is to expel, or at least to displace the tenacious plug of mucus obstructing the 
bronchus — the sound of respiration is re-established as suddenly as it had pre- 
viously disappeared ; and the dyspnoea also ceases. In some rarer cases, how- 
ever, the noise of the pulmonary expansion does not return, the difficulty of 
breathing increases, suffocation becomes imminent, and death by apncea rapidly 
takes place. The slightest attack of bronchitis may in this way be suddenly 
transformed into a most serious and quickly fatal malady. 

Andral relates two instances of death from this cause ; one of which was the 
following. A coachman, fifty years old, had been several times a patient in La 
Charite, for obstinate pulmonary catarrh, with slight dyspnoea, and puriform ex- 
pectoration. Every time he went away relieved, but not cured. On both sides 
of his chest could be heard all the varieties of rhonchus. In one spot the column 
of air which penetrated the bronchi imitated the snoring of one in a deep sleep; 
in another spot it was like a duil and prolonged groan ; in a third, a sound re- 
sembling that made by bellows ; and in a fourth the cooing of a turtle-dove was 
exactly simulated. On the last occasion of his entering the hospital, his respira- 
tion was still tolerably free. One morning he was found in a state of unusual 
anxiety. In the middle of the night, after a violent paroxysm of cough, his 
breathing (he said) had suddenly become very much oppressed. It was discovered, 
on auscultation of his chest, that no air penetrated into the upper lope of the right 
lung ; yet that part sounded well on percussion, even louder than the corresponding 



INFLUENZA.. 



551 



part of the other side, which was morbidly dull. The difficulty of breathing 
went on augmenting, and the man was soon dead. 

Besides other marks of disease in the lungs, the primary bronchus leading to 
the upper lobe on the right side was closed up completely by tough mucus, and 
exhibited the appearance of a full cylinder. 

In the other case, also, the obstructed bronchial tube supplied the upper lobe 
of the right lung. 

It may seem strange that the interruption of the access of air to so small a por- 
tion of the lungs should be attended with such serious consequences, when we 
know that the greater part of each lung may be impermeable by air, and yet the 
patient live a long time, and often without any great dyspnoea. The explanation 
of the apparent difficulty seems to be, that in the one case the prevention of the 
arrival of air in the part affected is sudden, in the other gradual. Moreover, the 
remaining portions of the lungs are performing their functions imperfectly. 

When once attention has been awakened to the kind of accident just mentioned, 
the diagnosis would not seem to be difficult. We may suspect obstruction of one 
of the bronchi when considerable dyspnoea comes on suddenly during the con- 
tinuance of simple bronchitis: and our suspicion will be confirmed if at the same 
time respiration ceases to be audible in a certain portion of the lung, while the 
sound given by percussion over the same part remains unaltered. Emphysema 
of the lung (which I shall explain hereafter) is the only other condition which 
could give rise to a similar set of symptoms. 

Andral judiciously suggests the employment of emetics, and the inhalation of 
steam, in such cases. 



LECTURE XLIX. 

Influenza. Symptoms and progress. Conjectures as to its cause. Treatment. 
Hay asthma. Chronic Bronchitis. Its varieties. Morbid anatomy of these 
affections. 

Catarrh, which was the principal subject of the last lecture, occasionally pre- 
vails far and wide as an epidemic disease. I speak, indeed, (February 4, 1837,) 
during the immediate presence of one such visitation, although the extreme vio- 
lence of the complaint that has been raging among us is now fast subsiding. You 
can hardly be without curiosity to know what has been learned respecting an in- 
fluence which has thus, on a sudden, before your eyes, disturbed and sickened a 
whole community. I have here used, without thinking of it, the very word by 
which, in a foreign version, the disorder is denominated. It has received, how- 
ever, various names ; for it has been known and noticed from remote antiquity. 
Cullen calls it catarrhus e contagio : and under that head, in his Nosology, you 
will find a copious reference to recorded accounts of epidemic catarrh, as it has 
been observed to spread over great portions of the world. In France the dis- 
order thus prevailing is styled the grippe. The Italians, putting the cause for 
the effect, call it influenza, the influence: and this last term, influenza, has now 
become naturalized in our language. Since Cullen wrote there have been four or 
five more of these epidemics. One in 1782, which extended over all Europe, 
visiting every country therein, affecting more than one half of its inhabitants, and 
proving fatal to very many of them. You will find, in the third volume of the 
Transactions of the College of Physicians, a good account of the disease as it 
then showed itself in this country. In the spring of 1803 another instance of it 
occurred ; and of this the history, as compiled from the testimony of a hundred 
and twenty-four observers, is preserved in the ninth and tenth volumes of the 
London Medical and Physical Journal. In the month of April, in the year 



552 



INFLUENZA. 



1833, the influenza again made its appearance, and prevailed extensively, both 
here and elsewhere: and of the influenza of 1837 you have had, and you still 
have, the opportunity of being observers. A very good and instructive sketch of 
this epidemic malady, compiled by Dr. Hancock, is to be found in the Cyclopaedia 
of Practical Medicine. To that article, to the publications I just now mentioned, 
and to the works enumerated by Cullen, I may refer you for much which is 
curious and interesting in the history of the disease; but which would not be so 
well adapted to our immediate purpose in this place — namely, that of seizing 
upon the practical facts which have been ascertained respecting influenza. 

One characteristic feature of this species of catarrh, as distinguished from the 
ordinary sporadic disorder, is the sudden occurrence, in the outset, of more de- 
cided febrile disturbance. The first two patients whom I saw in the epidemic of 
1833 had just the symptoms which frequently mark the commencement of an 
attack of continued fever ; and I did not know, at my first visit, what was about 
to happen to them. The symptoms, taking them altogether, are somewhat as 
follows. The patient is chilly, and perhaps shivers; presently headache occurs, 
and a sense of tightness across the forehead, in the situation of the frontal sinuses ; 
the eyes become tender and watery ; and sneezing and a copious defluxion from 
the nose ensue-, followed or accompanied by heat and uneasiness about the throat, 
hoarseness, a troublesome cough, and oppression of the breathing. In short, the 
symptoms are the symptoms of catarrh; including in that term all the varieties 
thereof that are sometimes met with separately — gravedo, coryza, bronchitis: 
and with these symptoms a sudden, early and extraordinary subdual of the 
strength ; and, most commonly, great depression of spirits. The debility which 
comes on at the very outset of the complaint, is one of its most singujar pheno- 
mena, taking place, in some cases, almost instantly, and in a much greater degree 
than would seem proportioned to the other symptoms of the malady which it 
thus ushers in. Indeed, this rapid and remarkable prostration of strength is 
more essentially a part of the disorder than the catarrhal affection, which some- 
times (though rarely) is absent, or imperceptible. It is upon the mucous mem- 
branes, however, that the stress of the disease generally falls ; especially upon 
the internal lining of the air-passages. Those of the alimentary canal seldom 
escape entirely ; but they suffer in a less degree. The tongue is white and 
creamy, the palate loses its sensibility, the appetite fails, nausea and vomiting 
are not uncommon, and sometimes there is diarrhoea. The pulse, in the un- 
complicated disease, is soft, and generally weak. The patients complain also 
of pains in the limbs and back, and of much soreness, a bruised, fatigued, or 
tender feel, along the edges of the ribs and in various parts of the body. 

In its simple form and ordinary course, the disease abates of its violence after 
two, three, or four days, and the patient is usually convalescent before the ter- 
mination of the week : but cough and much debility are apt to survive the other 
symptoms, and while these continue, the complaint is very easily renewed. Pre- 
existing disease, and peculiar constitutional habits and tendencies, modify consi- 
derably the character of the influenza, as it affects different persons. I do not 
attempt to represent its various phases ; they are fit subjects of study for your- 
selves. 

I have remarked that Cullen makes this species of catarrh to proceed from con- 
tagion. But the visitation is a great deal too sudden and too widely spread to be 
capable of explanation in that way. I will not say that the disease may not be 
in some degree infectious; for there is reason to believe that other epidemic dis- 
orders, having many points of analogy with the influenza, are somehow imparted 
from one individual to another, although they are mainly produced by some influ- 
ence which resides in the atmosphere. There are points in the history of influ- 
enza which furnish a strong presumption that the exciting cause of the disorder 
is material, not a mere quality of the atmosphere; and that it is at least portable. 
The instances are very numerous, too numerous to be attributed to mere chance, 
in which the complaint has first broken out in those particular houses of a town 



INFLUENZA. 553 

at which travelers have recently arrived from infected places. But this great and 
important question of contagion I hope to examine with you more rigorously on 
a future occasion. What I wish to point out now is the fact that the influenza 
pervades large tracts of country in a manner much too sudden and simultaneous 
to be consistent with the notion that its prevalence depends exclusively upon any 
contagious properties that it may possess. You are aware that it has recently 
seized upon all parts of this metropolis — and I believe I may say of nearly the 
whole kingdom — within the space of a very few days. It has been observed to 
occur also, at the same time, on land, and on board different ships which have 
had no communication with the shore, nor with each other. Thus it is stated in 
the Transactions of the College of Physicians, that on the 2d of May, 1782, 
Admiral Kempenfelt sailed from Spithead with a squadron, of which the Goliah 
was one. The crew of that vessel were attacked with influenza on the 29th of 
May ; and the rest were at different times affected, and so many of the men were 
rendered incapable of duty by this prevailing sickness that the whole squadron 
was obliged to return into port about the second week in June, not having had 
communicaiion with any shore, but having cruised solely between Brest and the 
Lizard. This happened in one part of the fleet. In the beginning of the same 
month, another large squadron sailed, all in perfect health, under Lord Howe's 
command, for the Dutch coast. Towards the end of the month, just at the time, 
therefore, when the Goliah became full of the disease, it appeared in the Rippon, 
the Princess Amelia, and other ships of the last-mentioned fleet, although there 
had been no intercourse with the land. Similar events were noticed in the epi- 
demic of 1833. One or two curious instances of the sudden sickening of consi- 
derable bodies of men in different places at the same time, were related to me on 
good authority. On the 3d of April in that year — the very day on which I saw 
the first two cases that I did see of the influenza, all London being smitten with 
it on that and the following day — on that same day the Slag was coming up the 
channel, and arrived at two o'clock off Berry Head, on the Devonshire coast, all 
on board being at that time well. In half an hour afterwards, the breeze being 
easterly and blowing off the land, 40 men were down with the influenza, by six 
o'clock the number was increased to 60, and by two o'clock the next day to 160. 
On the self-same evening a regiment on duty at Portsmouth was in a perfectly 
healthy state, but by the next morning so many of the soldiers of that regiment 
were affected by the influenza, that the garrison duty could not be performed by 
it. I make no doubt that facts of a like nature have occurred during the present 
epidemic, and will be made known in due time. They illustrate several import- 
ant points in respect to the disease: viz. r the impossibility of accounting for its 
prevalence upon the principle of mere contagion — the suddenness of its invasion 
— and the early and extreme prostration of strength with which it is attended. 

The occurrence of epidemic catarrh, as well as of most other epidemics, is 
unquestionably connected with some particular state or contamination of the 
atmosphere. What that state is, or what may be the kind of contamination, no 
one knows. The present epidemic followed hard upon the sudden thaw that suc- 
ceeded the remarkable snow-storm of the last week of the last year. A similar 
coincidence between the breaking out of the same disorder, and a sudden eleva- 
tion of the temperature of the atmosphere, happened at St. Petersburgh in the 
epidemic of 1782. " On a cold night (Maertens says), the thermometer rose 30° 
of Fahrenheit ; the next morning 40,000 people were taken ill with the influ- 
enza." Now if every epidemic had been preceded by similar changes in the 
weather, we might resolve the universal prevalence and sudden accession of the 
complaint, into the effect of the cold and damp state of the air, produced by the 
thaw. But it is not so ; for, as Dr. Hancock observes, there has not been any 
uniform connection between any one sensible quality of the atmosphere as to heat 
or cold, rain or drought, wind or calm — and the invasion of the epidemic. " Et 
tempore frigidiori et calidiori, et flante tam Austro quam Borea, et pluvioso et 
sereno caelo, peragravit hasce omnes Europos regiones, et omnia loca indiscrimi- 



554 



INFLUENZA. 



natim." Irregularities and great vicissitudes of weather have, however, gone 
before the disease in very many instances : but sometimes one condition of the 
atmosphere, and sometimes another, has been its immediate forerunner: and the 
epidemic has frequently been observed to fall partially and capriciously : as a 
blight falls upon a field or district. Short, in his chronological history of the wea- 
ther, says that thick ill-smelling fogs preceded, some days, the epidemic catarrh 
of 1557. Jussieu states that the grippe of the spring of 1733 appeared in France 
immediately after offensive fogs, " more dense than the darkness of Egypt." So 
also in 1775, Petit informs us that in France the disease was ushered in by thick 
noisome fogs. In the same year it visited the shire of Galloway in Scotland, 
where, we are told, " a continual dark fog and particularly smoky smell prevailed 
in the atmosphere for five weeks, the sun being seldom seen." Dr. Darwin has 
recorded that, in 1782, " the sun was for many weeks obscured by a dry fog, and 
appeared red as through a common mist:" and he supposes that " the material 
which thus rendered the air muddy, probably caused the epidemic catarrh which 
prevailed in that year." You will call to mind here the dark fog which brooded 
over this city in the midst of the raging of the distemper about ten days ago, and 
which was repeated in a less degree, on Wednesday last (Feb. 1). 

It has been observed also, that shortly before, or during, or soon after, the pre- 
valence of these epidemic catarrhs — epizootic diseases have raged ; various species 
of brutes, and of birds, have been extensively affected with sickness : while on 
some occasions prodigious swarms of insects have made their appearance. In 
short, a great variety of facts concur to render it probable that some peculiar con- 
dition of the air existed, which, though it might be favourable to the multiplication 
of some species of living creatures, such as the insects just referred to, operated 
as a poison upon the human body, and upon the bodies of many of the brute 
creation. 

It is a very curious circumstance in the history of epidemic catarrhs, and worthy 
of your reflection, that they travel; migrate as it were from one place to another: 
and moreover, that they hold, for the most part, to certain courses, in spite even 
of opposite winds, and of variations of temperature. It has been noticed that the 
influenza generally follows a westerly direction, or one from the south towards 
the north-west. In this remarkable property it resembles, as you may perhaps 
be aware, the epidemic cholera. 

Although the general descent of the malady is, as I have said, very sudden and 
diffused, scattered cases of it, like the first droppings of a thunder-shower, have 
usually been remembered as halving preceded it. The disorder is most violent at 
the commencement of the visitation : then its severity abates; and the epidemic 
is mostly over in about six weeks. Yet the morbific influence would seem to have 
a longer duration. In a given place nearly all the inhabitants who are susceptible 
of the distemper suffer it within that period, or become proof against its power. 
But strangers who, after that period, arrive from uninfected places, have not, appa- 
rently, the same immunity. 

The locality does not appear to be thoroughly cleared of the poison for some 
time: or perhaps a more cautious statement of the fact would be, that the disorder 
generally shows itself again in succeeding years, but in a milder and less general 
form. This must depend either upon some remaining dregs, or possibly some 
revival, of the injurious influence ; or else upon some abiding predisposition 
impressed upon the bodies of men by its former visit. You may hear, every 
year, of Mr. So-and-so having the influenza. In many instances, no doubt, 
common sporadic catarrh is dignified by that name; but it is certain also that 
many' of the colds, and bronchial disorders, of the seasons which immediately 
follow a period of genuine influenza, are attended with much more languor, de- 
bility, muscular aching, and distress, than belong to an ordinary attack of catarrh. 

All this is very curious ; and very mysterious. All this, or much of it, is irue 
also of all the diseases which are known to prevail occasionally as epidemics. The 
facts that have now been mentioned respecting the influenza, warrant, I think, the 



INFLUENZA. 



555 



conclusion that it does not depend upon any mutations in the ordinary qualities of 
the atmosphere; upon any degrees or variations, I mean, of its temperature, its 
motions, or its moisture ; upon what is expressed in the single word weather. 
Concerning a calamity so generally felt, and so obscure in its origin, conjecture, 
you may well believe, has not been idle. One hypothesis assigns the complaint 
to some change in the electrical condition of the air: to its becoming negatively 
electric: or to its being such as to cause an excessive accumulation of electricity 
in the animal economy. The facts adduced in support of these views are of this 
kind. Meat, sent up by means of a kite, high into the atmosphere, during the pre- 
valence of the disease, has returned putrid. Large heavy separate clouds, in a state 
of negative electricity, have been observed just before the setting in of an epidemic. 
Thunder-storms, and tumults of the atmosphere, have occurred at the same periods. 
During the raging of one epidemic, 300 women engaged in coal- dredging at New- 
castle, and wading all day in the sea, escaped the complaint. It has been thought 
that this exemption might be accounted for by supposing that the almost constant 
immersion of the body in a conducting medium prevented any undue collection of 
electricity. 

Again, it has been fancied that the tolerably definite course of the epidemic, in 
its migrations, might be somehow connected with magnetic currents. 

Another hypothesis, more fanciful, perhaps, at first sight, than these, yet more 
easily accommodated to the known phenomena of the distemper, attributes it to 
the presence of innumerable minute substances, endowed with vegetable or with 
animal life, and developed in unusual abundance under specific states of the atmo- 
sphere, in which they float, and by which they are carried hither and thither. 
Myriads of these animalcules, or of these vegetable germs, coming in contact with 
the mucous membranes, and especially with that of the air-passages, irritate (it is 
imagined) these surfaces, and exercise a poisonous influence upon the system. 
Now, the sporules of certain fungi, which ruin the health, and destroy the vitality 
of larger plants, on which they prey, are inconceivably small. I shall prove to 
you, presently, that vegetable effluvia are capable of producing, in the human body, 
symptoms not very dissimilar from those of influenza. Again, that the waters of 
this globe swarm with living creatures, which are invisible by our unaided eyes, 
the microscope has taught us. Others, too small even to be estimated by that 
wonder-showing instrument, in all probability exist. We cannot doubt that the 
gaseous fluid which surrounds this planet, equally teem-s with living atoms. We 
know that multitudes of insects, and of cryptogamous plants, infinite in number 
in respect to our finite powers of computation, are sometimes suddenly hatched 
or developed, in places which were previously free from them. It is easy to 
conceive that atmospheric infusoria (so to speak) may rapidly congregate, or 
vivify, in masses sufficient to render deleterious the very air we breathe. If this 
be so, we can understand how such a cause of disease may first act here and there, 
and presently overspread large districts ; how it may move, or be wafted from 
place to place, or be carried about by persons; how its course and operation may 
be circumscribed and definite ; and how some germs or ova may remain after the 
visit, retaining their vitality, and ready in future seasons again to start into life 
and activity under favouring circumstances. Taking the insect hypothesis, and 
knowing as we do that some animal poisons, (that of small-pox, for example,) 
have the singular property of multiplying themselves in the huma*n body, like 
yeast in beer, we may conceive that diseases, produced by animalcules, may thus 
infect the fluids of the body, and become contagious in the fullest sense of that 
term. Lastly, the uniform duration of these epidemics has been supposed to add 
probability to the hypothesis that they result from the operation of some organic 
principle, which has its definite periods of growth and of decay. All this is sheer 
hypothesis : but it is as good an hypothesis as I am able to offer you ; and you 
must be content to conceive of it as being possibly the true one, until a better shall 
be proposed. 

The character of debility which is so conspicuously impressed upon this dis- 



556 



INFLUENZA. 



ease, bears closely upon the treatment required for its cure, or its safe conduct. 
As in all other epidemics, the severity of the complaint is extremely variable in 
different persons. In some it proves a very trifling malady, which soon passes 
off, and requires little or no assistance from medicine. In others it is a very dis- 
tressing affection, and lays the foundation for other and still more serious, though 
more chronic diseases ; and in some, and more especially in the old and the un- 
sound, it shows itself a very fatal disorder. The absolute mortality under the 
recent epidemic has been immense: the daily newspaper obituaries have been 
unusually long; and you may have remarked, that the ages of the persons whose 
deaths they announced were in almost all cases great. The funerals have been 
so frequent, that difficulty has been found in performing them without indecent 
hurry and confusion. One undertaker, of whom I was informed, had at one time 
75 dead bodies to inter — above ground, as he expressed it; and mourning coaches, 
and black horses, could not be procured in sufficient numbers to meet the demand 
for them. The absolute "mortality, therefore, I say, has been enormous; yet the 
relative mortality has been small. You will hear people comparing the ravages 
of the influenza with those of the cholera, and inferring that the latter is the less 
dangerous complaint of the two ; but this is plainly a great misapprehension. 
Less dangerous to the community at large (in this country at least) it certainly 
has been ; but infinitely more dangerous to the individuals attacked by it. More 
persons have died of the influenza in the'present year than died of the cholera 
when it raged in 1832; but then a vastly greater number have been affected with 
the one disease than with the other. I suppose that nearly one-half of those who 
were seized with the cholera perished ; while but a very small fraction indeed of 
those who suffered influenza have sunk under it. The only fatal cases that I 
have seen have been in persons advanced in life, or in persons whose lungs were 
previously known to be unsound. 

Now the treatment of the influenza is pretty well understood. The chief risk 
of mistake is that of being too busy with the lancet. Certainly those affected by 
this disorder do not well bear active depletion. Of course no one would think of 
blood-letting except the symptoms were severe, and the distress great; but even 
in such cases, much caution is requisite in adopting that remedy. If you find 
that the inflammation has extended to the pleura, or to the substance of the lungs, 
it may be necessary to open a vein, or to apply cupping-glasses over the chest;, 
but this is a very unpleasant necessity. Such is the result of all that I have seen, 
and heard from others, of the present epidemic ; and such is the result of the 
recorded experience of nearly all previous epidemics. You will find abundant 
evidence of this collected into a summary view by Dr. Hancock. In 1510, Dr. 
Short says bleeding and purging did harm. In 1557, bleeding was said to be so 
fatal, that in a small town near Madrid, two thousand persons died after it in the 
month of September. In 1580, Sennertus, after stating that where blood-letting 
was omitted, the mortality was not greater than one in one thousand, adds, " Ex- 
perientia enim hoc comprobavit, omnes fere mortuos esse quibus vena aperie- 
batur." Dr. Ash observes that, in 1775, it was never necessary to bleed at 
Birmingham ; and that, in a neighbouring town, three died who were bled, and 
all recovered who were not bled. And a great deal more evidence to the same 
purpose you may find in the article I have referred to. 

I believe the best plan of management — as far as any general plan can be laid 
down — is to keep the patient in bed, and after clearing the bowels by a mild 
aperient, to give a couple of grains of James's powder every six hours, with a 
saline draught, and slops, till the first brunt of the disorder is over; and then, if 
the cough be troublesome, and the breathing laborious, and much rhonchus, or 
sibilus, or crepitation, is audible in the chest, to apply a blister, and to give ex- 
pectorants and diuretics. What I prescribed a great many times was something 
of this kind : half a drachm of oxymel of squills, a drachm of the sweet spirit of 
nitre, and sometimes another drachm of paregoric, in almond emulsion. With 
respect to full doses of opium, when the feverishness is abated and the headache 



HAY-ASTHMA. 



557 



gone, I should recommend the same practice which I described in the last lecture. 
If there be any lividity of the skin, or of the mucous membranes, it is dangerous 
to give a full dose of opium. On the other hand, if there be no visible indication 
in the complexion that venous blood is circulating in the arteries, opium given at 
bed-time will have sometimes a magical effect in relieving distress, and (by giving 
rest and refreshing sleep) in recruiting the strength also. In cases in which the 
powers of the system are prostrate, and the face and lips are livid, and the patient 
is tugging to expectorate the mucus that is filling up his air passages, you should 
have recourse to ammonia, to nourishing broths, and it may be to wine and water: 
and when all danger from the disease is over, but the patient remains feeble, 
languid, and out of spirits, then is the fit time to administer tonic medicines ; and 
although snake-root and cascarilla are well spoken of by many practitioners, I 
know no tonics so good as the sulphate of quina, or of iron, for such patients. 

As to external applications, mustard poultices, blisters, and the like — and to 
the inhalation of the steam of hot water, — these may each and all be very useful ; 
but I have nothing to add concerning the time and manner of their employment 
to what I said upon the same subject in the last lecture. 

There is one point in the treatment which I must not omit to notice, although 
I cannot tell you much about it from my own experience. Dr. Thomas Davies, 
an accurate observer, and one well qualified to form a judgment in the matter, 
states that he found a mercurial treatment answer well in severe cases, in the 
epidemic of 1833. He perceived that active depletion was not well borne, and 
discovering that in the bad cases there was always crepitation in the lower lobes 
of the lungs, he thought mercury was one of the most proper remedies to subdue 
the inflammation, and to occasion absorption of the fluid effused into the air-cells. 
He had severe cases to deal with. He says that it happened to be his duty to 
admit the patients into the London Hospital during the week the epidemic was at its 
height, and that thirty-two beds which were placed at his disposal were all soon 
filled with individuals labouring under the severe forms of influenza; so severe, 
that he believed the greater number of them would have perished if they had been 
allowed to wander about the streets, or even to have remained at their own homes, 
with the insufficient attention they could there have obtained. Only one or two 
of these patients were bled, but they were all put under the influence of mercury. 
This treatment commenced on Thursday, and all who, by Saturday night, were 
affected in the usual way by the remedy, safely and gradually recovered, with the 
exception of two; and one of these had hypertrophy of the heart, and diseased 
aortic valves. His object was not to salivate, but merely to make the gums tender. 
It was of course necessary that the action of mercury should be prompt ; and he 
found that the most quick and efficacious way of obtaining it was by rubbing in 
the linimentum hydrargyri. 

There is another kind of catarrh described as depending upon a peculiar local 
cause, and therefore requiring to be briefly noticed. I have seen only one instance 
of it; but it has been observed and described by several medical men. Dr. Bostock, 
in the Medico- Chirurgical Transactions, gives an account of this complaint as it 
is apt to attack himself. It is called the catarrhus sestivus, and by some the hay- 
fever, or the hay-asthma. In Dr. Elliotson's lectures, also, as published in the 
Medical Gazette, there is a good deal of curious information upon this malady, 
contained in letters addressed to him from practitioners in various parts of the 
country, in consequence of some previous remarks he had made upon it in a 
clinical lecture, which had also been printed. Dr. Elliotson speaks of it as a com- 
bination of catarrh and asthma. It consists in excessive irritation of the eyes, 
nose, and the whole of the air-passages ; producing, in succession, itching of the 
eyes and nose, much sneezing occurring in paroxysms, with a copious defluxion 
from the nostrils ; pricking sensations in the throat ; cough, tightness of the chest, 
and difficulty of breathing, with or without considerable mucous expectoration. — 
This complaint affects certain persons only, and in them it always takes place at 



558 



HAY-ASTHMA. 



the same period of the year, in the latter end of May, or in June, when the grass 
comes into blossom, or when the hay-making is going on. It seems, in fact, to 
be produced by some kind of emanation from certain of the grasses that are in 
flower at that season, of the irritating qualities of which emanation some persons 
only, — and a very few persons in comparison with the entire population, — are 
susceptible. The disorder happens only at that one particular season; and it then 
attacks persons who- are not remarkably subject to catarrh at other times, nor from 
the ordinary causes of catarrh ; and if they avoid meadows and hay-fields, and the 
neighbourhood of hay-stacks, they escape the malady. Hence going to the sea' 
coast, and especially to those parts of the coast that are barren of grass, offers a means 
of protection ; and when this cannot be done, such persons obtain refuge, in some 
measure, from the cause of the irritation, by remaining within doors, and shutting 
out as much as possible the external air, during the hay-crop. One lady, who suf- 
fered annually from this strange affection, states that a paroxysm has been brought 
on by the approach of her children, who had been in a hay-field ; and once this 
happened when the hay-season had been for some time over, upon their joining 
her at tea, after playing in a barn in which the hay of that year had been deposited. 
She was in the habit of flying to Harwich, or some other part of the coast, as the 
dangerous season came on. On one occasion, while walking on the shore at 
Harwich, she was suddenly attacked by the complaint, to her great surprise, as 
she was not aware of any grass being in the neighbourhood ; but the next day she 
discovered that hay-making was in progress upon the top of the cliff at the time 
she was walking under it. In another year, she being at Cromer, and an attack 
that she had suffered having quite subsided, and all the hay-malting thereabouts 
being over, she was suddenly visited by the well-known symptoms, and on going 
into her bed-chamber perceived that they were building a large stack of hay in a 
yard near the house, having transferred it from a field five miles distant. 

Very lately I was asked by Mr. Cheyne to see with him the wife of a stable- 
keeper near Regent Street. I found her suffering under what is popularly called 
" a crying cold :" pain in the situation of the frontal sinuses, streaming eyes, 
sneezing and defluxion from the nostrils, and very urgent dyspnoea, which was 
accompanied by loud wheezing. Symptoms of this kind had come on, suddenly, 
some days before : and her distress was then so great, that her husband proposed 
to drive her in a gig to consult a medical friend of his who lived at Islington. On 
their way thither, every symptom disappeared, and she felt at once quite well. 
She subsequently stayed a night or two, in comfort, with some relations in the 
city. Immediately upon her return home the same symptoms recurred, with all 
their former severity, and resisted the means adopted for their relief by Mr. 
Cheyne, who had now been called in. He was soon led to suspect the cause of 
the attack, and of its obstinacy. There was a strong odour of hay in the house. 
The husband told him that his lofts were filled with a lot of hay which had re- 
cently arrived, and which had an unusually powerful smell. We learned that 
our patient was always worse at night, when the house was shut up; and better 
in the morning, when a free current of air blew through the open windows. We 
advised a temporary change, of residence : but our advice was not followed until 
two days afterwards, the disorder meanwhile continuing, and increasing in inten- 
sity. Then the patient removed to lodgings not one hundred yards distant; and 
immediately all the catarrh and distress again ceased, and she passed a perfectly 
tranquil night. Afterwards she went into the country, and did not return till the 
odoriferous parcel of hay had been consumed, and a new stock laid in. She was 
however revisited by some slight cough, and occasional dyspnoea — neither of 
which troubled her much or long. 

Avoidance, then, of the ascertained source of the complaint is the best thing 
that can be recommended to these persons. You may read almost every year 
in the newspapers that one of our Engligh dukes has gone to Brighton to escape 
the hay-fever. But it is* not in the power of every one to leave home for that 
purpose ; and it has been found that the system is capable of being fortified in 



CHRONIC BRONCHITIS. 



559 



some degree against the pernicious effects of these vegetable effluvia. Mr. Gor- 
don of Welton, in Yorkshire, had communicated some interesting observations to 
the .profession on this subject, before those of Dr. Elliotson were published. 
You may find Mr. Gordon's paper in the fourth volume of the Medical Gazette. 
He supposes that the aroma of the sweet-scented vernal grass, the anthoxanthum 
odoratum, is the principal exciting cause of the complaint. He found the symp- 
toms more speedily and effectually removed by the tincture of lobelia inflala, 
than by any thing else that he had tried at that time ; and he recommended the 
cold shower bath as the best preservative against the attack. But in a subsequent 
communication to Dr. Elliotson, he states that the sulphates of quina and of iron 
given in combination, had proved completely successful in emancipating from 
their tormenting disorder the two patients, from whose cases he had principally 
drawn up his account; although they had, in spite of all previous . treatment, 
suffered an annual return of it tor fifteen or twenty years. 

The susceptibility of this troublesome affection of the mucous membrane, 
from a peculiar cause, which, to most people, occasions no uneasiness, appears 
sometimes to run in families : and this is nothing more than one might expect. 

Dr. Elliotson, thinking it possible that the chlorides which have the power 
of decomposing, and disarming of their noxious qualities, certain animal effluvia, 
might exert a similar control over the vegetable emanations that excite the hay- 
catarrh, suggested to one of the sufferers a trial of the chloride of lime or of 
soda. He desired him to have it placed in saucers about his bed-chamber: to 
have rags dipped in it and hung about the rooms of the house ; to wash his hands 
and face with it night and morning ; and to carry a small bottle of it with him 
to smell repeatedly in the course of the day ; and this plan gave so much relief, 
— either by destroying the emanations, or by lessening the irritability of the 
mucous membranes, — that it was tried in other cases ; and though it did not suc- 
ceed in all, it did in most of them. Three patients out of four derived advan- 
tage from it. This expedient, therefore, is worth carrying in mind. 

There is another vegetable substance, better known to us, which produces in 
some few individuals symptoms very like those of the hay-asthma ; I mean the 
powder of ipecacuanha. I recollect a servant employed in the laboratory of St. 
Bartholomew's Hospital, when I was a pupil there, who had the peculiar ill luck 
to be liable to this affection. Whenever that drug was under peparation, he was 
obliged to fly the place. This idiosyncrasy is not very uncommon. A very 
small quantity of the ipecacuanha dust is sufficient in such persons to bring on a 
paroxysm of extreme dyspnoea, wheezing, and cough, with singular anxiety and 
great weakness. The distress usually terminates by a copious expectoration of 
mucus. 

These effects of a powdered root, and of certain emanations from grass or hay 
lend weight to the hypothesis which ascribes the influenza to subtle vegetable 
matter floating in the atmosphere. 

I would suggest a trial of the Respirator, as a defence against the particles of 
ipecacuanha, and against the volatile exciting cause (whatever it may be) of hay- 
asthma. 

Catarrh is very often met with in a chronic form ; in other words, the mucous 
membrane of the air-passages is very liable to be affected with chronic inflamma- 
tion. The accounts which you may read of this are exceedingly puzzling. 
Authors have endeavoured to draw nice distinctions between different species of 
chronic catarrh ; sometimes according to varying qualities in the matter expecto- 
rated : thus you have chronic mucous catarrh — pituitous catarrh — chroyiic pitui- 
tous catarrh — and dry catarrh, which, after all, is not dry, but only accompanied 
by less expectoration than some of the others ; and then again there is symptoma- 
tic catarrh. You will find all these enumerated by Laennec ; and the majority 
of writers since his time have trodden with too submissive reverence in his 
footsteps. There are by no means such differences in the symptoms or in the 



560 



CHRONIC BRONCHITIS. 



proper treatment of the several varieties of chronic inflammation of the mem- 
brane in question, as to make these numerous subdivisions of any practical utility. 
Chronic or moderate catarrh is often a sequel of acute bronchitis ; it is a very 
common accompaniment of disease of the heart ; it frequently arises during the 
course of the febrile exanthemata; it is seldom entirely absent in cases of con- 
tinued fever ; and it is a form of complaint that is full of interest on this account, 
if on no other, that it has so often been mistaken, and is so liable to be mistaken 
still for tubercular consumption ; of which indeed it is very frequently the com- 
panion. 9 

The constant symptoms of chronic catarrh, or bronchitis, are cough, some 
shortness of breath, expectoration of altered mucus. The variable symptoms, 
those which are oftentimes of the most importance, as determining the slight or 
the serious character of the disorder, consist in the quantity and quality of the 
matters expectorated, and the presence or absence of wasting, and of hectic fever. 

You will continually be meeting with cases of this kind. A person advanced 
in years has what he calls a slight cold, in the winter. He coughs, and expecto- 
rates a certain quantity of gray or transparent mucus. In the summer his cough 
diminishes, or ceases altogether. The next winter the same thing happens again; 
and each successive return of the colder seasons of the year brings back in increas- 
ing severity the cough and the expectoration: and if you listen to the breathing of 
such persons, while the cough is on them, you will find crepitation at the lower 
part of their lungs. Now these are examples, I believe, of a chronic state of 
slight inflammation of the membrane, — or it may be of passive congestion and 
effusion,- — depending upon slowly advancing cardiac alterations. Peripneumonia 
notha is very apt to supervene on this condition. 

But chronic bronchitis may take place at any age, as a sequel to the acute: just 
as active inflammation of other parts of the body is liable to degenerate into the 
chronic form ; and such cases are sometimes very equivocal and deceptive. Several 
years ago, a lady became my patient, having cough, expectoration of puriform 
matter, night-sweats, and diarrhoea. She had had hooping-cough a short time 
before; but though the hooping, and other symptoms proper to that disease had 
ceased, she continued to cough, and to waste. Gradually she got thinner and 
weaker, her pulse became like a thread, and beat 120 times in a minute; she 
took to her bed, the diarrhoea was scarcely restrained by astringents and opiates, 
and I thought she could not live a week. And, upon being pressed by her brother 
for my opinion, I said so. She had scarcely allowed me to listen to the sounds 
in the thorax: but I had once done so fairly, and I could find no morbid sounds, 
except at the lower part of the lungs. If I had trusted to that circumstance alone, 
I should have said that she had not tubercular consumption; but I had not then 
so much faith in the indications afforded by auscultation, nor in my own accuracy 
of ear in such matters, as I might have now ; and I concluded that she was dying 
of tubercular phthisis. Almost on the day, however, on which 1 ventured to give 
this prognosis, some slight amendment began: and she did gradually recover, and 
is alive and quite well at this time. Now it is in cases of this kind that cures are 
performed by those who boast of curing consumption. 

In truth, chronic bronchitis is, in some cases, as incapable of recovery, and as 
surely and progressively fatal, as tubercular phthisis itself; and even more so than 
some of the forms of phthisis. So long, however, as no organic change has 
taken place in the air-tubes, or in the mucous membrane lining them, these chronic 
forms of bronchitis that simulate phthisis in their general symptoms, are within 
the reach of cure. They are to be treated by counter-irritants to the chest — and 
by such measures as are calculated to relieve the most urgent symptoms. Opiates 
for cough, or for diarrhoea. Sometimes the patients bear steel well, and then it 
is almost sure to have a beneficial effect. Sometimes sarsaparilla appears to do 
good ; but, as far as I have observed, one of the most effectual restoratives in these 
cases is to be found, when the weather and the strength permit, in frequent change 
of air and place ; in gentle gestation in a carriage, or in a boat ; and in a nourish- 



CHRONIC BRONCHITIS. 



561 



ing but bland and unstimulating diet. When the membrane, and the tubes 
which it lines, become altered in structure, and pour forth a fluid which has all 
the qualities of pus, hectic fever generally is present, and the chronic disease 
tends, slowly perhaps, but surely, to death. 

There are certain cases of chronic bronchitis which are especially remarkable, 
on account of the great abundance of the bronchial secretion : so great that the 
patients appear to die principally from the daily exhausting drain thus made upon 
the system. There are sometimes no other evident signs of inflammation ; so 
that, as Andral observes, one might be led to separate these fluxes from the truly 
inflammatory affections. They differ from them apparently in their nature, and 
certainly in the treatment which they require. Andral has detailed two or three 
instances of this kind in his Clinique Medicate. The patients expectorated every 
day large quantities — a pint or more — of frothy fluid, resembling weak gum-water 
in colour and consistence. They had no fever; neither frequency of pulse nor 
heat of skin ; but they were exceedingly pale, like persons blanched by hemor- 
rhage, and their emaciation and weakness were also extreme. Very little appre- 
ciable deviation from the healthy state was detectible when the lungs and heart 
were examined after death. 

It does occasionally happen that even larger quantities — three or four pints 
daily — are, for a considerable period, spat up, without much wasting. 

Andral asks, whether, in such cases as these, which certainly occur, though 
they are not very common, the first indication of treatment should not be to check 
and diminish the excessive bronchial secretion; to treat it as you might treat a 
gleet of the other mucous membranes, with balsams, administered either by the 
stomach, or in the shape of vapour. He conjectures that it might have been in 
cases of this nature that the vapour of tar, and tar water, were once thought to be 
so useful. Probably the creasote would be well adapted to such cases. Certainly 
I have seen the excessive expectoration diminish, and the patients gain strength, 
under the use of the balsams; the compound tincture of benzoes, for example; a 
form of medicine much employed formerly, and too much neglected, I apprehend, 
at present. Another remedy, from which I have derived great advantage in somt 
cases of the same kind, is the sulphate of iron, given in two or three-grain doses, 
in the compound infusion of roses, thrice daily. When there is any fever present, 
these remedies are apt to augment it: but when the pulse is quiet, and the skin 
cool, I am quite sure that they are often of the greatest service ; and this you will 
find to be the opinion also of various practical authors. 

There is another very remarkable condition of the pulmonary mucous mem- 
brane, constituting also, I imagine, a species of chronic inflammation, and charac- 
terized chiefly, like the last, by the matters expectorated. I mean that state in 
which a firm substance, resembling a false membrane, forms in the smaller bronchi 
and their ramifications, and is coughed up, from time to time, in fragment?. I 
mentioned in a former lecture that the false membrane of croup sometimes descends 
a long way into the bronchi ; even to their extremities. But I am speaking now 
of a different and less acute form of disease, in which, the trachea being unaf- 
fected, concrete masses, evidently moulded in parts of the hollow bronchial tree, 
are spat up ; somewhat like bunches of worms, or the roots of a small plant. This 
I presume to be uncommon ; for I have met with it twice only in my life. It has 
been described, however, by several observers. The first Dr. Warren has a paper 
upon it in the first volume of the Medical Transactions, where he gives repre- 
sentations of the substances coughed up, which he calls bronchial polypi. Dr. 
Paris has told me that a patient of his coughed up considerable quantities of these 
branching casts of the ultimate air-tubes, now and then, for a long period. An 
interesting paper of Mr. North's, on the same subject, was read at one of the 
evening meetings of the College of Physicians. That gentleman possesses some 
beautiful specimens of these miscalled polypi. Dr. Carswell gives a figure repre- 
senting them. When the affection is extensive, it is attended with great distress, 
and dyspnoea, and violent fits of coughing; and the symptoms are wonderfully 



562 



CHRONIC BRONCHITIS. 



calmed upon each expulsion of the solid matter. The surprise is that such 
patients should ever recover; but I have never heard of an instance in which the 
complaint proved fatal. 

The two examples of it which have fallen under my own observation, were 
invested, by the circumstances attending them, with a peculiar interest. They 
occurred, within less than a twelvemonth of each other, in the persons of two 
brothers, of middle age, the one a barrister, the other well known to you all as 
one of my most valued colleagues in this place. Both of them were, and are, 
remarkably stout, strong, and healthy men. In both cases the expulsion of the 
so-called polypi was preceded byhaemoptysis, which came in considerable gushes, 
and was repeated at intervals of a few days, until the solid matters began also to 
be expelled, and then the hemorrhage soon subsided. 

The barrister, after having been annoyed for nearly a year by some huskiness 
of the voice, spat up, all of a sudden, a small quantity of bright blood ; and soon 
afterwards expectorated several ramifying masses of tolerably firm consistence, 
resembling fibrinous coagula of blood, deprived of most of its colouring matter. 
Some of them, which I saw and examined, were solid; others, I understood, 
were hollow. I found slight circumscribed crepitation in the lower and posterior 
part of his left lung. This trivial degree of haemoptysis, with the expulsion of 
what looked like casts of the interior of a bronchial tube, was once or twice re- 
peated within a few days. He had no fever — no dyspnoea. Mercury, inter alia, 
w r as prescribed; but as the patient did not feel in any way ill, I believe he soon 
became tired of physic, and of medical restraint. Whenever I have since seen 
him, he has appeared to be in perfect health. 

Of the professor's illness I saw more. In the midst of health which had been 
uninterrupted, save by a solitary fit of the gout some years before, he also spat 
some mouthfuls of florid blood. He had no cough, but the haemoptysis was 
accompanied by a rattling sensation in the right side of his chest. 

For about three weeks he continued, at intervals varying from three to six days, 
to expectorate blood in gushes. The smallest quantity brought up on any one 
occasion was two ounces ; the largest, eight. Just above the right nipple the 
respiratory murmur was mingled with large crepitation, which was always sensi- 
bly increased, and quite perceptible by the patient himself, during the attacks of 
hemorrhage. In the intervals between them his breathing and his p^lse were 
perfectly tranquil and regular. 

With the florid blood came up, in general, some black coagula: and at the end 
of three weeks, or thereabouts, in these black masses ragged shreds of a different 
and firmer material began to be visible : and presently afterwards, complete branch- 
like casts of the ramifying air-tubes were expelled ; and the bleeding ceased. 

Of these casts there were two kinds ; the one solid, somewhat coloured, evi- 
dently fibrinous, and resembling the branchingcoagula that may sometimes be drawn 
out of the arteries in the dead body ; the other white, membranous, tubular, but 
ramifying also. None of them were of very firm consistence. 

Till these substances made their appearance, our anxiety about the patient was 
extreme, and he underwent some rigorous discipline at our hands. He was con- 
fined to bed, forbidden to speak, kept strictly to the slenderest slop diet, several 
times bled, and extensively blistered. Lumps of ice were given him to swallow, 
and pounded ice was applied to his chest whenever the blood broke forth afresh. 
He took mercury till his gums were tender, and afterwards the acetate of lead, and 
other reputed styptics. 

To most of this I was a consenting party ; but, looking back upon the case now 
that its nature and result are known, I must confess that the treatment, though 
fairly justifiable at the time, was unnecessarily active. 

Mr. North, in the paper to which I have alluded (you may see it in the twenty- 
second volume of the Medical Gazette), draws a distinction, of which he gives 
the credit to Dr. Cheyne, between the hollow, membranous concretions, expelled 
without any blood ; and the solid branching masses which accompany or succeed 



MORBID ANATOMY OF THESE AFFECTIONS. 



563 



haemoptysis, and are obviously mere coagula of blood moulded in the smaller air- 
tubes, where it had stagnated. He points out the comparatively harmless charac- 
ter of the cases in which the first occur; and the far more serious import of the 
second: the hemorrhage denoting the presence of some organic mischief within 
the thorax, and the "polypous concretions" being simply an accident of the 
hemorrhage. 

I doubt the accuracy of this distinction. The brothers of whom I have spoken 
continue to be, as they were before, free from any symptom or suspicion, either 
of cardiac or of pulmonary disease. Moreover, in haemoptysis depending upon 
tubercles in the lungs, or upon organic disease of the heart, these concretions are 
very rarely observed. I have never seen them in such cases, common as such 
cases are. The barrister had a husky voice, and the professor was noticed to 
have been often " clearing his throat" for some time before the first eruption of 
blood: from which circumstances I infer a previous unhealty state of the mucous 
membrane. Upon the whole I incline to the views expressed by Dr. Todd, with 
whom I had the advantage of consulting in the latter case — that a chronic and 
limited inflammation of certain of the bronchial tubes first occurred ; disclosing 
itself by no marked symptoms, but leading to the formation of tubular membranes : 
that, after awhile, these membranes began to be detached : that hemorrhage re- 
sulted, and continued till the separation was complete: and that, at the same time, 
some of the extravasated blood coagulated in, and took the shape of, the air-tubes, 
and was afterwards expectorated. 

I understand that the barrister has since had a recurrence of this strange com- 
plaint, which he treated very lightly, and soon got rid of. 

He entertained a fixed belief that his attacks were attributable to the presence 
of one of Dr. Arnott's stoves, in his chambers ; the heated atmosphere of which 
always produced a slight feeling of constriction and distress within his chest. 
Whether this notion be well or ill founded I cannot pretend to say : but it is 
curious that the professor also had been using a similar stove, which, placed in his 
sitting-room, warmed both it and his bed-room adjoining. 

A word or two, before we separate, as to the morbid anatomy of these tissues. 

Chronic inflammation of the aerial mucous membrane may lead to changes in 
its colour; or to thickening of the membrane; or to ulceration; or to dilatation 
of the bronchi, and their ramifications. And it is proper that you should be 
informed respecting these morbid conditions. 

In general, when chronic inflammation has existed during life, the mucous 
membrane is found to be red: but it is not a bright redness; it is rather a livid, 
or violet, or brownish tint. And what is very curious, in some instances in which 
all the symptoms of inveterate bronchitis, with puriform expectoration, had been 
present, the inner membrane of the air-passages has been found scarcely rosy — 
or even perfectly white — throughout its whole extent. Of course we are not to 
infer from this that there has not been inflammation; for the same thing is known 
to occur in the intestinal mucous membrane, in that of the bladder, and even in 
serous membranes. Where pus is poured forth there must have been inflamma- 
tion. 

One effect of inflammation, as I formerly showed you, is a softening of the 
membrane ; but this is a much less common result of inflammation in the mucous 
membrane of the bronchi, than in that of the digestive organs. In regard to ulce- 
ration likewise there is a great difference between the two mucous surfaces: in 
that of the air-passages it is comparatively rare. 

Thickening of the mucous tissue occurs also in various degrees : but the most 
remarkable change undergone by the membrane, and the tubes which it lines, is 
the dilatation of those tubes, and the consequent alteration of the membrane, which 
expands with them. 

There are two or three varieties of this dilatation. In the first of them, one or 
more of the bronchi present, throughout the whole or the greater part of their ex* 



564 



THE BRONCHI. 



tent, an increase of capacity more or less considerable : so that tubes which result 
from the fourth or fifth, or even sixth division of the principal bronchus of each 
lung, may equal or exceed in diameter that bronchus itself. Tubes that ought not 
to be bigger than a crow-quill may become as large as the finger of one's glove. 
Sometimes this kind of dilatation is seen in a single branch only, sometimes in 
many. It may affect the bronchial ramifications of an entire lobe. It is more 
common in the branches of a bronchus than in the bronchus itself. 

It is not very easy to explain the manner in which this sort of dilatation is pro- 
duced. We might attribute it to simple distension of the bronchial parietes, were 
it not that these parietes are at the same time thickened, and the circular fibres 
hypertrophied, as you may see in this preparation, and in Dr. Carswell's plate. But 
there is another form of bronchial dilatation to which the explanation just adverted 
to is easily applicable. Instead of the uniform dilatation of one or more bronchial 
tubes, throughout their whole extent, we find a bellying, or globular expansion, at 
the extremity of one of them; and the walls of the tube, instead of being thick and 
hypertrophied, are wasted, and in a state of atrophy. The tissues composing the 
tube are often so thin, that when the cavity, for such it must be called, is laid open, 
the colour and structure of the pulmonary tissue may be seen through them. 
These cavities are generally found filled with a thick, tenacious, straw-coloured, 
muco-purulent fluid. Now it is easy to conceive how " the straining influence of 
repeated paroxysms of coughing" may cause dilatation of this kind. The primary 
branches are more easily cleared of the mucus that fills them : but the pressure 
which the lung undergoes under a forced expiration, operating on a portion of the 
same kind of mucus detained in the smaller branches, may be more than the elas- 
ticity of the tube is capable of resisting. And, in fact, all dilatations of the bron- 
chial tubes must be, in part at least, owing to the same influence of centrifugal 
pressure by imprisoned mucus. They are seldom met with except after those 
affections which are characterized by considerable secretion from the membrane; 
and by much and repeated cough : as after some forms of chronic bronchitis, and 
after hooping cough. 

A third variety of dilatation is that in which the same bronchus bellies out in 
different places ; is dilated at intervals ; so as to present in its course a series of 
successive enlargements and contractions. Here, again, the walls of the bronchi, 
though they may be traced in the parts dilated, do not appear to be thickened, but 
rather are diminished in thickness. We may suppose, therefore, that these small 
partial dilatations of the bronchi may result from mechanical distension, by mucus, 
in those places which offer the least resistance; either on account of diminished 
elasticity, or of actual thinning. This variety of dilatation is more frequent in 
children than in adults. 

In whatever way the dilatation may take place, one of its obvious and necessary* 
consequences is; the condensation of the pulmonary substance around the dilated 
tube, the obliteration of some of the cells, and a proportional abridgement of the 
function of the lung. Accordingly, when it is extensive, dilatation of the bronchi 
is attended with habitual dyspnoea. 

But the most important consideration arising out of this state of the bronchi, is 
this ; that the signs, both general and physical, by which it is accompanied, are 
apt to be exactly those which are most distinctive of phthisis. And it is on that 
account that I have now described these changes. I shall revert to them again 
when I come to the symptoms, revealed by auscultation,of tubercular disease of the 
lungs. 



HOOPING-COUGH. 



565 



LECTURE L. 

Hooping-cough: symptoms; duration; complications; pathology; treatment. 
Pneumonia; its stages and morbid anatomy; auscultatory signs. 

I have yet to consider one very important disorder, which is usually classed 
among the catarrhal affections, but which is marked by features so peculiarly its 
own, as to distinguish it effectually from every other form of disease. I allude to 
hooping-cough ; a remarkable complaint, well known everywhere, I believe, and 
much dreaded by parents. It has received a variety of names : chin-cough ; kink- 
hoast ; coqueluche ; tussis convulsiva ; tussis ferina ; and pertussis. This last 
name, which Sydenham bestowed upon it, and which was adopted by Cullen, is 
the technical appellation of the disease in this country, as hooping-cough is the 
popular. 

The phenomena that characterize hooping-cough are, I say, remarkable. It 
begins with the symptoms of an ordinary catarrh arising from cold. The child 
(for it is most especially a disease of children) has coryza, and coughs ; and; 
mothers and nurses are aware that the disease commences in this way, and ex- 
press their apprehensions lest it may turn to the hooping-cough. After this, the 
catarrhal stage, has lasted eight or ten days, or a fortnight, or sometimes a day or 
two longer, that kind of cough begins to be heard which is so distinctive. It 
comes on in paroxysms, in which a number of the expiratory motions belonging 
to the act of coughing are made in rapid succession, and with much violence, 
without any intervening inspirations; till the little patient turns black in the face, 
and seems on the point of being suffocated. Then one long-drawn act of inspira- 
tion takes place, attended with that peculiar crowing or hooping noise, which de- 
notes that the rima glottidis is partially closed, and which gives the disease its 
name. As soon as this protracted inspiration has been completed, the series of 
short expiratory coughs, repeated one immediately after the other till all the air 
appears to be expelled from the lungs, is renewed ; and then a second sonorous 
back-draught occurs ; and this alternation of a number of expiratory coughs, with 
one shrill inspiration, goes on, until a quantity of glairy mucus is forced up from 
the lungs, or until the child vomits, or until expectoration and vomiting both take 
place at once. During the urgency of the paroxysms the face becomes swelled, 
and red or livid, the eyes start, the little sufferer stamps sometimes with impa- 
tience, and generally clings to the person who is nursing him for support, or lays 
hold of a chair or table, or of whatever object may be near him, to diminish (as it 
would seem) the shock and jar by which his whole frame is shaken. As soon as 
expectoration or vomiting have happened, the paroxysm is over. The child 
may pant a little while, and appear fatigued ; but commonly the relief is so com- 
plete, that he returns immediately to the amusements, or the occupation, which 
the fit of coughing had interrupted, and is as gay and lively as if nothing had been 
the matter with him. When the fit terminates by vomiting, the patient is in 
general seized immediately after with a craving for food, asks for something to 
eat, and takes it with some greediness. 

Each paroxysm may consist of several alternations of the gasping coughs, and 
the characteristic hoop or kink; but Cullen remarks, that the expectoration or 
vomiting usually takes place after the second coughing, and puts an end to the fit. 

The number of paroxysms that occur in the twenty-four hours is variable also ; 
and they come on at irregular intervals. When the complaint is uncomplicated, 
the child, during the intermissions, appears to be quite well. This is another 
striking feature of the disorder. In the earlier paroxysms the mucus expelled is 
scanty and thin ; and in proportion as this is the case, the fits are the longer and 
the more violent. By degrees the expectoration becomes more abundant; and 



/ 



566 



HOOPING-COUGH. 



sometimes it is very copious : at the same time it is thicker, and more easily 
brought up ; and on that account the fits of coughing are less protracted. 

The ordinary duration of the disease is from six weeks to three months ; but it 
may run its course, I believe, in three weeks ; and it may continue for six months, 
or more. 

In an uncomplicated case, if you listen at the chest during the intermissions, 
you will probably hear the sounds that are proper to catarrh — some degree of 
rhonchus or sibilus: and in many parts there may be puerile respiration; and if 
you percuss the thorax, you get the natural hollow sounds. But what happens 
when you apply your ear to the chest during the paroxysms of coughing? Why, 
the information given us in this case by auscultation is very curious. You may 
perhaps hear, between the short explosive shocks of the cough, some snatches of 
wheezing, or of vesicular breathing; but during the long-drawn noisy inspiration 
that suceeeds, all ivithin the chest is silent. This is supposed to result from the 
slow and niggardly manner in which the air passes towards the lungs through the 
chink of the glottis, which is spasmodically narrowed. It may also depend, m 
part, as Laennec supposed, upon a spasmodic condition of the muscular or con- 
tractile fibres of the bronchi and their branches. When the fit is at an end, the* 
ordinary sounds of healthy, or of catarrhal respiration, are resumed. 

Children are very susceptible of this complaint; and it is a complaint which 
spreads by contagion. Hence it follows that few children escape an attack of iL 
It is also one of those contagious maladies which do not in general affect the 
same individual twice : and hence again it follows that it is rarely met with in 
adults. Such is the fact ; and such, I apprehend, is the explanation of it. It is 
not that adults are insusceptible of hooping-cough : for adults that have not had it 
during their childhood are readily affected when exposed to the contagion. But 
it is that the disorder, with very few exceptions, protects the system somehow 
from its future recurrence: and that most adults have had it when they were 
young, and for that reason do not take it afterwards. 

During the very early periods of infancy, i.e., within the first two or three 
months, hooping cough is said to be rare : I mentioned a case, however, before- — 
and I have read of others — in which the disorder appeared to have been con- 
tracted before the patient was born. My bedmaker's daughter in Cambridge had 
a child ill with hooping-cough in the house with her during the last weeks of 
another pregnancy, and the new comer hooped the first day he came into the 
world. 

As long as this disease is uncomplicated — unmixed with inflammation, and 
therefore, unattended with fever, or only with that slight inflammatory condition 
proper to mild catarrh — it is not at all a dangerous disease. Probably it will, 
under the most favourable circumstances, run a certain course. By degrees the 
violence and the frequency of the paroxysms diminish ; they occur only in the 
morning and the evening, then in the evening alone, and at length they cease 
altogether. But for some time after the disorder has apparently come to an end, 
if the child takes cold, and gets a cough, it is apt to assume a spasmodic character, 
and to be attended with a hooping noise in inspiration. 

Unfortunately hooping-cough is, in a great many cases, not simple — not uncom- 
plicated. It becomes mixed up with other kinds of disease in the chest; or in 
the head. In the chest severe bronchitis supervenes upon it, or inflammation of 
the substance of the lungs ; and then fever is lighted up, and permanent dyspnoea is 
present. When the disorder has been long drawn out, and has at last terminated 
fatally, dilatation of the bronchi, such as I described in the last lecture, is often 
found upon dissection ; or, still more commonly, I believe, what is called emphy- 
sema of the lungs — a change which I have yet to bring before you. 

That such effects should follow such violent and continued efforts of coughing, 
is no great matter for wonder. Neither can we be surprised that the disease fre- 
quently leads to cerebral disorder. During the fits there is a great and visible 
determination of blood towards the head, or rather a detention of the blood in the 



PATHOLOGY. 



567 



veins that proceed from the head ; — passive mechanical congestion: the transmis- 
sion of the blood through the lungs being obstructed, a«d its return from the head 
being interrupted. Hence, the face becomes turgid, the eyes are prominent, the 
superficial veins full and projecting, the lips and cheeks turn livid ; sometimes 
hemorrhage takes place from the nose or ears ; or the eyes become blood-shotten ; 
or the patient actually falls into convulsions ; nay, apoplexy is occasionally the 
result of the straining; and when life is not thus suddenly cut short, chronic mis- 
chief is apt to be set up in the brain, and the child ultimately dies hydrocephalic. 

All this is the more to be feared in proportion as the child is the younger. 
Head affections are particularly to be dreaded in scrofulous children ; and in any 
children during the first dentition. When the disease occurs within the first two 
years of life, it is usually attended with convulsions: and many more die within 
that period than afterwards. And Cullen's remark is undoubtedly true, that the 
older children are, the more secure they are, cseteris paribus, against an unhappy 
event. 

Hooping-cough may be complicated also with a disordered condition of the 
bowels; and with infantile remittent fever. This complication is more acci- 
dental, and less a consequence of the hooping-cough than the former; but it may 
very materially add to its peril. 

Dr. Cullen was of opinion that the complaint may exist in even a milder form 
than that which I have called simple hooping-cough. He thought he had seen 
" instances of a disease, which, though evidently arising from the chin-cough 
contagion, never put on any other form than that of a common catarrh." Others 
again believe that adults may have it without hooping. But all this seems to me 
very doubtful. Catarrh is an exceedingly common malady ; and I should be 
slow to consider any case a genuine case of pertussis, unless the characteristic 
paroxysms of coughing, and the stridulous inspiration, were present. 

Divers opinions have been held respecting the seat, and respecting the nature, 
of hooping-cough. Some suppose it to have its seat in the brain ; and that it is 
essentially a spasmodic disease. Others maintain that it is situated in the air- 
passages of the lungs, and that it is always an inflammatory disorder. I do not 
pretend to strike the balance between these conflicting judgments. Certainly the 
simple form of the disease is often unattended with any appreciable fever: and 
that is a strong ground for believing that its peculiar phenomena are not necessa- 
rily connected with inflammation. They who have ascribed the complaint to a 
morbid condition of the brain have deduced that opinion, I presume, from the 
cerebral symptoms that are sometimes so plainly marked in hooping-cough. But 
these symptoms are oftener, to all appearance, the consequence, than the cause, 
of the paroxysms of coughing. I would suggest it as an interesting point for 
your future inquiry, whether the pathology of hooping-cough may not receive 
some elucidation from the researches of the late Dr. Ley, respecting the crowing 
inspiration of infants. You remember his suggestion, that mere inflammation of 
the mucous membrane of the air-passages might cause swelling of the absorbent 
glands of the bronchi or of the neck. This is a circumstance which I have myself 
long thought probable, from having found enlargement of the cervical glands 
springing up during the existence of pulmonary irritation. Take notice that the 
spasmodic fits of hooping-cough are always preceded for some days by mere 
catarrhal symptoms. Observe further how the parts supplied by the pneu mo- 
gastric nerve are affected in these paroxysms: the larynx, the lungs, the stomach. 
This conjecture, that the crowing inspiration of infants, and the crowing inspira- 
tion of hooping-cough — though quite distinct affections — may both depend upon 
irritation of the recurrent nerve, or of the pneumogastric nerve generally ; and that 
even the irritation might in both cases arise out of enlargement of the glands that 
lie in the course of that nerve : this natural conjecture had presented itself to Dr. 
Ley's mind ; for, towards the end of his book, \ find this note : — " Recently four 
children have been brought to my house, labouring under hooping-cough. In all, 
the glandulae concatenate near the trachea were very considerably enlarged. Is 



568 



HOOPING-COUGH. 



this (he says) merely an accidental combination? or is there any essential con- 
nection between the two ? v May it not be that an enlargement of these glands, 
from a specific animal poison, similar to that of the parotid glands in mumps, is, 
after all, the essence of hooping-cough? The subject at least deserves inquiry, 
and further observation." 

In corrobation of this conjectural view of what may ultimately prove to be the 
true pathology of hooping-cough, I may remark that among the morbid appear- 
ances described as being met with after death from that disease, " an unusual 
swelling of the bronchial glands" is set down. It is also stated, by some of the 
Germans, that that portion of the pneumogastric nerve which lies in the cavity of 
the chest has been sometimes found red. Yet I should lay no stress upon this; 
for others have asserted that they have looked in vain for this redness: and even 
supposing it to exist, it is no sure or safe token that there had been inflammation 
of the nerve. The nerve, all things considered, would be likely to become tinged 
of that colour soon before, or even after, death, from the gorged condition of the 
iungs. In some cases, as you may well believe, serous fluid is met with in the 
ventricles of the brain, or in the meshes of the pia mater: in others the conse- 
quences of inflammation are traceable in the bronchi, the lungs, or the pleura. 
Portions of what is called hepatized lung are not unfrequently seen in the fatal 
cases.* 

* [The leading opinions in relation to the pathology of hooping cough, may be referred 
to one or other of the following heads. - 

1st. With some the disease is essentially a spasmodic affection of the air passages, arising 
from a primary irritation, inflammatory or nervous, of the brain, or of one or other set of 
the respiratory nerves. This theory, variously modified, is that advocated by Ho'fTmann, 
Cullen, Hufeland, Jahn, Lubel, Holzhausen, Leroy, Coiter, Guibert, Breschet, Gardien, 
Bauer, Albers, Claras, Webster, and Copland. Dr. Webster considers the affection of the 
respiratory organs as secondary, and dependent on a primary inflammatory irritation of 
the brain or of its membranes, or of both. Most of the advocates of the nervous theory, 
regard the pneumogastric nerves as the primary seat of the affection; others, however, 
locate the irritation in the phrenic nerves — the principal of these are Jager, Lobenstein, 
Lcbel and Leroy; others again, as Albers, of Bremen, Pinel, Laennec, Blache and Roe, 
refer the irritation to both the mucous membrane of the bronchi and the pneumogastric 
nerves. 

2d. Others consider the disease as an inflammatory affection of some part of the mucous 
membrane of the air -passages; this opinion numbers among its advocates, Darwin, Watt, Mar- 
cus Alcock, Dewees, Dawson, Pearson, Guersent, Fourcade-Prunet, Boisseau, Broussais, 
Rostan, and Duges. Dr. Watt believed it lo be "in all cases, an inflammatory, whose 
chief seat is in the mucous membrane of the larynx, trachea, bronchi, and air cells, possibly 
attended with a minute exanthematous eruption there." He considers that, when mild, 
" this inflammation runs its course without materially disturbing the other functions of the 
body, or even the functions of that very membrane in which it is seated, and that whenever 
hooping cough proves dangerous or fatal, it becomes so by the degree of inflammation in the 
natural seat of the disease, or by that inflammation extending or being translated to other 
parts." Most advocates, however, of the inflammatory origin of the disease, limit the in- 
flammation to the trachea and bronchi — Dawson confines y, at first, to the larynx, or 
strictly speaking to the glottis — an opinion, by the way, not widely differing from that of 
Astruc, who of old describes the disease as an "inflammation of the superior part of the 
larynx and pharynx." 

3d. Many view the complaint as at first, inflammatory and afterwards spasmodic, or as 
a specific inflammation of the respiratory mucous membrane combined with irritation of 
the respiratory nerves, in consequence of which, the muscles to which these are distributed 
are thrown into spasmodic action, which irritation continues after the inflammation has 
ceased. This doctrine, variously modified, is a favourite one with the writers on hooping 
cough. — Desruelles makes the disease to consist in a primary inflammation of the bronchi, 
complicated with a consecutive cerebral irritation, which by its influence over the dia- 
phragm and other respiratory muscles, and over those of the larynx and glottis, changes 
the simple cough of bronchitis into one of a convulsive character. This opinion is the one 
adopted, also, by Dr. C.Johnson in his able article on hooping cough in the Cyclopaedia of 
Practical Medicine, {Philadelphia Edition, vol. 2, page 453:) other writers who admit the 
occasional presence of cerebral disease, consider them to be invariably secondary to the 
bronchial affection : of this opinion are Boisseau, Begin, Otto, and Vondembush! 

4th. By not a few, especially of the older medical writers, hooping cough is referred to an 



PATHOLOGY. 



569 



The object of rational treatment in hooping-cough, supposing the disease to be 
simple, is to keep it simple: to keep it m ere hooping-cough: to obviate serious 
inflammation or mischief in the chest and head : and, if possible, to mitigate the 

irritation of the stomach and lungs. — Rosen, who supposed the disease to be produced by 
either an insect or a morbid poison, partly inhaled into the lungs and partly swallowed with 
the patient's saliva, considered that the stomach suffered more from the irritation than the 
lungs. Danz believed that the irritation is seated primarily in the stomach and bowels, the 
affection of the respiratory organs being secondary — this opinion had been previously 
advanced by Stoll, and is also that advocated by Chambon in his work " Des Maladies 
des Enfans." Tourtelle likewise describes the disease as a catarrhal affection of the lungs 
and stomach, (affection pneumogastrique pituiteuse). Millot entertains a somewhat similar 
opinion; he supposes, however, that the irritation of the stomach is secondary and not so 
intense as that of the lungs and larynx. Opinions somewhat similar are maintained by 
Meltzer, Holdefreund, Butler, Klinge, and Strack. 

5ih. The peculiar phenomena of the hooping cough have been ascribed, by a few, to a 
physical or chemical irritant introduced into the larynx, either from without or after it has 
been engendered in the blood, or in the secretions of the respiratory organs. Under this 
head may be arranged the opinion of Linnaeus, who referred it to the presence of minute 
insects; that of Sydenham, who imputed it to a subtle and irritating vapour in the blood 
which affected the lungs, — that of Bohme, and Klinge, and, also, partially, that of Rosen, 
who ascribed it to to a peculiar miasm, acting chiefly on the nerves. Dr. Blaud, of the Hos- 
pital Beaucaire, (Revue Medicale, March, 1831,) considers the primary cause of hooping 
cough to consist in an irritation, not inflammatory, of the mucous membrane of the bronchi, 
under which the glands and follicles of the membrane pour forth a specific secretion satu- 
rated with hydrochlorate of soda, the irritation caused by which, when it reaches the upper 
part of the trachea and larynx, throws the muscles of the glottis and of respiration into 
spasmodic action for its expulsion, in a manner exactly similar to any foreign body which 
accidentally enters the larynx. This theory of the disease Mr. Streeter, of London, in a paper 
read before the Physical Society of Guy's Hospital, November, 1844, has adopted and zeal- 
ously advocated," as the one most consistent with the phenomena observable in the symp- 
toms, pathology, and successful treatment of the disease." 

Mr. Streeter regards, however, the primary affection of the bronchial membranes as 
inflammatory, and believes that it will be found, on careful observation, to be attended by 
more or Jess fever of an analogous character to that which attends the influenza. 

The evidences of the truth of this theory upon which this gentleman places reliance are 
— " the testimony of adults, who have been attacked by the disease, to the unusual and exces- 
sive saline taste of the expectoration so long as the paroxysms are severe — the resemblance 
of the expiratory efforts in the hooping cough to those made by the excito-motory system 
for the expulsion of a foreign body from the larynx — the very adequate explanation it affords, 
both of the extraordinary and spasmodic muscular actions which accompany the cough, 
and of its occurrence in paroxysms after intervals of uncertain duration — and, lastly, the 
key which it furnishes to the chaotic host of apparently opposite remedies that have ob- 
tained professional or popular reputation in its treatment. Of these remedies, we find 
one group adapted to lessen the the original bronchial affections, and favour the expulsion, 
of the offending mucus — as emetics, antimonials, and counter-irritants applied over the 
chest; another which acts by altering the quality of the secretion, as the alkaline carbo- 
nates, ammonia, and sulphuret of potass, so strongly recommended by Dr. Blaud himself; 
another, by exciting a new action in the bronchial membrane, and, by constringing the ves- 
sels, to put a stop to the secretion, in a manner perfectly familiar to the physician in chronic 
bronchitis, and to the surgeon in purulent ophthalmia; as the super-acetate of lead, alum, 
common resin, tine, cantharid., bals. copaiba, tar vapour, and even the inhalation of ni- 
trous vapours, &c. Others, again, as musk, both native and artificial, camphor, arsenic, 
conium, belladonna, opium, and hydrocyanic acid, are more especially adapted for the 
nervous lesions; while antiphlogistic measures meet the inflammatory lesions of the third 
or complicated stage. 

" When, he remarks, the convulsive hooping is fully established, it very commonly hap- 
pens that symptoms which mark the third, or what may be appropriately termed the com- 
plicated stage are developed, and continue to mark the varying and formidable phases of 
the disease which mostly attract attention in practice." These tertiary phenomena usually 
manifest themselves "1st — as special lesions of the nervous and muscular systems — An 
exalted sensibility and morbidly susceptible state of the membrane of the larynx, the 
pharynx, the epiglottis, under which death from asphyxia may suddenly occur— Morbid 
association of the action of the muscles of the glottis and respiration, in consequence of 
which the cough continues from mere habit, or is reprodued by the most trivial irritation of 
the air passages— reflex irritation often passing into inflammation of the nervous centres 
of the pneumogastric nerves, involving those of the phrenic nerves also; and, finally, these 



570 



HOOPING-COUGH. 



severity and shorten the duration of the fits of coughing. I have no notion that 
any thing we can do in the beginning will materially abridge the duration of the 
complaint as it appears in its unmixed form. It wilU I say, in all probability, 
run a certain course ; and our business is to conduct it evenly and safely to the 
end of its course. For this purpose the diet must, in the first place, be regulated 
and reduced. The child should not be allowed to eat meat: the bowels should 
be kept moderately open ; and the patient in cold weather should be confined to 
the equable temperature of the house, or protected by warm clothing. You will 
find different persons employing and praising different plans of treatment ; the 
object in all cases, however, being the same, viz., to ward off inflammation and 
to quiet irritation. One very good plan, as I believe, is that of giving a grain, 
or a grain and half, of ipecacuan, three or four times a day. This generally 
keeps the bowels sufficiently open, and seems to have a beneficial operation on 
the mucous membrane of the air-passages also. Or a few grains of rhubarb and 
ipecacuan may be given every night: and if the cough be very troublesome and 
urgent, small opiates may be administered: syrup of poppies : or the extract of 
hyoseyamus ; as many grains per diem as the child has year3. There is a me- 
thod recommended many years ago by a namesake of mine, which some people 
swear by. Sir William Watson's prescription was one grain of tartarized anti- 
mony and twenty drops of laudanum in an ounce of water. A teaspoonful, or 
a dessertspoonful, of that mixture was given every evening, or every other even- 
ing. I have heard the late Dr. Gooch say that his mother became famous as a 
village doctress by the help of that prescription. Fothergill's method was to 
give an emetic every day; or three or four times a week : and this plan answers 
best, I believe, when the expectoration is scanty, and brought up with difficulty, 
and after much coughing. The best emetic substance in such cases is, doubtless, 
ipecacuan. Mr. Pearson — who has had, I fancy, many imitators — used to give, 
after the operation of an emetic, one drop of laudanum, five drops of ipecacuan 
wine, and two grains of carbonate of soda, in a draught, every fourth hour, for 
several days. Under some such treatment as this, the disease will reach its ter- 
mination in from six to twelve weeks: and it frequently happens that when the 
child is quite well in all other respects, it still continues to cough. The cough 
would almost seem to be kept up by the mere influence of habit. Now, under 
these circumstances, change of air will often remove the cough, as if by magic: 
and the shower-bath, and iron' in some shape, will sometimes succeed, if change 
of air be not practicable. 

There is a great variely of medicines lauded as specifics against hooping-cough : 
but they are not to be trusted to. Many persons think highly of the prussic acid, 
as a remedy for the paroxysms of coughing. Others employ and laud the ex- 
tract of belladonna. But these are gigantic remedies to employ in such young 
subjects. If you give them at all, you must give them in very small quantities, 
and watch their effects. The artificial tincture of musk is another substance 

reflex affections may extend to the whole of the brain, or to the medulla oblongata and 
their meninges, and prove fatal by inducing general convulsions or hydrocephalus. All 
these, be it observed, are pathological conditions of the nervous system which have been 
so constantly put forward in high relief, by the advocates of the nervous theory, as proxi- 
mate causes of the disease itself." A second class of tertiary phenomena include "the various 
congestive and inflammatory affections that result from the mechanical disturbance of respi- 
ration and circulation, and the extension of the primary bronchial inflammation to the tra- 
chea, larynx and pharynx, and to the tissues of the lungs themselves. Epistaxis, haemop- 
tysis, and fatal emphysema from extensive rupture of the air cells, have occurred within 
my own experience, and have apparently resulted from the mechanical violence of the 
cough acting upon tissues previously weakened by disease." A third class of tertiary phe- 
nomena "include fever and cachexia," which are "present in individual cases in every 
conceivable variety of combination." — " In the absence of cerebral or pulmonary inflamma- 
tion, the fever of the third stage is always asthenic, and often assumes a remittent type 
when the cachexia is of a marasmic character." 

For an account of the various lesions met with in the bodies of those who die of hooping 
cough, the reader is referred to Condie on Diseases of Children, page 323.— C.J 



4 



PNEUMONIA. 571 

which some have found useful. Three or four minims of it may be given in the 
outset, and the dose increased till some sensible effect is produced; and then the 
dose that has been so reached should be persisted in without further augmentation. 
I have been assured, by a most intelligent practitioner, that he had got consider- 
able credit by prescribing this medicine, after other persons, with other modes of 
management, had failed. Digitalis, and cantharides, are other, and I think, ha- 
zardous remedies. Safer drugs recommended, and, for aught I know, equally 
efficacious with these poisons, are cochineal, oil of amber, musk, camphor, and 
the meadow narcissus. Ot late the carbonate of iron has been greatly praised by 
some of the continental physicians. 

External applications are also much in fashion in the treatment of hooping-cough. 
Frictions to the spine and to the chest; and as counter-irritants, they probably are 
of some service. The tartarized antimony is the least innocent of these applica- 
tions. It will often cause foul and very troublesome sores upon an adult skin : 
and till I am better advised than I am at present of its certain efficacy as a remedy for 
hooping-cough, no one (however authorized professionally ludere corio humano), 
should rub it upon a child of mine. Mothers are many of them fond of using 
Roche's Embrocation for the hooping-cough. This (Dr. Paris tells us) consists 
of olive oil, mixed with half its quantity of the oils of cloves and of amber. 

Such is the plan of management which you will do well to enforce — and such 
are the expedients which you may, if you please, make use of as auxiliaries to that 
plan — when the disease is mere hooping-cough. But when it becomes complicated 
with symptoms of inflammation within the chest, or with head symptoms — (and 
for such symptoms you must jealously watch) — then you must employ antiphlo- 
gistic remedies (in addition to the antiphlogistic v egimen) adapted to the circum- 
stances of the case. Now we know that the bronchi, or the lungs, are affected 
with inflammation, when we find that the child has fever, and that there is per- 
manent dyspnoea between the paroxysms of spasmodic cough. In such a case 
we must have recourse to the treatment required in such inflammation : leeches to 
the surface of the chest, bleeding even from the arm, if the child's age and strength 
should warrant it, tartar emetic, small doses of nitre, the warm bath, and blistering; 
and to these measures, modified and combined according to the particular emer- 
gency, it will be well to add small and repeated doses of mercury: of the hydrar- 
gyrum cum creta, or of calomel; the state of the bowels determining which. 
Some have recommended friction with the tartar emetic ointment to the chest in 
such cases: but I have the same objection to it there, in such young patients, as 
to the spine. 

When any head symptoms come on, threatening hydrocephalus — such as 
squinting, convulsions, stupor — those remedies must be adopted which I endea- 
voured to describe to you when I spoke of that disease ; leeches to the head, cold 
applied there, purgatives, the warm bath: but except in very young children, I 
believe there is more danger of fatal pulmonary changes in this disagreeable, and 
sometimes intractable disorder, than of cerebral mischief. 

I might pass, by a very natural transition, from the consideration of hooping- 
cough, to that of spasmodic asthma. But this last complaint is found to exist in 
connection with various organic changes within the chest, few of which have yet 
been treated of in these lectures. I shall, therefore, postpone what I have to say 
respecting asthma, till I have gone through some other thoracic diseases. And I 
now proceed to pneumonia, or inflammation of the substance of the lungs. Ques- 
tions have been raised as to the precise part and texture in which the inflamma- 
tion begins ; and to these questions I may briefly advert as we go on : but I hold 
that in pneumonia allthe textures composing the pulmonary substance in the part 
inflamed are involved in the inflammatory process. 

Now of pneumonia it is especially true, that we ascertain its extent, its situa- 
tion, and every step of its progress, by means of the ear. All the symptoms that 
give us the most sure information respecting the nature of the disease, the event 



572 



PNEUMONIA. 



to which it tends, and the remedial treatment which it requires, spring out of the 
actual changes wrought in the pulmonary substance itself; and these changes are 
disclosed to us by the method of auscultation. It is necessary, therefore, that you 
should understand, first of all, what those changes are which are produced by 
inflammation of the substance of the lungs: that you should know the morbid 
anatomy of pneumonia, as an indispensable groundwork for a knowledge of its 
pathology. 

There are three well-marked, and very constant conditions of the lung, corre- 
sponding to different degrees and periods of its inflammation. I will describe 
them in succession, in the order in which they take place. 

The first stage or condition is that of engorgement : all modern observers agree, 
I. believe, both as to the nature and as to the name of this condition. The sub- 
stance of the lung is gorged with blood, or bloody serum. It is of a dark-red 
colour externally, and crepitates less under pressure than sound lung does. We 
feel that there is more liquid than air in its cells. It is heavier also than natural, 
and inelastic, and retains, in some degree, the impression of the finger. When 
the engorged portion is cut, we find it red, and we see a great quantity of a 
reddish and frothy serum flow from it. Its cohesion is at the same time dimi- 
nished ; it is more easily torn ; more, in that respect, like the spleen ; and accord- 
ingly the term splenization of the lung has been given to this stage of its inflam- 
mation, as hepatization has to that which succeeds it. In this stage of engorgement 
the mucous membrane of the small bronchial ramifications is of a deep red colour. 
The portions most engorged, although their specific gravity is increased, will 
nevertheless almost always float on water. 

Now it is necessary to caution you, in the outset, against a very frequent 
source of fallacy in respect to this condition of inflammatory engorgement. Such 
a state of the pulmonary substance as I have been describing, you will meet with 
in half, at least, of the dead bodies which you may have to examine; and you 
must not necessarily infer therefrom that the persons deceased had inflammation 
of the lungs. There is almost always some degree of mechanical engorgement 
of the hack part of the lungs ; or of that part which has been undermost during 
the last hours of life, or after death ; and the two kinds of engorgement can scarcely 
be distinguished from each other by their anatomical characters alone. Andral 
at one time held, indeed, that if the engorged part were more friable, more easily 
torn or broken down under pressure than natural, that was a sufficient evidence of 
its inflammation ; but he afterwards saw reason to change that opinion. We judge 
by the situation of the engorgement sometimes: if it be not in a depending part 
of the lungs, it is surely inflammatory. We judge also by the antecedent symp- 
toms. 

If the inflammation continues, the lung undergoes a further alteration, and 
presents the following characters. It is still red — externally and within: but it 
crepitates no longer under pressure ; and it sinks in water: it contains in fact no 
air. Its cut surface presents sometimes a uniform red colour ; sometimes a slightly 
mottled or variegated appearance, produced by intermixture of specks of the 
black matter of the lung, and of the interlobular areolar tissue, which is less red 
than the other parts, and more than naturally obvious to the sight; but the 
spongy character of the organ is lost; it is evidently solid ; and the cut surface 
very much resembles the cut surface of the liver. Hence Laennec, and after him 
most other writers, have applied to this altered condition of the lung the term 
hepatization. There still flows out, under pressure, from the surface, when a 
fresh incision is made, some red fluid, but it is much less in quantity than in the 
former degree ; and it is not foamy ; and if the surface be gently scraped with a 
scalpel, you may often perceive in the red fluid so collected, some traces of a 
thicker and yellower matter, the first indication of commencing suppuration. The 
hepatized lung is denser and more solid than before, but it is also more friable; 
more easily crushed and broken : and this results from the softening of the areolar 
lissue which holds its component parts together. 



PNEUMONIA, 



573 



If you tear a portion of hepatized lung, and examine the torn surface with a 
magnifying glass, the pulmonary tissue will appear to be composed of a crowd 
of small red granulations, lying close to each other. These are, I presume, the 
air-vesicles, clogged up, thickened, and made red, by the inflammation. As no 
air is contained in the lung in this stage of the inflammation, it follows that if the 
entire organ be involved in the disease, it will not collapse when the thorax is laid 
open ; and will therefore appear to be increased in bulk. It is swelled, in fact — 
just as other inflamed parts are swelled-— by the congestion of its vessels, and 
by the effusion of blood, or of some of the constituent parts of the blood, into its 
hollows and interstices. The marks of the ribs are frequently visible on the sur- 
face of the distended lung. The texture of the lung in this condition is sometimes 
so rotten, that a moderate degree of pressure between the fingers will suffice to 
reduce it to a state of pulp; and this diminution of consistence has made Andral 
quarrel with the term hepatization : and he proposes to call this second stage of 
pneumonia, red softening, ramollissement rouge. All this is very unimportant, 
provided that you recollect the sense in which either nomenclature is employed. 
But as Laennec and Andral are both great authorities, and both have their disci- 
ples in this country, it is well that you should understand their language. 

I have been speaking of pneumonia as it is apt to attack the whole, or the larger 
portion, or a considerable portion, of the lung on one side: but it is a curious cir- 
cumstance that the changes I have been describing are sometimes exactly limited 
to certain of the pulmonary lobules; and this state is called, accordingly, lobular 
pneumonia. 

In a degree still further advanced, the pulmonary tissue, dense, solid, and im- 
pervious to air, as in the last stage, undergoes an alteration of colour; it presents 
a reddish yellow, or straw, or drab, or stone colour; or it is of a grayish hue, 
sometimes mottled with red, or with the black pulmonary matter. The little 
granulations which I just now mentionecTare whitish or gray, instead of being 
red ; and the texture of the lung is still more rotten and friable than before. It is 
full, in fact, of puriform matter, which is sometimes so abundant that it oozes out 
plentifully when incisions are made into the lung: or it may be made to exude by 
gentle pressure. The gray pus shows itself upon the cut surface in the form of 
minute drops. .The more the pulmonary texture is soaked or drenched with this 
fluid, the softer and more friable it becomes. When crushed between the thumb 
and fingers, it is reduced to a yellowish gray pulp, exactly like the fluid itself, only 
rather more consistent. And by gently forcing the finger into any part of the pa- 
renchyma in this state, a small cavity may be made which soon fills with pus, 
and which might readily be mistaken for a recently formed abscess. 

Laennec has called this third stage of the process of inflammation in the lung, 
gray hepatization, ox purulent infiltration. Andral denominates it gray soften- 
ing — ramollissement gris. In fact, it consists in diffused suppuration of the 
pulmonary texture. And it is a very remarkable circumstance, and one which 
the researches of modern times have brought to light, that, in the lung, inflam- 
mation going on to suppuration, does not lead to the formation of a circumscribed 
abscess, as it does when it affects the areolar tissue, or the parenchymatous tissue, 
in other parts of the body. Abscess of the lung usee! to be spoken of as a very 
common thing; but it is a very rare thing. In several hundred dissections of 
persons dead of pneumonia, made by Laennec during a space of more than twenty 
years, he only met with five or six collections of pus in the inflamed lung. Once 
only did he find a large abscess of that sort. Once only has Andral seen a real 
abscess of the lung form as a consequence of pneumonia. You may find collec- 
tions of pus in the lungs, sometimes, occurring in connection with the inflamma- 
tion of veins. Several instances of that kind have happened very recently in pa- 
tients who have died in the Middlesex Hospital. But these are not ordinary cases 
of pneumonia. I need scarcely caution you not to take tubercular vomicae and 
cavities, containing pus, for genuine abscesses of the lung. These, and the phle- 
bitic deposits of pus, are not exceptions to the general statement : they arise from 



574 



PNEUMONIA. 



different forms of disease: and you will find a circumscribed collection of pus, 
surrounded by hepatized lung, as a consequence of common pneumonia, to be an 
exceedingly rare event. 

Can we account for this in any way ? I do not know that any satisfactory ex- 
planation of the fact has ever been offered. But I would submit to your conside- 
ration what has occurred to my mind on this subject. When I was speaking of 
inflammation in general, I pointed out to you the remarkable influence which the 
presence of atmospheric air in contact with the inflamed part has in accelerating, 
or determining, the event of suppuration. In a recent cut, the admission or ex- 
clusion of the air to the cut surface will make all the difference between the adhe- 
sive and the suppurative inflammation ; and so in other cases which I then men- 
tioned, and will not now trouble you by repeating. Now it seems to me that the 
same principle obtains in inflammation of the lung. First, there is an effusion of 
serum and blood, then of lymph and blood; but the air passing into the surround- 
ing sounder tissue, and mingling for a time even with the inflamed portion itself, 
causes the suppurative process to supersede the adhesive; and so no wall of cir- 
cumvallation is formed by the coagulable lymph, as is the case in areolar tissue 
which is not accessible by the air. Whether this be a sufficient explanation of 
the fact (all explanations being the resolving a given fact into a certain class of 
other facts more general and comprehensive) ; I say whether it be a reasonable 
and satisfactory explanation, you will judge : at any rate it may serve to impress 
upon your memory that fact which it endeavours to elucidate. 

Gangrene is sometimes, but very seldom, the result of acute inflammation of 
the lung. It is almost as uncommon as the formation of an abscess. Yet it cer- 
tainly does now and then occur, as a consequence of acute inflammation of the pul- 
monary substance. It is somewhat more common (though under any shape rare) 
as an independent and primitive affection. Sometimes it occupies a large portion 
of the lung, and is uncircumscribed ; and sometimes it is more limited. The colour 
of the part which lias thus perished under inflammation, is dark, of a dirty olive, 
or greenish-brown colour. The gangrenous portion is moist and wet; sometimes 
of the consistence of the engorged lung ; more commonly softer, and even difflu- 
ent ; and it stinks most abominably. This horrible odour is in truth, during life, 
the most distinctive character of gangrene of the lung. It sometimes renders the 
room in which the unhappy patient is lying, scarcely endurable. I should have 
stated before that the puriform infiltration of the third stage of pneumonia, is at- 
tended with no fetor. 

There are some other points, connected with, or learned from investigating, the 
morbid anatomy of pneumonia, which I may as well take this opportunity of 
telling you, before we go on to consider the symptoms, physical and general, of 
that disease. 

There are two lungs, just as there are two tonsils, and two eyes; and in the 
one case as well as in the other, inflammation may affect both organs at once, or 
it may affect one of them alone. Technically speaking, pneumonia may be either 
double or single. Again, the inflammation may occupy a part of one lung, or 
the whole of it : in other words, it may be partial or general ; but it does not affect 
all parts, or both sides, indifferently or capriciously. In the first place, it. is (why 
I know not) greatly more common on the right side of the body than on the left. 
I will give you some statistical statements collected by Andral, in respect to this 
point. Of one hundred and fifty-one cases of pneumonia, noticed at La Chariie, 
ninety were of the right lung alone ; thirty-eight only of the left alone ; seventeen 
of both sides at once ; and in six the situation was uncertain. He was at the pains 
of collecting the particulars of fifty-nine other examples of pneumonia, from differ- 
ent authors, so fully described as to leave no doubt about the nature and situation 
of the disease. Among' these, the inflammation existed in the right lung alone 
in thirty-one patients ; in the left alone in twenty ; and in both sides at once in 
eight. Hence, taking botli series of observations together, we have two hundred 
and ten cases of pneumonia ; and there were one hundred and twenty-one in which 



PNEUMONIA. 



575 



the right side was solely the seat of the disease ; fifty-eight in which the left ; 
twenty-five in which the pneumonia was double ; and six in which the seat was 
uncertain. So that, at this rate, pneumonia is more than twice as common on 
the right side as on the left ; and does not occur on both sides together so often as 
once in eight times. 

Again, with regard to the part of the lung which is most obnoxious to inflam- 
mation, there are remarkable differences. It is well known, and it is a very im- 
portant fact in respect to diagnosis in some cases, that the lower lobes are more 
liable to inflammation than the upper. I speak, of course, of active idiopathic inflam- 
mation. But this circumstance, much insisted on by Laennec, and quite true in the 
main, has perhaps been somewhat exaggerated. I have not had leisure to frame 
any numerical statement of the cases that have come under my own observation, 
but the general impression which they have left upon my mind is in favour of the 
correctness of Laennec's statement — that pneumonia generally commences in the 
lower lobes, and spreads upwards frequently to the superior lobes. But I may 
adduce Andrai's statistical representation in respect to this question also. Of 
eighty-eight cases of pneumonia, he found that the inflammation affected the in- 
ferior lobe forty-seven times, the superior lobe thirty, and the whole lung at once, 
eleven. 

Inflammation of the bronchi constantly accompanies inflammation of the paren- 
chyma. The mucous membrane presents a red colour both in the large and in 
the small branches of the air-passages. And when a single lobe is inflamed, it has 
been observed that the redness of the mucous membrane existed in those bronchial 
tubes alone which were distributed to that lobe. You may have bronchitis with- 
out pneumonia; but pneumonia without a corresponding extent of bronchitis is 
perhaps never seen. 

The majority of cases of pneumonia are attended also with a degree of inflam- 
mation of the investing membrane of the lung: there is some pleurisy. So fre- 
quently indeed is this the case, that certain writers, Andral among others, call the 
disease by the compound name of pleuro-pneumonia. However, pneumonia may 
and does sometimes occur without any concurrent pleurisy. Of the latter com- 
plaint I must speak by itself; and I merely notice now the frequent combination 
of the two — the occurrence of a slight degree and extent of pleuritis in most cases 
of pneumonia — that you may the better understand some of the general symptoms 
of pneumonia. 

Now such being the changes which the lungs undergo when inflammation 
affects the pulmonary texture, we may next inquire what signals of its existence 
the inflammation holds out; and how far we, not having the power of seeing what 
is going on within the cavity of the thorax, may nevertheless ascertain the impor- 
tant processes which are there transacted. 

If the ear be applied to the surface of the chest, with or without the interven- 
tion of the stethoscope, and the portion of lung subjacent to that surface happen 
to be in the first stage of inflammation, that of engorgement, what does the lung, 
so suffering, say? what audible notice does it give of its morbid condition ? Why 
it speaks very plainly. You hear a peculiar crackling sound; the smallest and 
finest-possible kind of crepitation : which has been happily illustrated by saying 
that it resembles the multitudinous litile crackling explosions made by salt when 
it is scattered over red-hot coals. Andral has another resemblance for it, and not 
a bad one; he says the noise is often like that which is produced by rumpling a 
very fine piece of parchment. Dr. Williams observes that a pretty correct idea 
of this sound may be obtained in a ready way, by rubbing between the finger and 
thumb a lock of one's own hair, close to the ear. Laennec calls this crepitant 
rhonchus: I would speak of it as minute crepitation; or the crackling of pneumo- 
nia. This may be heard in a very limited spot in the beginning. And what an 
important sound it is ! " It is a direct symptom, having immediate reference to 
the structure of the part. And (says Dr. Latham) if we consider what the part 
is, and what the disease; the part the lungs, and the disease inflammation: we 



576 



PNEUMONIA. 



cannot too highly value this single symptom (simple and mean as it may seem), 
which gives the earliest and surest intimation that such a disease has begun, as 
tends to disorganization, and the inevitable loss of life, unless quickly arrested by 
its counteracting remedy." 

At first, when you catch the inflammation in its earliest stage, this minute 
crepitation, which announces commencing engorgement of the part, is heard 
mingled with the ordinary vesicular breathing. This obscures the natural sound, 
though it does not yet entirely cover it— but as the inflammation advances, the 
crackling becomes more and more pronounced, until at length it totally supersedes 
it. So long as the natural vesicular breathing prevails over the crackling, we may 
conclude that the inflammation is slight: and if the crackling should, in its turn, 
become predominant, if it should ultimately mask the murmur of respiration 
entirely, that infallibly denotes the progress of the pneumonia, and teaches us that 
it tends to pass from the first into the second degree. But the crackling sound 
does not long remain in any part. As the case proceeds, the sound is less and 
less heard, and at length is not heard at all, in that spot ; and it may be succeeded 
by one of two very different things. Its place may be taken by the natural respi- 
ratory murmur again. When this is so, it denotes the resolution of the inflam- 
mation. But the crackling may cease, and either no sound at all be heard in its 
stead, or another morbid sound which I shall presently describe: and this teaches 
us with absolute certainty, that the disease is growing more severe and serious ; 
that the lung is becoming, or has become, hepatized. 

Let us inquire, for a moment, before we go any further, what is the nature and 
the seat of this minute crepitation, so characteristic of the commencement of pul- 
monic inflammation. With respect to its seat, I apprehend, there can be no 
question. It proceeds from the very smallest ramifications of the bronchi, and 
the air- vesicles themselves. The common opinion is, and such, I confess, is 
mine, that the sound is the same in cause and kind, only different in degree, with 
the large and small crepitation described in a previous lecture: that it results from 
the passage of air through liquid ; from the formation and bursting in quick suc- 
cession of a multitude of little air-bubbles. The bubbles are necessarily minute, 
for they are formed, and they explode, in very slender tubes. This is Andral's 
view of the matter. Laennec does not appear to have formed very clear notions 
on the subject. But a different explanation has been offered by a well-known 
and able writer on the auscultatory signs of disease, in this country : I mean Dr. 
Williams. He holds that the distended blood-vessels, and the interstitial serous 
effusion, press upon the minutest bronchial ramifications, and obstruct, without 
wholly preventing, the passage of the air through them : that these small tubes are 
lined by a viscid secretion, such as is expectorated, and such as I shall have to 
describe : that the sides of the lubes stick together in consequence of the presence 
of this viscid matter; and that it is the separation of these adhering sides by little 
portions of air which successively pass in and out, that gives rise to the charac- 
teristic sound. However, what it is important to remember is, that the crackling 
sound proceeds from the minutest divisions of the air-tubes, and from the ultimate 
vesicles of the lungs. 

Sometimes, I say, when this crackling ceases, the ear applied to the correspond- 
ing surface of the chest, feels it heave up in inspiration, but catches no sound at 
all. Much more commonly, however, a new sound reaches the ear. It is not 
the vesicular rustle ; it is not the minute crepitation : but a whiffing sound is audi- 
ble, like that produced by blowing through a quill. Little gusts^of air are puffed 
in and out; most distinct, often, at the termination of a slight cougffior hem. This 
is the sound to which the term bronchial respiration has been given : and the 
name expresses well the fact. I mentioned before that in the healthy state we do 
not hear the air pass through the larger bronchi during inspiration and expiration : 
the sound doubtless is made, but it is obscured and hidden by the smooth rustle 
of the vesicular breathing,, which comes from the spongy lung surrounding the 
large divisions of the bronchi, and intervening between them and the ear. But that 



PNEUMONIA. 



577 



spongy structure is now filled up. The hepatized lung admits air to pass through 
the larger bronchi, which are still patent, but it admits none into the vesicles .and 
smaller tubes. It crepitates not when pressed between the thumb and finger: in 
fact, it is converted into a solid substance, and conducts the sound, in the living 
body, as any other solid substance might do: and therefore the whiffing, blowing, 
gusty sound of the breath, as it enters and departs from the larger bronchial tubes, 
which still remain open, is conveyed to the ear, and bronchial respiration is heard. 
At the same time, and in the same place, another auscultatory phenomenon gene- 
rally arises, and admits of a similar explanation. The voice of the patient descends 
into the pervious bronchi, and is conveyed to the ear of the listener through the 
solid lung: and it is quite altered by that circumstance. The tone of it is modi- 
fied ; it sounds like the voice of one speaking through a tube. It is totally differ- 
ent from the same voice heard through the healthy lung at the corresponding point 
on the other side. It approaches in distinctness and quality, but it does not reach, 
the sound heard in speaking, when the stethoscope is placed over the trachea. A 
humming and muttering are audible, but the words are not distinctly articulated 
into the ear. It is hard to describe these things in words. Three minutes, at the 
bedside of a patient in whom the bronchial breathing and the bronchial voice were 
tolerably well marked, would put you in possession of them for ever. They are 
striking sounds : requiring no fine tact to distinguish : and exceedingly informing 
sounds. But I must resume this subject when we meet again. 



LECTURE LI. 

Pneumonia continued; its general symptoms ; pain, dyspnoea, cough , expectora- 
tion. Course of the disease. Prognosis. Treatment. 

I was describing, at the close of the last lecture, the auscultatory signs which 
lead us to the knowledge that the inflamed lung, in a case of pneumonia, has passed 
from the first into the second stage of inflammation, and become solid, or hepa- 
tized. The altered condition of the organ gives rise to altered sounds. Instead 
of the vesicular breathing, which is the natural sound: or of the minute crepita- 
tion, which is the sound belonging to the first stage of the inflammation, we 
either hear no sound at all, although we feel the chest heave up against our ear, 
or we hear what I described under the denomination of bronchial respiration $ 
that is to say, a puffing sound which is conveyed to the ear from the larger and 
still pervious branches of the bronchi, through the solid portion of the lung around 
them, and through the solid walls of the chest. This is what the listener hears 
when the patient breathes. And when he speaks, his voice is heard, much more 
resonant than is natural, much more resonant than in the corresponding spot on 
the opposite side of the chest, entering the same open air-tubes, and conducted to 
the ear by ihe dense and solid lung. We thus become acquainted with two 
entirely new sounds; sounds which are never heard in tSie healthy state of the 
lungs; bronchial respiration, and bronchial voice, or bronchophony ; and you 
will do well to remember these two sounds, and to familiarize your ear to them ; 
fur they speak a most significant language in other pulmonary diseases, as well as 
in pneumonia. 

But I say, sometimes we hear these morbid sounds, in the case in question, and 
sometimes we hear no sound at all during the breathing. How is that? Why the 
existence and degree (if the bronchial respiration, and bronchial voice, vary accord- 
ing to the place and extent of the inflammation. These morbid sounds are most 
plainly marked, where the number and size of the bronchial tubes involved in (lie 
hepaiization are the greater. They are most distinct, therefore, when the in flam- 



578 



PNEUMONIA. 



mation occupies the upper part of the lung ; or the central parts, what are called the 
roots of the lungs : and when it extends thence to the surface : but when the lower 
portions alone are inflamed, or the inflammation is merely superficial or partial, 
they may not be heard at all. Again, if the hepatization should be so general and 
complete, as to prevent the chest, on the affected side, from expanding — you will, 
in that case, hear no bronchial respiration ; for the air in the large bronchi must 
be stagnant. Bronchophony, however, may remain. 

When we have the bronchial respiration, usually also we have dullness on per- 
cussion. The degree in which this is present will depend upon the circumstances 
of the case. If a portion of crepitant and permeable lung, even a thin portion, 
should intervene between the inflamed parts and the walls of the chest, there will 
still be resonance, though it will not be exactly the natural resonance, on percus- 
sion. If the hepatized part come close up to the ribs, the sound elicited by 
mediate percussion will be flat or dead. With all this, you will generally hear, 
in the sound lung, if the whole of the other be engaged in» the inflammation ; — 
or in those parts of the inflamed lung that are healthy; — you will hear, I say, 
puerile respiration ; and this is a strong confirming symptom that a part of the 
breathing apparatus is spoiled, and that the remaining part is endeavouring to 
compensate for its deficiency. 

Now this period in pneumonia, when no sound but bronchial breathing is 
audible during respiration, is a period of anxious and painful interest. We cannot 
tell whether the lung will revert gradually to its healthy state; or whether it is 
passing into the third stage, that of purulent infiltration. But taking first the most 
favourable of these two suppositions — what happens? Why, there, where for a 
while we heard nothing but bronchial respiration, a slight crepitation begins again 
to be distinguishable, especially at the end of each act of inspiration : gradually 
this increases, in extent and intensity, and as it increases, the bronchial breathing, 
and the bronchial voice, become proportionally less distinct, in consequence of the 
texture of the lungs becoming again permeable by air, and therefore a worse con- 
ducter of sound. By degrees, the bronchial breathing and voice disappear alto- 
gether ; the vesicular murmur begins again to mix with the crepitation, and at 
length supersedes it; and the lung is restored to its previous fitness for the pur- 
poses of respiration. The same symptoms therefore recur, over again, but in a 
reversed order; the returning crepitation is however coarser and larger, and less 
regularly diffused, than that of the advancing pneumonia: — and even when nothing 
is heard in the ordinary condition of the breathing, but the natural vesicular rustle, 
some crepitation is found for some little while to mingle with it, towards the end 
of a full inspiration. This is believed to depend upon an eedematous state of the 
pulmonary texture, left after the active inflammation has been displaced. Next, 
let us take the worst of the two suppositions. Auscultation has traced the dis- 
ease through its stage of engorgement, and into its stage of hepatization. Can 
it trace it further? I believe not, with any certainty. We cannot say whether 
the lung remains in the state of hepatization (as it may remain), or whether it has 
passed into the third stage. But at last, if the structure of the lung breaks down, 
and a portion of it is expectorated, air finds its way into the vacant spot, and gives 
rise to large gurgling crepitation. But the other signs sometimes come to our aid 
when this state has been reached. 

We often find, after death, the three degrees of pneumonia existing in different 
parts of the same lung ; and therefore it is not to be wondered at that the different 
parts of the chest should during life yield sounds indicative of each of those 
degrees, or at least of the first two ; minute crepitation here, bronchial breathing, 
and bronchophony, and dullness on percussion there, and in another spot no 
sound at all, or on the other hand, puerile respiration. 

Again, it must be confessed — and I am desirous of confessing it, for I am sure 
that the method of auscultation is brought into undeserved suspicion and disre- 
pute by attempts made to assert its all-sufficiency in all cases — it must be con- 
fessed that in some instances, although pneumonia exists, the ear is able to collect 



PNEUMONIA. 



579 



nothing of it ; nothing indicative of its situation, or of its extent, or even of its 
existence. The pulmonary expansion is clear, all over the thorax; nay much 
more strong than is natural : and this circumstance justifies the belief that, from 
some cause or other, not necessarily from pneumonia, a portion of the lung has 
ceased to discharge its function, and the other portions have taken it up. This 
failure on the part of auscultation happens when the inflammation occupies only 
a small portion of the lung, and that portion central, or deeply situated ; at a 
distance from the walls of the chest. For this reason auscultation may give little 
or no account of lobular pneumonia. 

Such are, then, the physical signs that accompany and reveal the successive 
changes of texture, destructive and reparatory, which take place in inflammation 
of the lungs. I do not know whether I have made them clear to you ; but I 
know that no very long apprenticeship, if I may so speak, in the wards of a 
hospital, will be sufficient, with a little guidance, to render you master of them. 
There are indeed varieties, and modifications, and exceptions, which nothing but 
such an apprenticeship can ever teach you. Of these it would be idle and unpro- 
fitable for me here to speak : and I go on to consider the general signs of pneu- 
monia ; some of which, either in themselves, or in combination with the physical 
signs, are of no less importance than these. 

In the majority of cases the commencement of inflammation of the lung is 
marked by shivering, followed by heat and increased frequency of pulse ; in one 
word, by inflammatory fever; and at the same time, or presently after, a stitch in 
the side comes on, with cough, and a sense of oppression in the chest. In other 
instances the disease steals on more insidiously, and succeeds to bronchitis; the 
inflammation appearing to propagate itself by little and little from the larger to 
the smaller bronchi, and ultimately to reach the air vesicles themselves, and the 
interstitial textures; and this may be accomplished with or without the sharp pain 
or stitch in the side. At first the cough may be dry, but it soon is attended with 
a very characteristic sort of expectoration. The dyspnoea is sometimes but slight 
in the outset ; sometimes severe. 

Apart, therefore, from the physical signs, we may say that the usual symptoms 
of pneumonia are pain, more or less severe, on one side of the chest; dyspnoea ; 
cough ; a peculiar expectoration ; and fever. 

The pain in pneumonia appears to exist only in those cases in which the inflam- 
mation of the lung is accompanied by some degree of pleurisy. But these are the 
most numerous cases. It is most commonly experienced on a level with, or a 
little below, one or other breast; but it may exist in almost any other part of the 
thoracic parietes. Generally it is most severe at the beginning, declines by 
degrees, and ceases altogether for some time before the pneumonia ceases. It is 
aggravated by cough ; by a full inspiration ; often by sudden changes of posture ; 
by pressure made upon the ribs or intercostal spaces ; or by percussion^ of that 
part. For the same reason the patients cannot lie on the painful side. Andral 
declares that in all the individuals in whom he had noticed this pain, and who died, 
he found the pleura inflamed, and covered more or less with coagulable lymph ; 
and, on the other hand, that he had constantly known the absence of pain coincide 
with a sound condition of the pleura. When there is no sharp pain, there is, 
however, some morbid sensation, of trouble, or tightness, or weight, or heat on 
the affected side. He quotes, with approbation of its justness, the ancient ob- 
servation respecting pneumonia: — " Affert plus periculi quam doloris." When 
I come to speak of pleurisy as a distinct and substantial affection, I shall revert to 
this pain. 

It is, or it was, a common doctrine, that one of the general symptoms of pneu- 
monia relates to the posture which the patient assumes; that the decubitus, to 
speak technically, is on the side affected. The truth, however, is as I have just 
now stated it. The breathing, indeed, is more oppressed when the patient lies 
on the sound than when on the diseased side ; but, in point of fact, patients 
labouring under this disease almost all lie upon their backs : the decubitus is 



580 



PNEUMONIA. 



dorsal. The difficulty of breathing deserves some notice. In general it bears a 
direct proportion to the extent and severity of the inflammation. But there are 
many exceptions to this. In some persons the inflammation of even a very small 
portion of one lung will embarrass the respiration greatly. In others, who have 
a much larger portion of the pulmonary tissue intensely inflamed, the dyspnoea is 
but slight. So that the degree of difficulty of breathing is not a certain measure 
of the seriousness, or rather of the extent and the degree, of the inflammation. 
It is probable, that if we knew of what kind was the ordinary breathing of the 
individuals thus differently affected, we should find that they whose respiration 
is generally indistinct, or noiseless, who do not seem to want all their lung for 
(he purpose of breathing, would best bear to have a part of it inflamed ; and vice 
versa. Cseteris paribus, inflammation of the upper lobe causes greater dyspnoea 
£han inflammation of the lower. I may observe further with respect to dyspnoea 
in general, that you must not trust implicitly to what patients tell you on that 
head. They will often deny that they have any shortness of breath, when one 
may see them respiring with unnatural rapidity, or observe that, in their discourse, 
*hey pause between every three or four words to take breath. 

However, the dyspnoea produced by pneumonia varies greatly in its degree in 
different cases. Sometimes it is so slight that the patient is not conscious of it, 
and the physician scarcely perceives it: sometimes it is so extreme, that the 
patient, entirely regardless of what is going on about him, seems wholly occupied 
with respiring; is unable to lie down; can scarcely speak; his face becomes 
lividly red or pale, and is expressive of the utmost anxiety; his nostrils are ex- 
panded, and in full action ; the respiratory movements are very frequent and very 
short or shallow, as if the air was not able to penetrate beyond the primary divi- 
sions of the bronchi. From this state of extreme dyspnoea few patients recover: 
and between this, and the slightest hurry or embarrassment of the breathing, there 
are of course many degrees. 

Delirium is a symptom which very frequently occurs in the course of an attack 
of pneumonia; and a very ugly symptom it is. It denotes that the due arteriali- 
Eation of the blood is largely interfered with by the pulmonary affection. It 
measures, in one sense, the quantity of mischief which is going on within the 
thorax : and it is a direct evidence that the pectoral mischief is telling, through 
*he circulation of venous blood, upon the brain. 

The cough, in pneumonia, has no particular character; and affords but little 
information. It does not usually take place in paroxysms ; and its severity w and 
frequency are not always proportioned to the intensity and extent of the inflam- 
mation. It is usually dry in the outset; but in a few hours it is accompanied by 
the expectoration of peculiar sputa, which constitute one of the most certain indi- 
cations of the presence of pneumonia: and as this is a symptom which every one 
can easily recognize, I will describe this characteristic expectoration, and endea- 
vour to explain the cause of it. 

The expectoration of pneumonia, when well marked, consists of transparent 
and tawny or rust-coloured sputa, uniting, in the vessel containing them, into one 
jelly-like and trembling mass; and of such viscidity that the vessel may be turned 
upside down, and strongly shaken, without their being detached from its bottom 
or sides. It cannot be said that when there is no such expectoration as this, there 
is no pneumonia: but it may be affirmed that where we do find such expectora- 
tion, there almost certainly we have pneumonia. At the outset of the disease, 
either nothing is spat up, or simply some bronchial mucus: but on the second or 
third day generally, the matters expectorated assume the characteristic appearance: 
«. e. y they come to be composed of mucus, intimately united and combined with 
blood. It is not that the sputa are streaked with blood, as often happens in 
bronchitis: nor have we the unmixed blood of hsemoptysis. But the blood and 
the mucus are amalgamated together; and in proportion to the quantity of the 
former, the sputa become of a yellow colour, or of the colour of rust, or of a 
decided red : and at the same time they become glutinous and tenacious : they 



PNEUMONIA. 



581 



adhere together, so as to form one transparent homogeneous mass. So long as 
this mass flows readily along the sides of the vessel when it is tilted, so long have 
we reason to hope (judging from that circumstance alone) that the inflammation of 
the lung does not pass its first degree. But, as I said before, the sputa often 
acquire an extraordinary degree of viscidity: so as no longer to separate them- 
selves from the vessel when it is inverted: you cannot even shake them out 
When this happens, we are obliged to fear that the pneumonia reaches its second 
degree. In fact, when the sputa become thus rusty and very viscid, the stricken 
chest almost always returns a duller sound, and the vesicular breathing is abolished, 
and bronchial respiration takes its place. The pneumonia is then at its acme; 
and the expectoration remains for some time stationary. At length, if the inflam- 
mation recedes, the sputa become again less tenacious, less red or yellow, and 
more like the expectoration of mere catarrh. But if the disease goes on from bad 
to worse, the rust-coloured sputa may continue to the end. Commonly there is 
less expectoration in that case, or even none at all. Not that the mucus ceases to 
be secreted, but that its excretion is no longer possible: either on account of its 
extreme tenacity, or on account of the patient's debility. The sputa then accu- 
mulate in the bronchi, trachea, and larynx, in succession: they fill up the air- 
passages; and suffocate the patient. In some instances the expectoration, in the 
advanced stages of the disease, consists of a fluid having the consistence of gum- 
water, and of a brownish red colour: like (as Andral says) liquorice-water, or 
plum-juice. He states that the mere occurrence of this kind of expectoration has 
led him to announce the existence of the third stage of pneumonia; and that the 
subsequent examination of the dead body has seldom failed to justify his diagnosis. 
Sometimes again, during the third stage, very perfect pus is excreted. 

That the colour of the sputa peculiar to pneumonia depends upon an intimate 
union of blood with the altered mucus, is perfectly obvious when that colour is 
deep. And even when this transparent mucus is yellow, you may satisfy your- 
selves by the following simple experiment that the source of the colour is the 
same, and that the yellowness does not result, as some have fancied, from .an ad- 
mixture of bile with the matter expectorated : — If to water, rendered viscid by 
dissolving a certain quantity of gum in it, you add blood, drop by drop, you will 
obtain, in succession, all the shades of colour that are presented by the pneumonic 
sputa : first a yellow tinge ; then a tawny yellow which loses itself in a red, and 
comes to represent the colour of the rust of iron ; and lastly an intense red. The 
sputa may indeed, sometimes, but I believe that does not often happen, be 
coloured by bile ; but bile is not the source of the yellowness which they assume 
in cases of pneumonia. 

Sputa composed of very red mucus, indicate pneumonia less surely than such 
as are tawny. The very red masses, in which there is more blood than mucus, 
often belong to pulmonary apoplexy. 

Although these rust or orange-coloured sputa are commonly present during the 
more active period of pneumonia, and, as far as my experience £oes, are peculiar 
to that disease, you ought to be aware that they do not constantly accompany it. 
Sometimes the matters expectorated are like those of catarrh : and sometimes 
there is scarcely any expectoration at all. 

When the pneumonia passes into gangrene — which I repeat is an exceedingly 
rare consequence of inflammation in that organ, — the expectoration becomes of a 
greenish, or reddish, or dirty gray colour ; and exhales a fetid smell, resembling 
that which proceeds from gangrene of the external parts. 

I have now described, seriatim, the main symptoms, general and physical, 
which mark the existence and the progress of pneumonia. And in order to give 
you a just notion of each, I have spoken of them separately. But they exist toge- 
ther; and they must be studied together: and some will be found to confirm or to 
correct the indications that might be drawn from the others. I must briefly there- 
fore run over the phenomena of the disease we have been considering, as it actually 
presents itself in most cases. 



582 



PNEUMONIA. 



The first symptom felt is commonly pain in the side ; which may or may not 
have been preceded by rigors. At the same time the breathing is constrained ; 
and the patient coughs without expectorating. At this period, the ear may gene- 
rally detect a slight degree of minute crepitation, which is not strong enough to 
mask entirely the vesicular rustle ; and the stricken thorax still sounds well : and 
there is fever withal. This assemblage of phenomena constitutes the first period 
of the disease. From the second to the third day, new symptoms appear. The 
expectoration, hitherto absent, or merely catarrhal, becomes characteristic ; being 
at first moderately viscid, and having a degree of colour proportioned to the variable 
quantity of blood which it contains. The minute crepitation increases, and drowns 
or supersedes the natural respiratory murmur: the clear sound produced by per- 
cussion begins to diminish on that side on which the crackling is heard and the 
pain is felt ; and that pain is commonly less sharp than in the beginning. The 
dyspnoea increases, as is quite apparent from the short and frequent inspirations 
made by the patient. If the pain be acute, he cannot lie, on that account, on the 
side affected ; neither can he place himself on the sound side, because in that posi- 
tion his respiration becomes more laborious ; he remains, therefore, almost con- 
stantly, lying upon his back. 

In this condition of pneumonia, though the disease may be severe, the inflam- 
mation is as yet in its primary stage. It often remains stationary for a while, and 
then recedes, and terminates by resolution. The dyspnoea diminishes, the slight 
dullness of sound disappears, the crackling is gradually displaced by the natural 
murmur of the pulmonary expansion, the sputa again become those of simple 
bronchitis, the fever subsides, and ceases ; and all is well again. 

At other times, instead of retrograding towards resolution, the pneumonia be- 
comes more intense, or rather more extensive, without passing beyond its primary 
stage ; and the patient may die while it is still in that stage. But this is unusual. 
Ordinarily, if the inflammatory engorgement does not cease by resolution, and 
the symptoms that announce it are exasperated, we must expect that the second 
stage will be established. And we may be certain that it exists when we observe 
the following phenomena : — the breathing becomes more and more constrained, 
short, accelerated ; the speech ceases to be free ; the patient can do no more than 
pronounce a few interrupted words in a panting manner. The sputa acquire 
such a degree of viscidity, that they can no longer be detached from the vessel by 
shaking it; the sound afforded by percussion, on the side affected, is decidedly 
dull : at first we still hear a little of the minute crepitation, without the admixture 
of any pure vesicular breathing; then that little crepitation ceases, and either no 
sound at all is perceived by the ear, or, in the part where the percussion is dull, 
bronchial respiration is heard, and this is almost always accompanied with bron- 
chophony. The patient continues to lie on his back. 

In this degree of the disease the prognosis is always uncertain. The patient 
often sinks rapidly, and dies from apnoea. Yet even in this degree resolution 
may still take place. In that case the dullness on percussion diminishes; the 
bronchial breathing disappears ; we hear afresh the small crepitation, at first alone, 
then mixed with the natural respiratory murmur, which, in its turn, becomes 
alone audible. The sputa return to their catarrhal character. In the meanwhile 
the dyspnoea and fever diminish, and then cease entirely. 

It would doubtless be very interesting to determine, in a given case, whether 
the lung of our patient was in the second or the third stage of inflammation. But 
there are no certain means for making this distinction. We may guess that the 
third stage is established if the face becomes exceedingly pale and corpse-like : 
we maybe more confident of it if the prune-juice expectoration should occur; 
and our presumption will be strengthened if the disease has existed for a certain 
time. However, this last circumstance will not help us much; for sometimes the 
lung has bees found to be in a state of suppuration on the fifth day of the disease, 
and sometimes it has been found in a state of red hepatization after fifteen or 
twenty days. 



PNEUMONIA. 



583 



Whether, when the lung has reached this third stage, it is still susceptible of 
repair, is a question which no one can answer. We have not the materials for 
its solution, inasmuch as we have no sure sign of the existence of this third stage 
during life. I should think that recovery from diffused suppuration of the lung 
is not possible. The rarer form of circumscribed abscess certainly is not of 
necessity fatal. 

The duration of pneumonia may be laid, upon an average, at ten days. In a 
table collected by Andral for another purpose, viz., to determine whether there 
were any fixed critical days in respect to the termination of the disease (a question 
which I shall not now discuss), the duration, in 112 cases, varied from four days 
to six weeks. But one only was thus protracted ; 23 cases lasted each seven 
days; and only 15 of the 112 instances continued longer than a fortnight. 

I haA'e very little to add to what I have stated already of the morbid anatomy of 
pneumonia. Of the changes which the lung itself undergoes you are now I hope 
fully apprized. The pleurisy, which often attends the disease, is seldom ac- 
companied by much effusion ; indeed, when the whole of one lung is solidified 
by inflammation, it fills the cavity of the pleura, atfd prevents much effusion. The 
heart is found to be in that condition which I formerly described to you, as being 
both a consequence, and an index, of death by apnoea. Its right cavities espe- 
cially are distended by black coagulated blood; and a remarkable degree of venous 
congestion is frequently met with in the liver, and spleen, and intestines. The 
amount of this varies according as the process of dissolution — what the French 
call the agony — has been more or less protracted, and the breathing more or less 
difficult. 

Neither need I enter upon any formal discussion of the causes of pneumonia. 
Sometimes no cause can be traced ; sometimes the disease is clearly the conse- 
quence of exposure to cold ; especially under those circumstances which were for- 
merly described as aiding the injurious operation of cold upon the human body. 
Why, in one person, such exposure causes peritonitis, in another pleurisy, and in 
a third inflammation of the substance of the Jungs, we can give no satisfactory 
account. 

It remains, then, only that I should speak, first of the prognosis, and secondly 
of the treatment, of pneumonia ; and of the first of these matters, of the prognosis, 
I have already, incidentally, told you nearly all that is made out, or worth know- 
ing. It is almost superfluous to say that the first degree of the disease is less 
dangerous than the second, and the second than the third. There is no doubt that 
pulmonary inflammation may still undergo resolution, although a great part of one 
lung should be hepatized ; but there are no facts which prove — indeed there is no 
possibility of proving — that the lung may recover from the state of purulent infil- 
tration — the third degree. 

Something will depend upon the extent of the inflammation ; I mean that pneu- 
monia in the first degree and of great extent, is generally as serious as pneumonia 
in the second degree but much more circumscribed. Inflammation of the upper 
lobes is also more perilous than inflammation, to the same extent and degree, of 
the lower. 

Of the general symptoms, those which we learn independently of auscultation, 
the respiration, as a prognostic sign, is the most important. Considerable 
dyspnoea, whatever may otherwise be the condition of the lung, is always a bad 
omen. We get less help from the state of the pulse. If, however, a feeble pulse 
goes along with great difficulty of breathing, and if it does not develop itself after 
the first bleeding, we must conclude that the inflammation is intense, and form 
therefore an unfavourable prognosis. The supervention of delirium is also a dis- 
couraging circumstance. You will have inferred already the information which 
may be gleaned from the character of the expectoration, in respect to the probable 
issue of the disease. Great viscidity of the sputa, and a deep rusty colour, an- 
nounce intensity of inflammation : their return to the catarrhal condition indicates 
that resolution is going on. Watery and brownish sputa, more or less like plum- 



§84 



PNEUMONIA. 



juice, should induce us to suspect suppuration of the lung, and are therefore of 
bad augury. 

The great instruments to be employed in the treatment of inflammation of the 
lungs, are the same which have so often been recommended by me, in other 
inflammatory affections, before: blood-letting, tartarized antimony, mercury. Of 
these, blood-letting is the chief. Both reason and experience attest the especial 
power of bleeding upon acute pneumonia. In the first place, it tends to restrain 
or extinguish the inflammation as inflammation. But, in the next place, it has 
the effect of relieving the particular function of the lungs. The more blood is 
gent to them in excess, the more dyspnoea must there be, the more venous blood 
passing into the arteries, as well as the more risk of the effusion of lymph and the 
obliteration of the cellular texture of the organ. When we bleed, therefore, in 
pneumonia, we kill two birds (as a phrase is) with one stone. We do that for 
ihe lung, which we do for an inflamed eye when we darken the room, or for an 
inflamed joint when we keep it absolutely at rest ; i: e., we do all that we can to 
spare the exercise of the organ, and to prevent aggravation of the inflammation 
from that cause. And the result of the free abstraction of blood in this disease, 
fully vindicates the value of a practice which has been pursued for ages. The 
late Dr. Gregory, of Edinburgh, was in the habit of saying, in his lectures, that 
provided he was called early to a case of pneumonia, he would be contented to 
dispense with all other aids than those of a lancet, and water-gruel. I am far from 
desiring you to believe that blood-letting is the only expedient required : but cer- 
tainly the amount of the best experience, ancient and modern, is strongly in favour 
of its free, and I might almost say, its prodigal, employment. Very lately, one 
most distinguished French writer, M. Louis, has endeavoured to show that vene- 
section has not much control over the progress or event of pneumonia ; and I 
advert to his opinion on this subject merely to caution you against being misled 
by it; as you might otherwise be, considering his well-merited reputation as an 
exact and faithful observer. 

I can only lay down general rules and indications with respect to the manner 
and amount of blood-letting in this disease, or in any other disease. The abstrac- 
tion of blood will be effectual, cxteris paribus, in proportion as it is early ; during 
the first stage — the stage of engorgement — and before the spongy texture of the 
lung has been obliterated. The patient should be bled in an upright position, by 
a large orifice and in a full stream; and the bleeding should be continued until 
some sensible impression is made upon the system : until ihe pulse becomes softer ; 
or, if it were contracted, until it becomes fuller $ until the sensational constriction 
is abated, and the dyspnoea relieved ; or until syncope appears to be at hand. 

Bleeding, in this early stage, often gives very speedy relief, both to the pain 
and to the dyspnoea. Sometimes the pain does not cease at once, but goes off a 
few hours afterwards ; but I believe that if the breathing be not at all relieved at 
first, the case generally (though not always) ends ill. However, you are not to 
expect that one blood-letting will suffice, even when it is performed early in the 
disease. Such a favourable case may happen, but not often. The patient should 
always be seen within four or five hours from the period of the first venesection, 
that a timely repetition of it may take place, if the relief has not been complete, 
or has not been permanent. Many fatal cases have probably been fatal from want 
of this attention; from too long an interval having been suffered to elapse between 
the bleedings. A vein may be opened, if necessary, two or three times in the 
twenty-four hours; and the ultimate loss of strength, and even loss of blood, will 
be less under such treatment than if the blood-lettings were repeated at longer 
intervals; and the necessity of the repetition must be judged of from the circum- 
stances of the case. As an auxiliary to the lancet, I am much in the habit of 
taking blood from the surface of the chest itself, by means of cupping-glasses, or 
of a large number of leeches. I believe that much good is done by this local 
emptying of the blood-vessels. It is particularly indicated if there be pain; and 
the part to which the leeches or cupping-glasses are applied should be determined 



PNEUMONIA. 



585 



by the situation of the inflamed portion of lung, when that is ascertained by the 
ear. I scarcely need say that the whole of the antiphlogistic regimen must be 
rigidly enforced ; that the patient must keep his bed ; and that all superfluous 
exertion of his lungs in speaking must be forbidden. 

When the inflammation has advanced into the second stage, we cannot expect 
that the removal of blood will have so decided an influence upon the inflamed and 
solid parts ; but even then, if duly moderated, it will have these good conse- 
quences : it will diminish the force of the heart and arteries, and so tend to pre- 
vent the extension of the inflammatory process ; it will lessen the whole quantity 
of blood circulating through those portions of the lung which are still pervious, 
and thus relieve dyspnoea ; and it will put the system at large into the condition most 
favourable for the reabsorption of the lymph by which the air-tubes and vesicles 
of the affected parts have been blocked up. 

But a time arrives when bleeding is no longer of use, or when it is positively 
hurtful : when it ceases to have any good influence on the local disease, and has 
an injurious influence on the whole system ; reducing the patient's strength, and 
incapacitating him for bringing up, and ridding his lungs, of the tenacious mucus 
exhaled by the bronchial membrane. This is what lakes place in those cases in 
which the expectoration is said to be stopped by a bleeding. I have mentioned 
Dr. Gregory's reliance on blood-letting for the cure of pneumonia ; and I ought to 
tell you at the same time what I have been informed respecting the result of his 
practice. He " used to bleed to the verge of convulsion. His colleague, Dr. 
Rutherford, seldom went beyond three bleedings, and generally accomplished his 
object by two, judiciously timed and measured. Bis patients recovered quickly; 
Dr. Gregory's very slowly." 

We want some remedy, therefore, to assist the lancet, or to employ alone when 
the lancetxan do no more ; and we have two such, in tartarized antimony, and 
in mercury. The tartar emetic plan I believe to be the best adapted to the first 
degree of the inflammation — that of engorgement; and the mercurial plan to the 
second — to that of hepatization. 

I need not tell you that the tartarized antimony is not given in this disorder with 
the object of producing vomiting. It is a very curious thing that although, when 
administered in a considerable dose, its first effect is usually sickness, followed 
perhaps by purging, a repetition of the same dose is, in the majority of cases, at 
length borne without any further vomiting. The stomach comes to tolerate the 
medicine, as our continental brethren say ; and then its beneficial influence upon 
the disease is no less marked than when nausea and retching take place. Some 
patients do not vomit at all ; others, the majority in fact, vomit two or three times, 
and then tolerance is established. If the sickness and purging go on, they may 
be checked by adding a few drops of laudanum to each dose. Dr. Thomas Davies, 
who had tried this remedy largely, and, as he tells us, with great success, gives 
the following'as his own plan of administering it, and perhaps it is as good as any. 
After free bleeding, he begins with one-third of a grain of tartar emetic in half a 
wineglassful of water, with a few drops of laudanum or syrup of poppies. Two 
doses of this strength he gives at the interval of one hour from each other. He 
then, if the patient does not vomit, omits the opium, but continues it if he does, 
doubling, however, the quantity of the tartar emetic, giving two-thirds of a grain 
for two successive hours ; and in this way he goes on, adding a third of a grain 
every two hours, until he reaches two grains every hour. This last quantity he 
has not exceeded, and he says that he has continued it for many days without 
producing any injurious consequences. 

Under this plan of treatment the symptoms will often undergo a marked change 
for the better, in three or four hours. Sometimes, however, the relief is not con* 
spicuous for twenty-four or even for thirty-six hours. He states, and this is 
accordant with my own experience of the remedy, that the tartar emetic always 
acts best when it produces no effect except upon the inflammation itself; i. e. 9 
when it does not cause vomiting, or purging, or a general depression of the powers 



586 



PNEUMONIA. 



of the system. This is an important practical remark, because many persons have 
supposed that it subdues the disease only when it previously gives rise to these 
symptoms. I consider this testimony of Dr. Davies to the power of the tartarized 
antimony in controlling inflammation of the lungs the more valuable, because he 
informs us, that before he had occasion to see its admirable effects in the first 
stage of pneumonia, he had been in the habit of trusting to the free use of mercury, 
after due depletion. 

When the dyspnoea has been put an end to by antimony thus exhibited, the 
medicine may be intermitted ; and if the inflammation shows any disposition to 
rekindle, it must be again extinguished by a repetition of the tartar emetic. 

When, however, the inflammation has reached the second stage, that of solidi- 
fication, mercury is more worthy of confidence, in my opinion, than tartarized 
antimony. And I have little or nothing to add to what I formerly said in respect 
to the mode in which it ought to be administered. The object of giving it is to 
make the gums tender; and it is expedient to do this as speedily as may be. 
Small doses of calomel repeated at short intervals — a grain every hour, or two 
grains every two hours, or three grains every three hours — combined with so 
much of laudanum or of opium as may be requisite to prevent it from running off 
by the bowels — offer the most certain way of accomplishing our object. If the 
bowels are irritable under the calomel, blue pill or the hydrargyrum cum creta 
may be substituted for it with advantage : and if the internal use of mercury is 
any how contra-indicated, or if it appears slow in occasioning its specific effect, 
the linimentum hydrargyri may' be rubbed in, or the strong mercurial ointment. 

Many persons, I am persuaded, are saved by treatment of this kind, pushed to 
slight ptyalism : the effusion of lymph, tending to spoil the texture of the lung, is 
arrested ; and the lymph already effused begins to be again absorbed : and the 
ease and comfort of the patient, as well as the alteration for the better of the phy- 
sical signs, attest the healing qualities of the remedy. 

After the inflamed lung has become solid and impermeable, the treatment must 
be regulated rather by the state of the system at large, than by the actual or pre- 
sumed condition of the lung: we must look more for guidance to the general 
symptoms than to the physical signs. If the pulse continues steady and firm, 
wait patiently the effect of the mercury. But when sunken features, a pallid 
face, coldness of the surface or extremities, a tendency to delirium, and (above all) 
a feeble or irregular pulse, proclaim that the vital powers are giving way, it will 
be requisite, as in other cases where death is threatened by asthenia, to administer 
cordial and stimulant medicines ; the carbonate of ammonia in a decoction of 
seneka; wine: and to feed the patient well on milk, or beef-tea. 

Among what may be called the routine remedies of pneumonia, we must rank 
counter-irritation by means of blisters. When one is called, in consultation, to 
see a patient labouring under inflammation of the lungs, we may safely speculate 
upon the conclusion, that bleeding and blistering, and purging by calomel, have 
all been duly performed. And I believe that bisters are often applied to the chest 
much too early in such cases. In the outset, while there is yet considerable fever 
present, they add to the irritation, and distress the patient ; and probably tend to 
aggravate the existing inflammation. They are also attended with this inconve- 
nience, that they interfere with the exploration of the lungs by the ear: and this 
is not a slight or fanciful disadvantage; for the information we receive, by the 
sense of hearing, of the state of the lung — whether the inflammation be making 
progress, or receding, or stationary — is of great use in directing the remedial 
management of the case. But of course this is a consideration not to be put in 
competition with the benefit which may be expected sometimes from a blister. 
When the fever is no longer high, and the skin no longer burning, but the expec- 
toration is still difficult, the dyspnoea considerable, and a sensation of pain, or 
tightness, or oppression, is experienced in the chest, then a large blister is often 
productive of very sensible benefit; but it should be a large one. The patient 
should have a waistcoat almost, or at any rate a breast-plate, of blistering-plaster. 



PNEUMONIA. 



587 



I have never seen such good effects from placing blisters upon distant parts in this 
disease, upon the thighs or arms for instance, as would lead me to plague the 
patient with them in those situations. 

Purgatives are of less certain value in pneumonia than in many other inflamma- 
tory diseases ; and less, especially, than in cerebral inflammation. Still it will 
always be right to give an active aperient at the outset ; and afterwards to take 
care that the bowels be unloaded at least once every day. A continued drain by- 
purgation would not consist at all with the mercurial plan, which promises to be 
most useful when the inflammation has already reached the stage of hepatization. 

This then is the outline of the treatment which is most likely to save the life 
of those who are affected with acute idiopathic pneumonia. Different cases will 
require different modifications of it ; for which, I repeat, no particular rules can 
be laid down. 

All that I have hitherto been saying relates to acute pneumonia, occurring in a 
previously healthy person. But pneumonia having that character, and so occur- 
ring, is a much less common disorder than most persons appear, to suppose, or 
than I formerly thought it to be. I have been surprised to find how few cases of 
pure idiopathic inflammation of the lungs present themselves among my hospital 
patients. Five or six in the year are as many as I see there. Intercurrent pneu- 
monia, however, — pneumonia engrafted upon some other pre-existing disease — is 
abundantly frequent; and requires, in general, a much less vigorous, and more 
wary plan of treatment. Inflammation of the pulmonary substance is apt to 
supervene insidiously upon various disorders which are of every-day occurrence: 
upon bronchitis ; upon phthisis; upon disease of the heart ; and upon fevers, 
especially the exanthematous fevers. In these cases, while the physical signs 
are necessarily the same as in the unmixed acute disease, the general symptoms 
are often but slightly pronounced. During the progress of continued fever of a 
low type, inflammation may steal upon the lung, and run quickly through all its 
stages, and spoil the organ irrecoverably, without giving any notice of its pre- 
sence : unless, indeed, you suspect, and search for it with your ear. The pneu- 
monia is said, in such cases, to be latent. It seldom needs, the associated dis- 
order would seldom bear, any active depletion. Much benefit often follows the 
abstraction of small quantities of blood, but they should be taken from the surface 
of the chest by the cupping-glass, and not by the lancet from the arm ; and it is 
often good practice thus to aim at reducing the local mischief with one hand, 
while with the other we support the patient's strength by means of ammonia, 
wine, and nourishing broths. Blisters are also of service: more so than in the 
sthenic forms of pure pneumonia; and they may be applied at an earlier period. 
In conjunction with these remedies I should advise the cautious employment of 
mercury. 

When the convalescence from acute pneumonia is decided, and real, it is shorter 
than might have been supposed. From the period when the pulmonary inflam- 
mation is fairly over, the strength returns with unexpected facility, even when 
larcre bleedings have been practised and repeated. But we have to guard, more 
perhaps in this disease than in most others, against false or merely apparent con- 
valescences. A patient can never be pronounced perfectly secure so long as any 
trace of crepitation remains in the affected lung, and this may often continue long: 
nay, it not unfrequently ceases only upon the supervention of another more surely 
fatal though less rapid disorder, — viz.: tubercular consumption; of which, how- 
ever, I must treat as a distinct disease. 

In the next lecture I shall speak of pleurisy, 



588 



PLEURISY. 



LECTURE LII. 

Pleurisy. Its anatomical characters ; false membranes ; liquid effusion ; effecti 
of these upon the shape and contents of the chest, and upon its healthy sounds. 
Symptoms of Pleurisy. 

I proceed this afternoon to the subject of pleurisy ; having in the last lecture 
concluded what I had to say on that of pneumonia: that is, I pass from inflamma- 
tion of the substance of the lung, to inflammation of its investing membrane. The 
two frequently exist together; but when that is the case, the one predominates 
greatly over the other. Pleurisy, however, without pneumonia, is much more 
common than pneumonia without pleurisy. When both are preseut, and the 
pneumonia predominates, the term pleuro-pneumonia is applied to the compound 
disease. The whole interest of such a case merges in the pneumonic inflamma- 
tion. Again, when both are present, and the pleurisy predominates, the com- 
pound affection is sometimes called pneumo-pleuritis . 

The pleura, as you know, is one of the serous membranes. Its inflammation 
is attended therefore with those events which I formerly took some pains to de- 
scribe as belonging especially to that particular tissue. The inflammation is of 
the adhesive kind: it is accompanied by pain; by the pouring out of serum, of 
coagulable lymph, of pus, or of blood. I think it will be best, in this instance 
also, to lay before you some account of the morbid anatomy of the disease, before 
I consider its symptoms. 

The alterations that take place in the inflamed membrane itself are not very 
striking or important. Experiments upon living animals, made by introducing 
some foreign substance, or injecting some slightly irritating liquid, into the cavity 
of the pleura, have proved that, as in other cases, inflammation is attended with 
redness of the part affected. But it is scarcely ever that we observe this effect 
alone of inflammation, in the pleura of a dead person; unless, indeed, he has 
died of some other complaint while he happened to have incipient pleurisy. The 
pleura has been said to be thickened by inflammation ; but that I apprehend to be 
a mistake. It often appears to be thickened, in consequence of the superposition 
of a false membrane — a layer, or several layers, of plastic lymph. But actual 
thickening of the pleura itself seldom or never happens. Neither does the pleura 
easily soften, or readily ulcerate, under inflammation. It peels off, in some cases, 
from the lung, or from the ribs, with more facility than in the sound stale. 

The most remarkable effects of pleurisy result from the effusion of coagulable 
lymph, or of serous liquid, or of boih, into a shut sac, having peculiar anatomical 
relations. One part of the membrane lines the firm walls of the chest : the other 
part envelops the soft and compressible lung. The opposed surfaces of this 
closed and empty bag being opposed also, but freely movable one upon the other, 
very different, and even contrary, effects may be produced by its inflammation. 
The pulmonary pleura may be glued to the costal pleura, so as to prevent all 
lateral movement between them, and to obliterate the pleural cavity ; or the two 
surfaces of the membrane which are naturally in contact, may be forced unnatu- 
rally apart by a pouring forth of serum between them; or the opposite surfaces of 
the pleurae may be united by coagulable lymph in some places, and separated by 
effused fluid in others. And great differences will arise in the symptoms, and in 
the gravity and tendency of the complaint, according as one or another of these 
different conditions of the contents of the thorax is established. 

Let us first consider the effect of the throwing out of coagulable lymph only ; 
or, of what comes to the same thing, the effusion of coagulable lymph with a small 
quantity of serum, which last is soon reabsorbed. 

One consequence of this is the formation of 'false membranes. These, indeed, 



PLEURISY. 



589 



are formed whether there be much or little serum poured out. We continually 
meet with them, sometimes when we least expect to do so, in the dead body. 
They vary greatly, in different cases, in respect to their thickness, situation, ex- 
tent, organization, and effects. 

When the lymph is first deposited upon the free surface of the inflamed pleura, 
it is soft, and of a grayish-white colour, like paste somewhat. It soon, however, 
acquires an increase of consistence, and shows marks of vitality ; becomes, in 
short, organized. Red points begin to appear in it, few in number and widely 
separated at first; but they presently multiply, and lengthen into reddish streaks, 
which run along the surface of the effused matter. Soon these red streaks may 
be perceived to be slender vascular canals ; and at length they inosculate with the 
vessels of the pleura, and the lymph, converted into a false membrane, becomes a 
constituent part of the living frame. 

It is curious, and useful too, to know how rapidly this work of organization 
may go on. 

Andral made experiments upon the pleurae of rabbits, by injecting acetic acid 
into them. He sometimes found, at the end of nineteen hours, soft and thin false 
membrane, traversed by numerous anastomosing red lines. In other rabbits, placed 
under circumstances which appeared to be exactly similar, no such result had 
taken place at the end of a much longer period ; but the pleura contained only a 
serous or puriform liquid, mixed with unorganized flakes of lymph. Now simi- 
lar differences have been remarked in the human subject, under disease. False 
membranes, already vascular, have been found in the bodies of persons who died 
of pleurisy after a very few days' illness: while in other patients, who had lived 
for many months after the invasion of the disease, there has been no trace of such 
vascular membranes. It is clear, therefore, that the organization of the lymph 
does not depend solely upon the length of time that has elapsed from the period 
at which it was poured forth. It has much more to do with the previous state and 
habit of ttie*patient. Caeteris paribus, plastic lymph and early adhesion are more 
to be expected in young, strong and healthy persons; curdy unorganized lymph, 
granular deposits, with copious and abiding serous effusion tending to become 
puriform, in such as are old, feeble, cachectic, and scrofulous. 

The extent of these false membranes varies according to the extent of the 
inflammation which has produced them. When that has been general, they cover 
the whole lung, and line the whole costal surface, and spread themselves over the 
diaphragm and mediastinum of.the same side. Supposing that there is no serous 
liquid effused, or that it is absorbed, the lung then becomes everywhere adherent 
to the sides of the cavity which contains it. The medium of adhesion, which is 
soft and tender while it is recent, grows firm, and assumes the characters of areolar 
tissue, when the union is of old standing. 

The thickness of the false membranes is also extremely variable. Sometimes 
it is not more than that of the pleura itself, and the lymph might then, in the 
absence of adhesion, be almost overlooked. But in the majority of eases their 
thickness is much greater than this. Frequently several distinct layers or strata 
are seen, superposed one upon another, to a considerable depth. 

Are there any auscultatory signs of this process of adhesion when it occurs ? 
Yes. There is a morbid sound, not hitherto mentioned by me, whereby it 19 
sometimes disclosed: ihe sound, namely, of friction; the sound produced by the 
rubbing together of the dry, or inflamed and roughened surfaces. You doubtless 
are aware that every time a tolerably deep inspiration takes place, the relation 
between the ribs and the lung undergoes a change. While the ribs are elevated, 
the lung descends a little: and consequently any given point of the surface of the 
lung is no longer in contact with the same point as before of the thoracic parietes. 
You may convince yourselves of this fact by carefully making a small incision 
through an intercostal space, in a living animal. Now the pulmonary pleura, 
when that membrane is inflamed, does not slip and glide over the costal in its 
usual smooth and noiseless manner; but it makes a creaking or rubbing sound, 



590 



PLEURISY. 



which the ear, applied to the corresponding surface of the chest, readily catches. 
^ I have many times heard this ; yet it is not at all a common sound : indeed I had 
heard it, in one instance, some time before I knew what the noise meant. The 
sound has, mostly, an interrupted character, occurring in a series of three or four 
jerks. The patient is often made aware of the harsh movement, by some internal 
sensation; and a bystander, who places his hand flat upon the corresponding 
surface ofthe thorax, may sometimes feel this grating of the membrane upon 
itself. You may wonder, as adhesions are so common, that this sound, and these 
sensations are not oftener heard, and felt. In trutft, they are transitory pheno- 
mena, and cease, of necessity, as soon as adhesion prevents any further motion 
of the opposed pleurae upon each other. If we do not happen to listen during 
that period, usually a short one, in which the pleurae, roughened by inflammation 
and effused lymph, but not separated by liquid, still chafe against each other, we 
lose the opportunity of hearing the sound at all. This rubbing sound, this noise 
of friction, we shall find to be of greater importance in relation to certain diseases 
of the heart, than in cases of acute pleurisy. In pleurisy the liquid matters 
poured into the membranous sac have far more interesting consequences : and to 
these I now beg your attention. 

In some instances we find, after death, a clear serous, or watery fluid, without 
colour, or of a pale lemon colour, and perfectly limpid and transparent. This 
may occur independently of inflammation of the pleura; from some mechanical 
obstacle to the circulation. It then constitutes a species of dropsy ; a true hydro- 
thorax: and this, though less common than ascites, is by no means an uncommon 
consequence of disease of the heart. When the effusion does not proceed from 
a cause of that kind, it is always, probably, the result of inflammation of the 
pleura itself, although we may find only a slight degree of redness upon its' sur- 
face, or a few patches of coagulable lymph. More frequently, besides this clear 
liquid, with flakes of albuminous matter floating in it, there is also a coating of 
lymph on the inflamed membrane. Very often the thinner fluid % turbid, or 
whitish, like whey ; sometimes it is distinctly puriform ; sometimes it«is tinged 
more or less deeply with blood; sometimes it consists of nothing else but blood, 
which* has separated into the serum and crassamentum. There being no wound, 
nor visible rupture, of large or of small vessels, we conclude, in such cases, that 
the blood has exuded, or been exhaled, from the membrane. 

The different kinds of fluid effused into the pleurae are always, or almost al- 
ways, without smell; — provided that it has remained a closed bag: I mean when 
no communication has been established between the cavity of the pleura and the 
external air, either through an opening in the walls ofthe chest, or through a pul- 
monary fistula leading to the trachea, or through some breach in the oesophagus. 
I have met with but one exception, and that a doubtful one, to this rule. A patient 
died in the hospital, who, some years before, had nearly killed himself by swal- 
lowing, in mistake for beer, a solution of caustic potass. The result of this had 
been ulceration, and subsequently stricture, of the gullet. His left pleura was 
perfectly full of most stinking pus ; and we were unable to detect any channel of 
communication with the outward air, although the circumstances of the case ren- 
dered it not improbable that such a channel might have existed. 

Sometimes air, or gas, is found in the cavity of the inflamed pleura ; either 
alone, or (what is much more common) together with a liquid. We ascertain this" 
fact, in the dead body, by the hissing sound that takes place as soon as a penetrat- 
ing incision is made between the ribs ; or by opening the thorax under water, 
and noticing the escape of air in the form of bubbles. It is probable that these 
gases are sometimes secreted or exhaled from the diseased membrane ; sometimes 
they are the product of decomposition within the cavity; but, for the most part, 
they are met with only when the sac of the pleura communicates somehow with 
the external air. 

Such being the fluid matters that frequently occupy the cavity of the pleura 
when that membrane has undergone inflammation, let us next examine the neces- 



PLEURISY. 



591 



sary effects of their being collected in that part. These effects will obviously 
vary considerably according to the quantity of the fluid that accumulates. 

Now the quantity of fluid may vary from less than an ounce to several pints. 
At first it is lodged in the cavity of the pleura solely at the expense of the yielding 
lung, which is compressed to make room for it. But if the quantity continues to 
augment, other parts at length displaced by the increasing pressure, the boun- 
daries of the eldest on that side are stretched, and even the abdominal viscera are 
thrust out of their natural position. The lung is pushed back towards the medi- 
astinum and vertebral column, and flattened, and brought to lie in the smallest 
possible compass; the diaphragm is forced downwards, which sometimes gives 
rise to a considerable prominence of one or the other hypochondrium, the spleen 
and stomach being displaced on the left side, or the liver on the right. The ribs 
are separated too ; the intercostal spaces become wider, and are pushed out to the 
level of the bones, and the whole of the affected side is smooth and obviously 
larger than the other. The mediastinum also undergoes some change of position, 
being driven more or less towards the side opposite to that on which the effusion 
exists. If the liquid happens to fill and distend the left side of the thorax, the 
heart may be moved out of its natural place, and be heard, and felt, and seen to 
beat on the right of the sternum. Andral mentions having met with only one 
instance of that kind. I suppose that I cannot have witnessed less than a dozen 
such. So again the heart may be carried beyond its proper place, to the left, by 
a large effusion into the right pleural cavity. 

I say when the liquid is accumulated in very considerable quantity, the lung is 
pressed into the form of a thin cake, which occupies a very small space alongside 
the vertebral column : and if it happens to be covered over and concealed, as it 
often is, by a strong layer of adventitious membrane, we might fancy, at first 
examination, that it had completely disappeared. It was in cases of this kind — 
especially when the effused fluid consisted of pus — that the lung was erroneously 
represented by the older observers as having been destroyed by suppuration. — 
However, you will always find the lung there if you take the pains to look for it, 
and to divide the false membranes that bind it down : and, in many instances, it 
is sound also. Its surface may, indeed, be wrinkled, but the lung itself is capable 
of being restored to nearly its former volume by insufflation, as it is called ; by 
blowing air into it through the principal bronchus of that side. Tn this compressed 
state the lung does not crepitate under the finger; it is dense, and sinks in water; 
in fact it is wholly void of air, and has been brought, by the pressure of the fluid 
around and upon it, into nearly the condition of the lung of the foetus that has 
never breathed. But its firmness, its resistance to being torn, and its capability 
of being again inflated, prevent our confounding it with hepatized lung. Some- 
times its cellular texture is obliterated ; the opposite surfaces of the vesicles and 
smaller air-tubes adhere together ; the lung will not admit air ; it looks like a piece 
of muscle, and is then said to be earnifted. 

Such is a general account of the anatomical characters of pleurisy, as they are 
disclosed to us by an examination of the body after death. We may now inquire 
what effect these changes are capable of producing on the sounds which are heard 
when the healthy chest is percussed, or listened at. We shall then be the better 
prepared to appreciate the several symptoms, general and physical, which are 
known actually to occur in pleurisy. Now it is clear that when the lung is pushed 
away from the walls of the thorax by fluid between the pleurae, it will be com- 
pressed also ; its capacity must be reduced ; less air will be able to enter it. 
There will consequently be a proportional diminution in the intensity of the respi- 
ratory murmur; and this murmur will, moreover, be less audible in consequence 
of the distance, from the ear, of the structure in which it takes place. The lung 
is attached by its roots (so anatomists speak) to the spinal column. A moderate 
amount of effusion will, therefore, cause it to recede upwards and inwards ; and a 
certain quantity of the liquid will ascend between the lung and the ribs, com- 
pressing the spongy pulmonary tissue around the larger and more resisting 



592 



PLEURISY. 



bronchial tubes. We might expect, in this condition of things, that the passing 
breath and the voice, would be audible in those tubes, through the partially con- 
densed lung, and through the circumfused layer of liquid : and it is so. We do 
hear bronchial respiration, and bronchial voice and cough ; with some modifica- 
tion, indeed, to be noticed presently. In this respect, therefore, you will observe 
that pneumonia, which solidifies the spongy texture of the lung around the bron- 
chial tubes by filling it with lymph or with blood, has the same effect, so far as 
acoustic principles are concerned, as pleurisy, which solidifies a portion of the 
lung by expressing air from it, and pours round the bronchial tubes a fluid which 
readily transmits sound. Hence bronchial respiration and bronchophony are not 
always indicative of the same condition of parts within the chest, but derive their 
true value and meaning from the context, if I may so say ; from the circumstances 
under which they occur, and with which they are associated. 

When the effusion is so copious as to squeeze all the air out of the spongy part 
of the lung, to pack the organ up along the vertebral column, to distend the thorax, 
and to compress strongly the bronchial tubes themselves, no respiratory murmur 
can then be heard, nor any tubular breathing; for the dilated chest can neither 
expand nor collapse, and, therefore, no air can pass along even the larger air- 
tubes ; neither can these compressed tubes vibrate with the patient's voice; 
wherefore bronchophony also ceases, or is but faintly audible. 

Again, if percussion be made over a portion of the chest, where there is incom- 
pressible serous fluid beneath, in the stead of healthy and spongy lung, a dull 
flat sound will be rendered. But a dull sound is rendered also when percussion 
is made over a solidified lung. Hence the mere dullness of the part struck does 
not inform us whether we have pneumonia or pleurisy to deal with, or some other 
disease that has the effect of making the lung solid, without plugging up the larger 
foronehj. 

But an expedient presents itself, by which we may, in some cases, render this 
"experiment of percussion conclusive. The dull sound occasioned by hepatization 
or other solidification of the lung occupies the same spot in every position of the 
patient. Not so, necessarily, the dull sound produced by the presence of liquid 
in the cavity of the pleura. The liquid will gravitate to the lowest part of that 
cavity, and will carry with it the dull sound. We place the patient, therefore, in 
different attitudes; and if we find that the chest, when struck, is always resonant 
in the higher, and always dull in the lower portions of the thorax, whatever the 
posture may be, then we may be sure that the cavity of the pleura contains liquid. 
In such a case, when the patient sits up, the dull sound will be elicited from the 
lower part of the chest, on one side, from the spine round to the sternum. When 
he lies on his back, the anterior of the thorax sounds hollow; the posterior dull: 
and when he reverses that position, and lies with his face downwards, these 
sounds change places also; the hollow sound is still uppermost, in the posterior 
part of the cavity ; the dull sound still undermost, in its anterior portion. 

There are just two states which may interfere with the true interpretation of 
the sounds produced by percussion in the manner now described ; and these are, 
first, partial adhesions of the pleurae, which may confine and isolate the effused 
liquid, and prevent its sinking from one part of the chest to another under the 
influence of gravity ! and, secondly, so large an amount of effusion as to fill 
entirely the cavity, and fix the compressed and empty lung in one position; for 
it is necessary, in order to obtain the shifting sounds in different attitudes of the 
body, that there should be light spongy lung to ascend, as well as heavier fluid to 
sink down, according to the posture of the patient. In this last case, that of 
excessive effusion, the whole surface of the affected side will yield a dull sound. 
It is seldom so in pneumonia; it is seldom that the entire lung on one side is so 
blocked up, in consequence of inflammation, as to give rise to universal dullness 
on percussion. But the diagnosis of these two conditions is an important one, 
and apt to puzzle a student. I hope to elucidate it as we go on. 

We may now consider, with a better chance of understanding some of them, 



PLEURISY. 



593 



the symptoms which are generally met with in a case of pleurisy under its ordinary 
form and progress. The general signs, then, of that complaint are rigors, p un in 
the chest, dyspnoea, cough, difficulty or impossibility of assuming certain pos- 
tures, and fever. Very much the same, therefore, (as Cullen truly stated) with 
those of pneumonia, and, it may be added, with those of pericarditis : but auscul- 
tation differentiates these diseases. The physical signs I will examine presently, 
The general symptoms will bear, each of them, a short comment. 

The pain which the patient feels — or the stitch in the side, as it is expressively 
called — is one of the most striking and characteristic signs of the disease. Point 
de cote the French name it. It occupies a point or spot; and patients feel as if 
some sharp stabbing instrument were driven in at that spot every time that the act 
of inspiration goes beyond a certain limit. The Latin medical writers, attending 
chiefly to this prominent symptom, call pleurisy " morbus lateris." 

This pleuritic stitch is subject to considerable variety in regard to its situation, 
its severity, and its duration. Most commonly it is felt on a level with or just 
beneath one or other of the breasts, in the part corresponding to the lateral attach- 
ments of the diaphragm: and this, even when the inflammation which occasions 
it is of much greater extent. Why is this? What is the cause of the pain? 
Wherefore should il be restricted to one small spot, when the inflammation 
perhaps pervades the whole of the pleura? Pathologists have made attempts to 
explain these matters; but perhaps their explanations are not very much to be 
trusted to. They say that there is a larger degree of motion at the lower part 
of the thorax, of the pulmonary over the costal pleura ; and that the pain resulting 
from that friction, when the membranes are'inflamed, is therefore felt where the 
friction is the greatest. However, the pain is not always confined to that spot. 
It is occasionally felt in other places, as in the shoulder; in the hollow of the 
axilla; beneath the clavicle; along the sternum : and sometimes it is complained 
of as extending over the whole of one side of the thorax. Andral states that he 
has observed the pain to prevail especially along the cartilaginous border of the 
false ribs, when the inflammation has attacked that portion of the pleura which 
covers the upper surface of the diaphragm. He says, too, that in such cases, 
the pain often affects the hypochondrium, and even extends as far as the flank, so 
that it might be mistaken for a symptom of abdominal inflammation. This ob- 
servation is worth remembering. Sharp pain, occupying the right hypochon- 
drium, belongs oftener to the pleura than to the peritoneum. I have known 
several instances in which such pain was erroneously supposed to be a sign of 
hepatitis, when in truth it resulted from inflammation of the pleura. Cruveilhier 
observes, also, that he has known the pain affect the loins, and simulate lumbago. 

Whatever may be the situation of the pleuritic pain, it is generally increased 
by percussion, by intercostal pressure, by lying on the affected side, by a deep 
inspiration, by cough, and by different movements of the body. 

In many patients the pain is exceedingly sharp, whether it be continued, or 
whether it occur only at intervals : the more circumscribed it is, generally the 
more acute it is. The patients are then in a state of great anxiety: they moke 
very short and imperfect inspirations, through fear of aggravating the pain ? they 
dread the least effort of coughing, or of sneezing, and suppress the desire to 
cough which the disease may occasion. There are other patients in whom the 
pain is moderate, is felt only when a deep inspiration is made, and is scarcely 
augmented by pressure or percussion. And there are even some cases of pleurisy 
which are unattended with pain from first to last. 

The pain commonly exists from the very outset of the pleurisy. It is some- 
times vague and fugitive at first, and becomes fixed and permanent after a day or 
two. In that case it may be mistaken for simple rheumatic pain ; for pleurodyne ; 
or for what is thought to be merely a nervous pain. When the pain is increased 
by slight pressure made upon the ribs as well as between them ; when it extends 
over a large space; when it is unattended with fever; when it is inconstant or 
fugitive — we may suspect that it is situated in the fibrous and muscular tissue; 
38 



594 



PLEURISY. 



but these circumstances do not afford any certainty that such is the case. In fact 
I have long been of opinion that some at least of the cases which pass under the 
name of pleurodyne, are really instances of what has been called dry pleurisy. 
You are aware perhaps that adhesions are very constantly found to exist between 
the lungs and the ribs in persons dead of pulmonary consumption. Such persons 
are liable to pains in the chest, beneath the clavicles, in the axilla, between the 
shoulders, at the upper part of the dorsal region: in short, in those situations 
where the adhesions are found after death most frequently and in the greatest 
number. The pains indicated, it may be presumed, the periods at which the 
slighter forms of circumscribed pleurisy, attended with no other effusion than that 
of coagulable lymph, took place. And it is probable that many cases of pleuro- 
dyne are really instances of the same kind of pleuritic inflammation. How often 
do we find, even when there are no tubercles in the lungs, firm adhesions between 
the pulmonary and costal pleurae, in the bodies of persons who were never known 
to have had any pectoral disease! The pain alone marks the inflammation in 
those cases ; adhesion presently ensues ; there is no fever perhaps, or none that 
attracts much notice; the pain soon subsides, and is soon forgotten; but the 
adhesion, the consequence of inflammation, remains: and this is a morbid con- 
dition which is neither revealed to the sense of hearing, nor in any other way. I 
am much disposed therefore to agree with Cruveilhier in thinking that "pleuro- 
dyne is nothing else (in many eases at least) than adhesive pleurisy." 

I need scarcely repeat the fact which has so many times before been mentioned 
in these lectures, viz., that the inflammation of membranous parts, and especially 
of serous membranes, is attended with much more pain than inflammation of 
parenchymatous parts. We cannot have a better example of it than is afforded 
in most cases of pneumonia. Most cases of pneumonia are accompanied in the 
beginning with a stitch in the side ; some cases are not. In those cases in which 
the stitch happens, the pleura also is inflamed to a certain degree, and the pain 
depends upon the coexistence of the pleurisy : they are cases of pleuro-pneumonia. 
In pure pneumonia, on the contrary, the pleurisy being wanting, the sharp pain 
is wanting also. 

The respiration in pleurisy, at its outset especially, and while there is still pain, 
is considerably embarrassed ; the movements of inspiration in particular are short, 
hurried, and often interrupted or jerking. And this depends evidently upon the 
pain, which forbids the free contraction of the muscles that dilate the thorax; and 
you may often observe that the dilatation is sensibly less on the affected side than 
on the other. Cruveilhier indeed denies this ; or rather he states that he has 
never observed it: but it certainly is not an uncommon phenomenon. I have 
noticed it, and drawn the attention of others to it, again and again. 

When effusion has taken place — that, one can easily understand, will be likely 
to aggravate the dyspnoea ; and it will aggravate it in a greater degree, or in a less, 
according to circumstances. Thus, if the other lung happens to be a diseased 
lung, then the compression of that which is on the side of the pleurisy will have 
a more injurious effect upon the breathing. The dyspnoea arising from the effu- 
sion and consequent pressure upon the lung will also be in proportion, first to the 
amount of the effusion ; and, secondly, to the rapidity with which it has taken 
place. When the effusion has been slow — or when it has long existed, and the 
case has become chronic — the circulation through the lung has had time to accom- 
modate itself to the altered condition of the parts, the disturbed equilibrium be- 
tween the quantity of air and the quantity of blood in the lung is restored, and 
the dyspnoea is consequently slight. 

But there are very singular exceptions, met with to all this." Andral states (and 
I have seen more than one instance confirmatory of his statement) that there are 
persons, with pleuritic effusion enough not merely to fill but to dilate that side of 
the chest on which it exists, (and you will observe that we cannot doubt about the 
presence of the effusion in such a case,) who appear nevertheless to be quite free 
from dyspnoea; and that, hot while they are at rest merely, for they talk, get up, 



PLEURISY. 



595 



walk about, even take long journeys, without their respiration becoming so short 
as to make them complain of it. Now this is conceivable enough in old and 
chronic cases ; but Andral further affirms that this absence of dyspnoea is not 
restricted to those cases in which the collection of fluid has taken place slowly ; 
but sometimes happens, even in patients in whom pleurisy has led to abundant 
effusion in a few days. He gives a case of this kind, in which the patient was 
not prevented by an enormous pleuritic effusion from carrying on, without fatigue, 
in the streets of Paris, his business as a carter. I remember having a butcher in 
the Middlesex Hospital in exactly the same predicament; and nothing could per- 
suade him that he was otherwise than well, and fit to go out; and out accordingly 
he went. Remember, therefore, that there are great varieties in this respect. In 
some patients the dyspnoea never ceases to be urgent from first to last; and these 
are apt to prove fatal cases. In others the respiration is very much impeded at 
first; then the difficulty of breathing diminishes; and at length it ceases long 
before the fluid is reabsorbed. In others again, by some unaccountable idiosyn- 
crasy, the respiration remains at all times very facile, both at the outset and during 
the progress of the disease. 

Cough is another of the ordinary symptoms of pleurisy. It does not occur in 
paroxysms. It is small, half-suppressed, ineffectual. In some few cases this 
symptom also is entirely absent, .even though the inflammation is intense, and the 
effusion into the pleura considerable. When cough does exist it is dry ; or it is 
accompanied by the expectoration of slight catarrh. If much frothy mucus should 
be expectorated, the pleurisy is complicated with bronchitis: if rust coloured sputa 
be brought up, it is complicated with pneumonia: and in each case other signs, 
proper respectively to those two diseases, will be present. 

A good deal has been said and written respecting the position which a patient 
assume who is labouring under pleurisy. The manner of the decubitus has 
even been regarded as one of the pathognomonic signs of the disease. Yet, 
strange to say, observers are much at variance with each other in respect to this 
so-called pathognomonic symptom. Some affirm that the patient lies on the 
side affected ; others that he can lie only on the sound side ; others again that he 
lies neither on the one side nor on the other ; or even that he lies indifferently in 
any posture. But this dispute is an exact counterpart of that celebrated quarrel 
which took place about the colour of the chameleon : " they all are right, and all 
are wrong." I believe that, if you narrowly inquire into the facts, they will be 
found to be somewhat as follows: — In the outset of the disease, while there is 
yet pain, the patient cannot lie on the affected side on account of the pain, which 
that position exasperates; he lies therefore on the sound side, or on his back; 
sometimes he is obliged to sit up. At a more advanced period of the disease, 
when the pain has ceased, and considerable effusion has taken place, he cannot 
lie on the sound side, because of dyspnoea: the dilatation of the chest on that side 
would be impeded by such a posture ; and what is more, the effusion, lying up- 
permost, would press upon the mediastinum, and so further tend to restrain the 
expansion of the sound lung. But he is no longer prevented by pain from lying 
on the diseased side, and consequently he does, in some instances, take that posi- 
tion : but more commonly still he lies in what Andral calls a diagonal posture; 
i. e., the patient is not on his back, nor on his side, but between the two ; on his 
back, we may say, but inclining towards the affected side. Again, however the 
fact may be explained, it is certain that there are some few persons who lie in- 
differently on the back or on either side without augmentation of the dyspnoea in 
any of these positions, though one side is choke-full of liquid. 

Now of the symptoms that we have hitherto been considering, the pain, the 
dyspnoea, the cough, the accommodation of position, there is not one which, taken 
alone, can be said to be strictly or absolutely pathognomonic ; or which indicates 
in a positive and certain manner the existence of pleurisy, or of pleuritic effusion. 
Yet when all, or several of them, occur together, they afford a degree of proba- 
bility on these points almost equivalent to certainty. There are yet some other, 
and more conclusive signs, which either in themselves, or taken in conjunction 



596 



PLEURISY.. 



with those already mentioned, render the diagnosis of pleurisy easy and sure. 
These signs are furnished by the size of the thorax on the affected side; by its 
form and motions ; and above all, as you will have anticipated, by percussion and 
auscultation. 

I have already stated that in some cases, that side of the chest which con- 
tains the effused fluid becomes evidently larger than the opposite side. The ribs 
and their cartilages present that position which they assume during a deep inspi- 
ration : the intercostal spaces are pushed outwards and brought up to the level of 
the ribs; and occasionally fluctuation may be perceived in those spaces, through 
the muscles. When these appearances are observable, no doubt (or scarcely a 
doubt) can remain concerning the nature of the disease. This dilatation of the 
thorax on the diseased side is more common in old chronic cases than in the earlier 
periods of acute pleurisy ; yet it may take place in a very short time. Andral 
declares that he has known it sometimes reach a great degree by the fourth or fifth 
day of the acute disease. You may satisfy yourselves that the side is dilated by 
measuring it with a string. Carry a string round the chest, upon a level with the 
extremity of the xyphoid cartilage, then fold it upon itself, and you will find that 
the half of it will more than encompass the sound moiety of the chest, and will 
not reach round the disease. The diseased side may measure an inch, or an inch 
and a half, or even sometimes two inches, more than the other. But this measure- 
ment by a string is seldom necessary. The eye takes a very accurate estimate of 
the comparative volume of the two sides; and the obliteration of th^ intercostal 
spaces can only be ascertained by seeing or feeling them. It is necessary to 
remember that, in most persons, the right side is naturally somewhat the larger 
of the two. 

I say when this dilatation is noticed, scarcely a doubt can exist of the true nature 
of the case. Some time ago I should have said no doubt: but having myself mis- 
taken such a case, and seen others mistake it, I introduce this slight qualification, 
although it is a thousand to one against another such instance occurring to puzzle 
or mislead the observer. My colleague Dr. Hawkins had a patient in the hospital, 
in whom this dilatation of one side of the chest was exceedingly well marked. It 
was the left side that was enlarged.; the heart was evidently pushed over to the 
right of the sternum. This is another circumstance strongly corroborating our 
conclusion in such cases. The intercostal spaces were effaced, and the whole of 
that side was perfectly dull on percussion. The poor fellow had a very unhealthy 
aspect; — and he had, some time before, suffered amputation of a leg, for what 
was understood to have been scrofulous disease of the knee-joint. It was not 
unnatural, therefore, that every one who saw him should have come to the conclu- 
sion that this was a case of empyema; of fluid, and most likely of pus, collected 
in the pleura, and very probably the result of the extension of scrofulous disease 
from the lungs. Under these circumstances, and inasmuch as his dyspnoea was 
not urgent, it was not thought right to take any steps for evacuating the presumed 
fluid. The case was pointed out to the pupils as a capital example of empyema. 
At length the patient died ; and when his body was examined we discovered — 
what think you ? not pus, nor serum, but a large red solid mass, in the centre of 
which, when it was divided, was still a red, but softer, pultaceous, half-fluid sub- 
stance. At first it was thought to be cancerous degeneration of the lung; but it 
was soon noticed that the solider part was arranged in concentric layers, like those 
which are often seen in aneurismal tumours ; and further research showed that 
the effusion had indeed once been liquid, for it consisted entirely of blood, which 
had coagulated in the manner I have just described. And the source of the blood 
was detected. A portion of two of the ribs had been destroyed by ulceration, 
and one of the intercostal arteries had thus been laid open. The lung was found 
uninjured, but totally empty of air, and pressed flat up against the mediastinum. 

No precaution could guard against such a source of fallacy ; and you are not 
likely ever to meet with just such another case : yet I have thought it sufficiently 
interesting to relate, in illustration of the subject immediately before us. 



PLEURISY. 



597 



It is unfortunate, as far as the diagnosis is concerned (but not in any other sense), 
that dilatation of the thorax is far from being a constant symptom, even in cases 
in which the effusion is very considerable. 

There is still a condition of the thorax to be described, which is the very oppo- 
site to this. When the effused fluid begins to be reabsorbed — and when some 
cause or other, generally the formation of adventitious membranes, prevents the 
lung from re-expanding, and approaching the ribs in proportion as the fluid is 
removed— then of course the ribs must sink in, and approach the lung, to prevent 
that void which would otherwise exist between the ribs and the lung. Conse- 
quently that side of the chest on which the fluid has existed becomes narrower 
than the sound side. And the actual difference between the two will be augmented 
by the circumstance that, in such cases, an amplification of the sound lung, and 
of the cavity in which it isiodged, a true compensatory hypertrophy, commonly 
takes place. 

This partial or general retraction of one side of the chest is not so much a sign 
of disease actually in progress, as of disease gone by; and it may exist without 
evident disturbance of the health of any kind. 

Persons who are thus affected have the appearance of being inclined towards 
the diseased side, even when they endeavour to hold themselves upright: and the 
deformity, for such it is, becomes manifest to the eye when the chest is uncovered. 
You see that the side is narrowed and shrunken. All its dimensions are contracted. 
It measures less, in circumference, by an inch or more, than the other side. The 
shoulder is depressed; the hypochondrium is tucked up ; and the ribs are drawn 
close together. A patient of mine, whose chest had been punctured (a remedial 
procedure to be spoken of presently), and who drew off daily, with a syphon, 
pus which did not otherwise find vent, had such difficulty at last in introducing 
the tube between his ribs, that excision of a piece of the bone was contemplated 
by the eminent surgeon who had performed the operation. The effect of the atmo- 
spheric pressure is sometimes so great as to crook the vertebral column, and pro- 
duce lateral curvature of the spine. This I have myself witnessed. And as one 
of the unseen walls of the cavity, viz., a part of the diaphragm, is carried perma- 
nently up under the ribs, so another of the unseen walls, the mediastinum, is liable 
to be influenced by the tendency to contraction. The heart which, when Xheleft 
pleura is distended, is apt to be thrust over, beyond the sternum on the right, may 
thus, when the right pleura is contracted, be dragged into the same position. In 
the former case, the dull sound given out by the diseased side when struck,^will 
transgress the mesial line, and encroach a little upon the healthy side: in the 
latter, the resonance yielded by the healthy will transgress the mesial line, and 
encroach a little upon the diseased side. 

The difference of the two sides is so striking, that, at first sight, an observer 
supposes it to be even greater than it is actually found to be by admeasurement. 
Yet Laennec tells us that he had met with this deformity in persons who were not 
themselves aware of its existence. But all such persons had suffered some long 
disease, which appeared to be situated chiefly in the thorax. 

The conditions I have just been describing are physical conditions; and the 
signs they furnish are physical signs. 1 have still to speak of the remaining phy- 
sical signs, which are also auscultatory signs. What I have already said upon 
this subject in the present lecture will, I trust, enable yoit almost to foresee the 
kind of information which these signs afford in actual practice. 

As soon as even a slight amount of effusion commences in the pleura, it is 
announced by a diminution of the hollow sound which percussion elicits in the 
healthy state. In proportion as the effusion becomes more considerable, the 
chest, when struck, gives a sound more and more dull. At first, this flat sound 
is rendered opposite the lowermost, depending part only of the cavity ; and this, 
as I showed you before, forms one ground of distinction between the dullness on 
percussion in pleurisy, and in pneumonia. However, at length, the effusion aug- 
menting, the dead flat sound may proceed from the whole of the affected side ; 



598 



PLEURISY. 



and this forms another ground of distinction ; for it is very seldom that the whole 
lung becomes so solid in pneumonia as to yield a uniform dead sound over the 
whole of one side of the chest. Either the dull sound is universal on one side, 
or it is not. If universal, it is not likely to be the result of solidification by pneu- 
monia; or, I may add, by tubercles : if not universal, the dull sound will (except 
in some rare cases), shift its place as the patient alters his posture. 

I may mention another ground of diagnosis, which may be of great assistance 
when the case is seen from the beginning. The dullness comes on much more 
quickly in pleurisy than in pneumonia. It has been noticed within twelve hours 
from the invasion of the disease. In living animals, a considerable quantity of 
serous effusion has often been very rapidly produced by injecting some slightly 
irritant matter into the cavity of the pleura. In pneumonia, the dullness is com- 
monly later in its appearance. The induration of the lung is gradual; and so is 
the pneumonic dullness on percussion: the effusion of serous fluid is early and 
rapid ; and so also is the coming on of the pleuritic dullness. Moreover, as 1 have 
just shown you, pleurisy may displace the mediastinum, and cause the whole 
sternum to give a dull sound. A hepatized lung will render one- half o\\\y of it dull. 

The intensity, or completeness too of the dull sound is generally greater in 
pleurisy than in pneumonia. In two days, or even in twenty-four hours the 
whole cavity of the pleura on one side may be filled quite full; and the whole of 
the corresponding surface of the chest, from its base to its summit, will yield a 
sound (to use one of Avenbrugger's strong expressions) tanquam percussifemoris. 
It is very uncommon for such total and universal mutile, as the French call it, to 
result from inflammation of the lung. 

Again, in the outset of the disease, while there is yet little or no effusion, but 
when the pain is acute, the vesicular breathing is heard more faintly and feebly 
on the painful side than on the other. On that side also the walls of the chest are 
less forcibly expanded. But percussion, when the pain will permit of its being 
practised, gives the same sound on each side. It is clear that the sharpness of 
the pain causes the patient instinctively to expand the chest on that side as little 
as possible; and consequently the quantity of air that penetrates the lung in a 
given time is diminished, and the respiratory murmur is feeble. 

As soon as effusion commences, the vesicular rustle is heard still less plainly 
on the affected side; and in proportion as the fluid increases, that rustle or mur- 
mur becomes more and more faint; and at the same time it becomes more distinct 
and noisy than natural — puerile, in fact — on the sound side. And while the 
respiratory murmur is disappearing on the diseased side, and the spongy lung is 
becoming empty of air from the pressure of the augmenting fluid, and the larger 
bronchi are surrounded by compressed lung and by incompressible liquid, the 
bronchial sounds begin to be heard, which I formerly described — the bronchial 
voice, the bronchial respiration. But the sounds are not exactly the same as those 
which are heard in pneumonia. They are modified by the nature of the sub- 
stances through which they pass. The voice, for example, is still bronchial, still 
the voice of a person talking into a tube : but it has a superadded character; it is 
trembling, quivering, thrilling, cracked, discordant. I strive in vain to convey to 
you by these epithets a notion of this remarkable modification of the voice. 
Laennec's happy similitudes may enable you to form a more exact conception of 
it. It is like (he says) the bleating of a goat; or, happier still, it resembles the 
voice of Punch. But when once you have heard the sound, you will never forget 
it again. I presume that this modification of bronchophony (for such it is, and 
such I would have you consider it), is caused by the rapid undulations communi- 
cated to the effused liquid by the vibrations of the bronchi and condensed pulmo- 
nary tissue. This sound is usually most distinctly heard near the inferior angle 
of the scapula, the patient being in a "sitting position. It disappears, or merges 
into pure and distant bronchophony, when the liquid exceeds a certain amount, 
so as to compress the bronchial tubes themselves, and to damp their vibration. 

I would have you recollect, therefore, that eegophony, which is the technical 



PLEURISY. 



599 



appellation of the sound I have just been describing (goat- voice), — aegophony is 
nothing more than a species or variety of bronchophony ; and the two run each 
into the other by such fine gradations, that it is sometimes difficult to say which 
it is we are listening to. When the quivering is strongly marked, we may be 
certain that it denotes effusion into the pleura ; when bronchophony only is heard, 
we cannot be sure, from that sound alone, whether there be indurated lung be- 
tween the ear and the bronchi ; or a liquid, and a portion of compressed and con- 
densed lung : but other phenomena complete the diagnosis. 

Do not forget that when any modification of the voice is heard, or thought to be 
heard, on the suspected side, the sound of the voice in the corresponding part of 
the other side of the chest must be ascertained also. It is only by a comparison 
of the two sides that we can come to any safe conclusion ; and that comparison 
becomes often a striking and most instructive contrast. 



LECTURE LIU. 

Pleurisy continued. Recapitulation of Symptoms; of Diagnostic Signs. 
Causes of Pleurisy. Pneumothorax ; its conditions, and Signs. Treatment 
of Pleurisy. Empyema. Paracentesis Thoracis. 

In the last lecture I enumerated the symptoms, general and physical, which are 
met with, more of them or fewer, in cases of acute pleurisy. I then considered 
them singly : it may be well to take a rapid recapitulatory view of them as they 
exist together or in succession, and compose the actual disease. 

The outset, then, of pleurisy is marked by sharp stabbing pain, most com- 
monly situated beneath one of the breasts, and preceded or accompanied by rigors. 
These two signs, the stitch and the shivering, are sufficient of themselves to awaken 
a strong suspicion that pleuritis has set in. At the same time there are usually a 
dry cough ; a dread of breathing ; a check or catch in the inspiration, which is 
curbed, so to speak, by the pain ; fever; often a comparatively feeble respiratory 
murmur on that side on which the pain is felt ; and the patient cannot lie on that 
side. If no liquid effusion takes place, these symptoms ordinarily disappear at 
the end of a few days, and the patient recovers. The case has been a case of dry 
pleurisy ; and the chances are much in favour of the lung having become perma- 
nently adherent to the ribs. 

I should have said, with respect to the fever, that at the outset of the pleurisy 
„ it is often high. And it was matter of observation long before the method of aus- 
cultation was thought of, as well as since, that in the acute period of the disease 
the pulse is remarkable for its hardness, and forms a contrast with the soft pulse 
of pneumonia, and with the small and contracted pulse of inflammation of the 
serous membranes of the abdomen. Indeed the older physicians laid great stress 
upon the quality of the pulse, in their endeavours to distinguish pleurisy from 
pneumonia. 

But to resume the description of the symptoms of pleuritis. Where effusion 
takes place (and it does so very early, so as to form a part of the complaint, just 
in the same sense in which expectoration forms a part of catarrh), the sound 
elicited by percussion becomes dull on the side on which the effusion exists. — 
While the effusion is moderate, the dullness shifts its place according to the pos- 
ture of the patient, and is heard only when the lowermost part of the chest is 
struck. But the fluid may soon increase so much as completely to fill the pleura ; 
and then the whole of that side is dull. Meanwhile the murmur of respiration 
becomes feeble and faint, and at length, as the effusion augments, ceases altoge- 
ther; while on the sound side it grows noisy and puerile. Tubular breathing, 
and that modification of the bronchial voice which medical men have agreed to 



600 



PLEURISY. 



call aegophony, become audible during the early periods of the effusion. .32 go- 
phony is heard, however, only so long as the quantity of liquid poured out ob- 
serves a specific limit. There must be a certain amount of effusion — and there 
must not be more than a certain amount. I have sometimes thought that the 
peculiar sound depended on the undulations produced in the' surface of the liquid, 
by the bronchial vibrations. It certainly is somehow connected with the presence 
of a stratum of liquid between the lung and the ear. When the lung is strongly 
compressed, and especially when the cavity is stretched and distended by the 
enclosed fluid, the side is necessarily motionless ; no tubular or other breathing 
can any longer be heard, or even occur : nor is the voice conducted, except per- 
haps very faintly, to the listening ear of the physician. 

When the effusion is great, that side of the thorax on which it has taken place 
becomes, often, more or less dilated; and I should add, that the integuments on 
the same side are frequently cedematous. The patient now cannot lie on the 
sound side: and the most common posture is that which is intermediate between 
the supine position and the lateral ; he lies towards, but not, in general, on, the 
affected side. 

I observed, in the last lecture, that this inability, after the effusion has reached 
a certain point, to lie on the sound side, might be accounted for in two ways. 
Partly it may be owing to the impediment which lying on the sound side, offers 
to that side's expansion. The muscles which dilate the healthy side have then 
to lift, as it were, the weight of the body, and are, some of them, pressed upon 
and encumbered in their action, by that posture. But the inability in question is 
chiefly attributable to another circumstance, viz., the pressure exercised by the 
effused fluid downwards, through the mediastinum, upon the only lung that is 
left to perform the function of breathing. Now disputes, or differences of Opinion, 
have arisen as to which of these two circumstances is the most efficient cause in 
this matter: and therefore it may not be amiss to provide you with the facts which 
prove that the last-mentioned cause is, in reality, the most operative— I mean the 
weight of the superincumbent liquid, in the supposed position, upon the medias- 
tinum and upon the healthy lung below it. This is shown by the fact, that 
patients, to whom the decubitus on the sound side had previously been impossi- 
ble, on account of dyspnoea, have been able to rest in that position immediately 
after the artificial evacuation of the fluid. Now in such a case the obstruction to 
the dilatation of the healthy side, produced by placing it under the weight of the 
body, would remain the same as before, or nearly so. A hospital patient of mine, 
named Coggs, could not breathe if he attempted to lie on his right side. His left 
pleura was distended by liquid effusion. I thought fit to have paracentesis per- 
formed : and the poor man was greatly delighted to find himself at once enabled 
by it to assume the posture which his weariness had long made him wish for, but 
which he had not been capable of enduring. We found, by percussion, that the 
diseased side was now filled with air; the compressed lung had not risen at all; 
so that the necessity for the free expansion of the sound side was just as great as 
before the operation. You may find a precisely similar consequence of the same 
operation related in the fifth volume of the Dublin Transactions. 

The oedema that is sometimes observed on the diseased side is more or less 
connected, probably, with the habitual position of the patient. 

There is yet another sign of pleuritic effusion, which, as it is very simple, and 
readily perceived by even the least instructed observer, is too valuable to be ne- 
glected. In most persons, one's open hand, laid flat upon the surface of the chest, 
feels the vibration or thrill which the voice occasions when the person speaks. 
Now in a case of pleurisy with effusion, you will generally find a remarkable 
contrast between the two sides in this respect : i.e., the thrill is strong and evident 
on the sound side, and not perceptible at all on the other. W^hereas, when the 
whole side is dull in consequence of solidity of the lung, the thrill is much aug- 
mented on that side. But this thrill is not always present in the healthy state, 
and then we can infer nothing from its absence on the diseased side. 



PLEURISY. 



601 



After a while, when the fever has ceased, the liquid begins to be reabsorbed: 
but as, in many cases, the lung is more or less bound down by adhesions, or 
overlaid by a membranous stratum of lymph, it cannot expand in proportion as 
the liquid is removed : and the necessary consequence is, that shrinking of the 
affected side in all its dimensions which I fully described yesterday. 

Let me now briefly re-state the points of distinction between pleuritic effusion 
and pneumonic consolidation, when the one or the other of these two morbid con- 
ditions is proved to exist by dullness on percussion, extending over the whole of 
one side of the chest. The question is one which frequently arises ; and it is one 
of much interest and importance. 

First, then, we distinguish these different conditions, having some physical 
signs in common, by their history. In pleurisy, sharp pain, and a dry cough, 
or perhaps no cough, precede the dullness : and we have not the crepitation, nor 
the rust-coloured sputa, which are antecedent to the dullness of pneumonia. 

We cannot, however, always learn the previous history of a given case. 

Secondly, a lung rendered solid by inflammation does not distend the cavity. 
Copious pleuritic effusion most frequently does. In the first case, therefore, we 
have not that separation of the ribs., that obliteration of the intercostal depressions, 
that protrusion of the corresponding hypochondrium, that mensurable enlargement 
of the side, that extension of the dull sound beyond the middle of the sternum, or 
that displacement of the heart, which are, some or all of them, apt to result from 
a collection of liquid in the pleura. 

Thirdly, the solid lung transmits the voice from the pervious bronchi to the 
surface of the thorax; and if any motion of the affected side remains, it transmits 
also the sound made by the passage of the air through them. These phenomena 
are wanting when the pleura is so stretched by its liquid contents as to make the 
side everywhere dull to percussion. 

Fourthly, the vibration of the thoracic parieles, caused by the patient's voice, 
is augmented by consolidation of the lung ; prevented when it is strongly com- 
pressed by imprisoned liquid. The increase of this thrill can be felt therefore in 
the one case; its diminution in the other. 

The simple test fails to be applicable when, from the feebleness, or the high 
pitch, of the person's voice, no thrill is perceptible on either side in the healthy 
state. 

Fifthly, a patient having one lung solid, is generally indifferent as to posture. 
A patient having one pleura quite full of liquid, lies (usually) on or towards that 
side ; and is distressed and suffers dyspnoea if he attempts to lie on the other. 

It is of more importance that we should inquire into the exciting causes of 
pleurisy than into those which give rise to pneumonia. They are more numerous 
and complicated, and have a more direct bearing upon the prognosis and treatment 
in the one case than in the other. I do not desire to refine too much ; and there- 
fore I shall restrict myself to those causes which are obvious, and which you are 
likely to meet with in practice. 

I merely say of exposure to cold, as an exciting cause of pleurisy, that it is a 
very common — the most common — cause. You know already all that I can Jell 
you of the circumstances that are likely to render that cause effectual in producing 
internal inflammations, and, among the rest, pleuritic inflammation. 

But pleurisy is often occasioned by mechanical violence ; or by the accidental 
extension of disease from other parts; and the course, and the event of the disease, 
are liable to be considerably modified by the nature of its cause in such cases. 

Pleurisy may be excited by the splintered ends of a broken rib ; and if the pul- 
monary pleura be wounded in that manner, air may get into the pleural cavity, 
as well as into the areolar tissue beneath the skin ; constituting the true and genu- 
ine emphysema of our forefathers. Pleurisy may be determined also by a pene- 
trating wound of the thorax;, or by a perforating ulcer of the pulmonary pleura, 
the extension of a tubercular excavation. In the one case air will enter from 



602 



PLEURISY. 



without, if the aperture be sufficiently large ; in the other, air will pass from the 
lung into the cavity of the pleura. In all of these cases of air finding its way into 
this serous sac while in a state of inflammation, the event of that inflammation is 
much more likely to be the effusion of pus, than when no communication exists 
between the inflamed membrane and the atmosphere. This I have mentioned, 
and offered some explanation of, before. But another very curious consequence 
results from the admission of the air, and its coexistence with puriform or other 
liquids in the sac of the pleura. New auscultatory signs arise, very easily appre- 
ciated, very instructive, and therefore very necessary for you to be acquainted 
with. 

You must know that when the pleura contains air alone, the patient is said to 
have pneumothorax ; and when (what is infinitely more common) the air is there 
in company with liquid, he is said to have pneumothorax with effusion. This 
is the name given to that condition of the chest by Laennec; and it serves its pur- 
pose sufficiently well. I shall take leave to employ the simple term pneumothorax, 
in speaking of either condition; whether there be liquid also in the pleural cavity 
or not. Pneumothorax, then, often proceeds from one or other of those causes 
of pleurisy just mentioned. It is sometimes produced by the operation of para- 
centesis thoracis ; by the opening made into the thorax by the trocar of the sur- 
geon, in order to let out its fluid contents ; in plain English, by tapping the chest. 
The modifications of sound that result are particularly curious. Of course the 
air occupies the higher portion of the cavity and the liquid the lower, in whatever 
position the patient may be placed. And this being the case, percussion will 
give a remarkably hollow sound when made upon the uppermost part, and a 
totally dull and flat sound when made upon the lowermost part: and the change 
from the hollow to the dull sound will often take place quite abruptly, so that you 
may trace out the exact level at which the surface of the effused liquid stands. 
And if you reverse the posture of the patient, the resonant and the dull sounds will 
interchange their respective places : the uppermost part always yielding theelear, 
and the undermost the flat sound. This is just what you would expect. The 
result of the experiment is the same whether you make it upon the human thorax, 
or upon a beer barrel. The resonant part, you are to observe, will be much more 
resonant than it would be in health — more resonant (you have always the other 
lung to test it by) than the corresponding portion of the opposite side of the chest 
—tympanitic, drum-like : for the air is not involved in spongy lung, but contained 
in a free space ; and the sound is not damped, as in a healthy chest it is damped 
somewhat, by the presence of the lung. Moreover no respiratory murmur can be 
heard where this tympanitic resonance occurs: nor can any thrill be felt. Now 
I say all this is no more than you must have foreseen. But the sounds detected 
in this new condition of things by the ear applied to the chest, as the patient 
breathes, or speaks, or coughs, you would not, I think, have anticipated. You 
hear then a sound which I must endeavour to describe in words, but which you 
will scarcely form a right conception of till you have heard it, and then all further 
verbal description will be needless. I can describe it by similitudes only. The 
patient's breathing is like the noise produced by blowing obliquely into an empty 
flask ; and so the French have given the sound the somewhat magnificent title of 
" amphoric resonance." I have heard, fifty times over, exactly the sound in 
question when I have been out shooting in a rough day, and the wind has blown 
sideways into the gun-barrel. It is a ringing metallic sound. When this is pre- 
sent during the breathing, the voice also has, even more strongly in general, this 
metallic character; and so has the cough ; and each of them is apt to be succeeded 
by a tinkling echo. The voice and cough resemble those of a person who speaks 
or coughs into a deep well : or with his head bent over an empty copper boiler. 
The same ringing quality is often heard when one speaks in a large vaulted room; 
or beneath the arch of a stone bridge. You may perhaps now have some idea of 
what these metallic sounds are. They are very singular: and they are perfectly 
(decisive (as far as my experience has gone) of the presence of air in a considerable 



PLEURISY. 



603 



cavity, within the thorax; which cavity mostly contains liquid also: and of the 
presence of air and liquid in the cavity of the pleura in particular. I do not know 
that the liquid is essential: I do not believe it is ; but commonly there is some 
liquid, and a good deal of air. Almost always too — but that is not indispensable 
— the cavity communicates with the externa! air, either through the walls of the 
chest, or through the bronchi. Neither is it necessary that the cavity should be 
in the pleura, for it may be in the lung: and when we come to speak of phthisis 
I shall point out the circumstances which will enable you to determine whether 
the sounds proceed from a tubercular cavity, or from the sac of the pleura. What 
you will please to remember is, that in actual practice, in ninety-nine cases out of 
a hundred, these sounds will be found to denote the presence of both air and liquid 
in the cavity of the pleura; and the probable existence of some passage of com- 
munication between that cavity and the external air : in a single word, they will 
reveal the existence of pneumothorax. The voice reverberates in the little cavern 
just as it does in a large empty room with a stone roof; and this is the best expla- 
nation I can give you of the phenomenon. Sometimes, as you are listening, 
especially if the patient has recently changed his posture, you will hear a sound 
just like that occasioned by dropping a pin's head into a glass vase, or into a metal 
basin; and to this sound the name of metallic tinkling has been given. It really 
often closely resembles the distant tinkling of a sheep-bell. This is supposed to 
result from the dropping of the liquid from the upper part of the cavity ; or some- 
times from the bursting of a bubble on the surface of the liquid during respiration. 
You may succeed now and then in hearing a species of the same metallic tinkling 
by applying the stethoscope over the stomach, when percussion has already taught 
you that it is distended with gas, and by getting the patient to swallow some drink 
in successive teaspoonfuls. 

Another auscultatory sound, arising out of the same condition, viz., the presence 
of both air and liquid in the cavity of the pleura, and known even as early as the 
time of Hippocrates, is rendered audible by succussion of the patient's body You 
lay your ear upon his side, and get him to give his body a sudden jerk or jog; or 
you get some one else to take him by the shoulders and shake him; and you hear 
the liquid splashing within : just as you hear it when you shake a cask that is 
neither full nor empty of water. This is an unequivocal indication of pneumo- 
thorax ; and demonstrates beyond a doubt that there are both air and liquid in the 
pleural sac ; for no sound would arise if there was liquid only. A moderate quan- 
tity of liquid will make a greater squash than a large quantity. Unequivocal I 
say it is, because one could scarcely be misled by the splashing which may some- 
times arise from wind and water mingling in the stomach. I wish that a patient, 
who was under my observation for some months last year in the Middlesex Hos- 
pital, and could produce this splashing noise at will, Were there now ; for he was 
not a little proud of his fatal gift, and I should have brought him down here to-day, 
and given you an opportunity of hearing this sound for yourselves, worth a dozen 
descriptions of it. 

It is surprising how long this stale of things within the thorax may last, with- 
out any great declension of the patient's general health and strength, even when 
the disease is (as it mostly is) incurable. Two men, patients of mine, both of 
whom had well-marked pneumothorax in connection with tubercular phthisis, 
remained in the hospital for several months ; till, in fact I could conscientiously 
keep them there no longer: and each of them went away in very tolerable plight. 
I was unable to trace them afterwards, for they returned to their homes, the one 
in Ireland, the other in the north of Scotland. 

You see, then, that the conditions of pleurisy, and the symptoms of those con- 
ditions, may be modified by its causes. All those causes that imply the intro- 
duction of air into the cavity of the pleura, imply also a more serious state of 
disease than results from most other causes. The perforation of the pleura, by 
the extension of a vomica, I have mentioned as one of those causes, But tubercles 
in the lungs are frequently, very frequently, the cause of pleurisy, when no such 



604 



PLEURISY. 



perforation has taken place. A tubercle, or a group of tubercles, approaches the 
surface of the lung, but does not break through. Generally the pleurisy so pro- 
duced is slight and partial, and ends in the formation of adhesions : it is dry 
pleurisy. And this very common occurrence of adhesions between the costal and 
pulmonary pleurae, in the course of tubercular disease of the lungs, is, in truth, 
one reason why perforation of the pleura, and pneumothorax from that cause, is 
comparatively so rare. The part where the perforation is likely to take place 
has generally, though not always, been secured and clouted, as it were, by pre- 
vious adhesion. So that even here we find that inflammation has a conservative 
tendency, and helps to postpone the fatal ending of the specific disease. 

Pleurisy may terminate in resolution and complete recovery ; or in adhesion, 
which is its next best termination, and which obtains for the patient, at the 
expense of some trifling embarrassment of his breathing, complete security for 
the future against the dangers of pleuritic effusion. Again, acute pleurisy may 
end in chronic disease of the pleural cavity : i. e., in a shrinking inwards of the 
walls of the chest, attended with total uselessness, or a very imperfect and limited 
use, of the corresponding lung. Lastly, pleurisy may terminate in death. It 
may cause effusion so copious, that the patient will die of actual suffocation, 
unless the fluid be removed by art. On the other hand, he may die worn out 
and exhausted by the disease, especially if it be attended with suppuration. In 
that case he will suffer hectic fever, and all its wasting and mournful accompani- 
ments; and death ultimately by asthenia. It is seldom that simple idiopathic 
pleurisy proves fatal. 

As the matter from a tubercular cavity may break in upon the pleural sac, and 
lead to the admission of air, and the establishment of pneumothorax; so the puri- 
form fluid which has resulted from inflammation of the pleura, and was for some 
time imprisoned in its sac, may also break out, and the result will still be the 
admission of air, and pneumothorax. This is not a very frequent result of pleu- 
risy, however. When it occurs, an abscess forms externally, generally in front 
of the chest; and either the abscess bursts, or it is opened hy the surgeon, and 
then it is found to communicate with the cavity of the pleura. 

Sometimes air is effused into the sac of the pleura, in consequence of the 
rupture of dilated air-cells on the surface of the lung: sometimes gas is generated 
there from the decomposition of effused liquids ; and in such cases the gas has a 
strong odour, like that of sulphuretted hydrogen: sometimes, again, gas appears 
to be secreted from the membrane itself. All these events are, however, uncom- 
mon. When air, from whatever source, is shut up in the cavity of the pleura, 
and goes on accumulating there, it will compress the lung, just as certainly and 
effectually as if there were a liquid extravasated. And such compression, if 
suddenly brought about, may cause speedy death by apncea : and this is more apt 
to occur from a puncture of the pulmonary pleura by the extremity of a fractured 
rib, than from any other cause. 

As to the treatment of pleurisy, you will have anticipated that in the outset of 
the disease we must have recourse to the lancet. I have stated, more than once, 
that blood-letting tells more, and is better borne, in inflammation of serous mem- 
branes, than in any other case. If you see the patient while the stitch in the 
side, and the restrained and cautious respiration are present, you will bleed him, 
in the upright posture, from a large orifice, until the pain is relieved, and he can 
draw a full breath again with ease and satisfaction; or until he is about to faint. 
And if the pain and catch in the breathing should return, and the pulse continue 
firm and hard, you will bleed again in the same way; or cover the painful side 
with leeches; or abstract blood by the cupping-glass and scarificator. It is best 
to bleed fearlessly at first; and in proportion as you do so, the chance will be 
diminished of a repetition of the blood-letting being needed. The blood, in pleu- 
ritis, is always deeply buffed and cupped. 

Tartar emetic, which is so useful when the mucous membrane of the air-pas- 



PLEURISY*. 



605 



sages is inflamed, is not adapted to inflammation of the pleura. On the other 
hand, mercury, from its well-known power to check the effusion of coagulable 
lymph, is especially indicated. Of course it is to be given with a view to its 
specific effect on the system ; i. e., in equal doses, repeated at frequent and equal 
intervals, and guarded by a small quantity of opium. And in very severe cases, 
or when the internal employment of mercury is in any way contra-indicated, re- 
course must be had to inunction of the linimentum hydrargyri, or of the strong 
mercurial ointment. 

By the early and vigorous adoption of these measures, the inflammation may 
generally be subdued in no long time. If, though the fever diminish, there still 
be pain in any part of the chest, leeches may be again applied, or the part may 
be covered with a blister. I do not think a blister does any good, — on the con- 
trary, it is likely, by the additional irritation it causes, to do harm — while the 
inflammation is yet recent and active. 

But though pain may have ceased, and no fever remains, and the patient is not 
conscious of much dyspnoea, there may be, and there often will be evidence, not 
to be mistaken, of effusion into the cavity of the pleura. Dullness, I mean, on 
percussion, bronchial respiration, aegophony ; and the object of our treatment is 
now to get rid of the fluid. We seek to do so by keeping the patient on low diet. 
The more (says Broussais^ with some quaintness), the more the patient eats, the 
sooner he will die. We pursue the same object by keeping his gums tender 
with mercury ; by applying blisters one after another to the affected side; and by 
purgatives, and diuretics. By keeping the vessels empty we facilitate as much as 
in us lies, the absorption of the liquid contents of the pleura. A very good form 
of diuretic for this state of matters is a combination of squills, digitalis, and mer- 
cury. Half a grain of digitalis, one grain of squills, and three or five grains of 
blue pill, repeated and continued according to the state of the mouth. 

Under this kind of treatment the effused fluid will often be completely removed ; 
and the chest restored to its former state. I last week dismissed a lad from the 
hospital in whom all this was accomplished. 

But in other cases, though the fever and the inflammation are at an end, and 
absorption of the liquid takes place, the parts within the thorax do not revert to 
their original condition. This we know by that shrinking of its dimensions on 
tne side affected, which was described in the last lecture. This shrinking and 
narrowing are the necessary consequence of the absorption of the liquid, unless 
the compressed lung dilates again in proportion as the fluid is taken up. In most 
cases of this kind the lung cannot rise ; being bound down by thick and firm false 
membranes: and then the deformity is irremediable, and lasts for life. If the lung 
is completely emptied of air, and enveloped by strong bands of lymph, so that it 
is permanently unable to admit air again — in that case, as the bony framework 
of the thorax can yield to a certain extent only, there will always remain, I pre- 
sume, some liquid in the pleural cavity. If, again, the lung recovers a part of its 
lost volume, and meets the contracting parietes of the chest, adhesion may take 
place: and the cavity of the pleura be obliterated by thick layers of false mem- 
brane. And other changes are apt to arise in the lymph which is adherent to the 
pleura in these cases of imperfect repair. Sometimes tubercles form in it. Some- 
times ossific matter is deposited. I siiow you a fine specimen of this kind of 
ossification of the pleura. There is yet another supposable case: the investing 
adventitious membrane may be thin and weak, and yielding; and though the lung 
may not expand to its full dimensions at first, it may gradually force its way 
against the binding power of the coagulable lymph, and then the external configu- 
ration of the chest may be restored, and the symmetry between the two sides 
return. That this sometimes takes place I cannot doubt: but I have only once 
met with a case in which the dwindling of the side was entirely recovered from. 
In May, 1834, 1 was asked to see a child four years old, who had had cough, and 
had wasted to mere skin and bone, afier scarlet fever. I found the whole of the 
right side of the chest perfectly dull on percussion, and no respiration could be 



606 



PLEURISY. 



heard on thai side. He was taken by his parents into the country, and I did not 
see him again for some weeks. He then had ceased to cough, and, in a great 
measure, had regained his strength ; but he presented, on the side which had been 
dull, the most marked and complete example I ever saw of the sinking in of the 
ribs, flattening and contraction of the chest, and depression of the shoulder, which 
denote bygone pleurisy and diminished size of the lung. About a year from the 
occurrence of the original disease his father brought him to my house, that I 
might see the change which had again taken place. The boy was plump and 
rosy, and in perfect health ; the right side of the chest was as full and round as 
the other ; the symmetry of the two sides was completely restored ; the breathing 
natural and perfect ; and the sound on percussion hollow. His father, to whom 
the former shrunk state of the side had been pointed out, told me that he had 
watched, with deep interest, the process of recovery, and that it had been very 
gradual. Whether after once having sunk in, the ribs ever quite return to their 
natural position in the adult subject, I do not know. I have never seen that 
happen. 

There are yet other cases in which the effusion continues and increases, and 
the side, instead of shrinking, enlarges ; the functions of the lung on that side are 
entirely abolished ; nay, the use of the remaining lung is greatly interfered with, 
by the pushing over of the mediastinum ; and the patient is in imminent danger of 
suffocation. In such cases, whether. the effusion has taken place rapidly or slowly 
— whether the disease has been acute or chronic pleurisy — we must relieve the 
oppressed lung by letting the fluid out — by tapping the thorax ; and the sooner 
that is done, when such a state of things exists, the better. 

The operation is not difficult, nor formidable; but a mistake in the diagnosis 
may be very formidable. I have heard of two instances, one in Scotland, and one 
in this town, in which the operation of paracentesis thoracis was determined on, 
to relieve the oppression caused by empyema: but the opening was made on the 
wrong side; and the patient in three minutes was, in each case, a corpse. There 
was effusion, which had already put a stop to the play of one lung; and upon air 
being admitted to the surface of the other, it collapsed also, and immediate suffo- 
cation took place. I do not mention these mishaps to deter you from performing 
the operation. They both took place some years ago. Such a mistake would 
be unpardonable now. But I mention them to show the necessity of our being 
sure of our ground before we proceed to open the thorax of a living person. A 
surgeon told me very recently that with the sanction, and at the suggestion, of a 
physician, who understands auscultation exceedingly well I believe, he passed a 
trocar into the chest of a patient; but no fluid followed, to the no small mortifica- 
tion of the physician. This proved to be a case of malignant disease of the lung ; 
and fluid was let out afterwards by puncturing the thorax in another place, and 
much relief afforded; although of course the disease proved ultimately fatal. The 
surgeon informed me that he had suspected the true nature of the case, from ob- 
serving a livid protrusion in front; which was in fact, the specific disease making 
its way through. 

You will take care, then, to survey the chest narrowly before you plunge a 
trocar into it. If you see by your eye, and ascertain by measurement, that one 
side is larger than the other ; if the intercostal depressions.be effaced on that side ; 
if the whole surface affords a dull sound when percussed ; if the side does not 
move at all, or scarcely moves during respiration; if no vibration can be felt on 
that side when the patient speaks; if no breathing can be heard in the correspond- 
ing lung ; if the heart be found beating in an unnatural place, down towards the 
left hypochondrium, or in the other direction on the right of the sternum ; and if, 
at the same time, the other side of the chest moves freely, sounds resonantly, com- 
municates a thrill to the hand while the patient converses, and is full of puerile 
respiration ; then you may be sure that the larger side is distended with fluid. 

But it does not follow that you should, therefore, open that side. The pro- 
priety of doing so will depend upon circumstances. 



PLEURISY. 



607 



In my judgment, that operation ought never to be performed unless the life of 
the patient is, or seems to be, in jeopardy, from the continued presence of the 
liquid within the thorax. 

Now life is plainly in jeopardy when the vital functions of the lungs, or of the 
heart, are greatly hindered ; when symptoms present themselves of approaching 
death by apncea, or by syncope. If we discover no cause for those symptoms, 
except the increasing pressure of liquid pent up in the pleura, we are warranted 
in ascribing them to such pressure, and bouud to act upon that persuasion. When- 
ever, with the physical signs of abundant effusion, we have great labour and 
distress of breathing; an anxious and livid aspect; a tendency to delirium — or 
extreme faintness, and a vanishing pulse — there is no time to be lost: it is our 
duty to propose and to urge the mechanical removal of the pressure which must 
else be fatal. 

Again, when the patient, without suffering much dyspnoea while he lies quiet, 
is yet evidently losing ground from day to day, and early death by asthenia appears 
to be inevitable, .without the operation ; and when all other means for getting rid 
of the imprisoned liquid have failed ; and when no other condition of disease, or 
of advanced age, exists to account tor the progressive sinking; then also, in my 
opinion, the patient should not be denied the chance which the operation may 
afford. 

Thirdly, whenever (no matter how we ascertain the fact) the effused liquid 
consists of pus, it should be let out. 

In either of these three predicaments, and in no other, should we be justified 
(as I think) in making an opening into the living thorax. 

But I wish to be understood as giving you simply the impression which my 
own experience has made upon my own mind. I know that some practitioners 
recommend the early employment of the trocar; while (they say) the false mem- 
branes, which are apt to prevent the compressed lung from expanding again, are 
yet tender and unorganized. But surely we should risk much, and gain nothing, 
by admitting air into the pleura while the inflammation <is still in progress. Most 
cases of mere pleurisy with effusion do well. The mortality from uncomplicated 
pleurisy is exceedingly small. It would, I fear, be vastly augmented if every 
patient having manifest effusion were to be tapped. The danger of the operation 
is this; — that it may, and probably will, induce suppuration, or cause "the effused 
liquid to become putrid. Generally the effusion consists of serous fluid, which 
is at length spontaneously re-absorbed ; the lung expands again, or the walls of the 
chest shrink inwards: and the ultimate state of such a patient is as good as it 
probably would have been after a successful tapping. 

To make assurance doubly sure, it is always right, before proceeding to the 
operation of paracentesis, to adopt theexpedient first suggested and used, I believe, 
by Dr. Thomas Davies, of trying the chest by means of a grooved needle ; making 
a tentative exploration of the nature of its contents in that manner. The passage 
of this little instrument — like the dismissal of a pilot balloon — affords information 
which is useful in guiding the particulars of the subsequent process. It not only 
ascertains that there really is liquid within the pleura, but it discovers the kind 
and quality, and exact place, of the liquid. If it be serous, it will flow readily 
along the groove, and trickle down the patient's side. If it be puriform and thick, 
it will not exude so freely, but a drop or two will probably be visible at the exter- 
nal orifice; and when the needle is withdrawn, its groove will be found to contain 
pus. In the former case it is possible that there may be no false membranes; in 
the latter they are likely to be thick. You would use a larger trocar to evacuate 
the thicker fluid. 

The puncture thus made is quite harmless; and inflicts very trifling pain. Dr. 
Davies gives this useful piece of advice in respect to the trocar, that its point should 
be sharp; for otherwise, after the serous membrane has been penetrated, if there 
happen to be thick tough layers of coagulable lymph, not very closely attached to 



608 



PLEURISY. 



the costal pleura, they may be driven before the instrument, and so the liquid will 
not be reached, but the operator will be perplexed and baffled. 

Connected with the operation itself there are some questions concerning which 
medical opinions and medical practice are not yet settled. I do not pretend to 
decide these questions: yet I cannot pass them by; I must point them out to 
you ; and I shall, at the same time, state what my own observation has suggested 
in regard to them. 

1. Should all the liquid be let out at once? 

Some say yes: some say no. If we appeal to experience on this point, we 
obtain no satisfactory answer. I have known patients get rapidly and perfectly 
well, after as complete an evacuation of the liquid as was possible. On the other 
hand, I have heard of speedy recovery when, by a sort of accident, very little had 
been withdrawn : enough to relieve the pressing distress; but much less than the 
operator intended. 

We must try the matter, therefore, by our reason. 

I think it very probable that when the serous membrane is stretched by the 
pressure of its contents, its natural absorbing power may be lessened. But we 
have no reason to suppose that the mere relief of this tension will often suffice to 
renew the process of absorption, and to enable the flattened lung to re-expand. 

The theoretic objection to the thorough emptying of the thorax in such cases 
is (I conceive), that the introduction of air is likely to be hurtful, by converting 
the adhesive into the suppurative form of inflammation, and by promoting decom- 
position of the extravasated fluids. No doubt there is this risk; but, in general, 
it cannot be avoided. Unless the lung freely rises at once, the liquid cannot all, 
nor even much of it, come out, without air getting in. Some attempts have indeed 
been made, of late, to draw the water into an exhausted bag, by the help of a pipe 
and stop-cocks. But it is obvious that, in most cases, very little can be so ab- 
stracted. The mere admission of air to the pleura does not necessarily create 
inflammation of the membrane. This we know from what happens sometimes 
in emphysema produced by a fractured rib. In the only instance of pure pneu- 
mothorax which I ever saw, the sac of the pleura had become half filled with air, 
through a very minute opening in the pulmonary membrane, communicating with 
the air-passages. There was no inflammation of the pleura in that case. Except 
that it was preternaturally dry, it seemed perfectly healthy. Neither does the 
access of air necessarily superinduce suppuration in the membrane already in- 
flamed. Certainly, if pus follows the passage of the instrument, as much should 
be removed as we can get. And, for my own part, I should take away as much 
as would come, if the inclosed liquid proved to be serous. 

2dly. Is the orifice to be healed up, or to be kept open? 

Here, also, practical men differ. I should say, if pus comes out, by all means 
keep the aperture open ; and inasmuch as detention of the pus would be injurious, 
and the depending point is difficult to hit, and the orifice is apt to clog, I would 
do more than leave it open : I would draw the puriform fluid off twice a day by a 
syphon. 

If serum is let out, by all means close and heal the wound. Then, if all goes 
on well, our object is achieved. But should the condition of the patient fail to 
improve ; should hectic fever, after a day or two, set in or even continue ; should 
much constitutional distress or disturbance arise; — under such circumstances I 
would re-open the wound. Theresas mere serum, or liquor sanguinis : there 
now is, in ail probability, puriform matter pent up in the pleura; and even stink- 
ing and poisonous gases. 

On six occasions I have myself witnessed the evacuation, by puncture, from the 
human pleura, of a clear transparent liquid. Some of the patients were under my 
own charge, some under the charge of others. Of these six patients one died the 
day after the operation ; I can scarcely say why. She was an extremely timid 
and susceptible young woman ; and I am inclined to attribute her death to the 
shock produced, by apprehension of the operation, upon her sensitive nervous 



PLEURISY. 



609 



system. Two others recovered forthwith, and perfectly. The wound presently 
healed in the three remaining cases also; but in one of the three it soon broke out 
again, and a quantity of healthy pus was discharged daily. After some time, the 
expedient of keeping the cavity free from accumulated pus by the use of a syphon 
was resorted to. Under this plan the discharge became gradually less and less, 
and at the end of many months it finally ceased. The patient has a contracted 
chest, but his general health is quite re-established. He was on the brink of suf- 
focation when the operation was performed. I have been told of a man who, for 
the last fifteen years, has had a similar thoracic fistula, and who has nevertheless, 
during nearly the whole of that period, been actively engaged in the various labours 
of a farm-servant. 

I have still two of the six patients to account for. They were both much 
relieved by the operation for a while ; but after a few days they again fell off ; and 
after many more days of gradual sinking and distress, they died. The cavity of 
the pleura contained, in both cases, much puriform liquid, and a quantity of most 
offensive gas, consisting in great part, as I judged from its odour, of sulphuretted 
hydrogen. I have since thought that both these patients would have had a much 
better chance for life, if this corrupt and corrupting mass had been duly removed. 

Again, I have twice seen pus let out, by the primary puncture of the chest. 
One of these two patients sunk, exhausted, some months after the opening, which 
never healed, was made. The empyema of the other had been occasioned by 
fracture of a rib. The discharge continued for a short time, then ceased, the ori- 
fice closed, and the lad got well. 

This constitutes the amount, or nearly so, of my personal experience of the 
operation of paracentesis thoracis. You will see, in the statement I have been 
making, the grounds of those opinions which I have formed and expressed respect- 
ing it. A full and final solution of the grave and difficult questions that it involves 
would require a much wider field of observation than any one individual is likely 
to command. Dr. Thomas Davies has published a tabular account of the several 
cases of operation which he had then superintended. In sixteen cases of empyema, 
so treated, there were twelve recoveries; that is, the operation was successful in 
three-fourths of the whole number of cases : a very encouraging result. In three 
of the less fortunate cases, the lung could not expand after the evacuation of the 
fluid, in consequence of the thickness of the false membranes covering it. 

The value of Dr. Davies' table would have been greater, if it had shown in 
each case the time, after the commencement of the disease, at which the operation 
was performed ; the symptoms that called for its performance ; the nature of the 
liquid evacuated ; and whether the orifice made by the trocar was closed or not. 

The quantity of liquid which the distended pleura is capable of holding is enor- 
mous. I have seen upwards of a gallon let out at once. Dr. Townsend mentions 
the case of a patient of Dr. Croker's, in Dublin, from whose left pleura Mr. 
Crampton drew off the almost incredible quantity of fourteen imperial pints of 
pus. Of course this could not have accumulated there without making injurious 
pressure in all directions: upon the ribs, upon the heart and mediastinum, upon 
the diaphragm, and the abdominal viscera beneath it. It is interesting to know 
with what rapidity the capacity of the diseased side of the thorax will, in favour- 
able cases, diminish. The same writer gives the history of a boy, 12 years old, 
in whom the circumference of the diseased side was sixteen inches and six lines, 
while that of the sound side was fourteen inches and one line. Nine days after 
the operation the circumference of the diseased side has decreased nearly three 
inches : it measured thirteen inches and nine lines ; that is, rather less than the 
circumference of the healthy side. The side had shrunk somewhat within its 
natural size. This is common in such cases. 

There is yet a third question of some importance. Whereabouts should the 
opening be made ? 

If any soft inelastic tumour has appeared, marking a tendency in the effused 
liquid to make its own way outwards, that tumour should be punctured without 
39 



610 



PLEURISY. 



loss of time ; for there will then be no chance of the reabsorption of the pus ; 
and if the swelling be left to itself, troublesome, burrowing sinuses will be apt to 
form in the thoracic and abdominal parietes. As we have no choice in such a 
case about the place where the aperture is to be made, authors have termed the 
operation the operation of necessity; and they distinguish the case in which the 
surgeon is at liberty to introduce his trocar whenever he pleases ; they say that 
then the operation of election takes place. Now the question is, what spot is the 
best for this operation of election ? 

If there be any part of the surface which is resonant on percussion, or which 
affords any sound of respiration, that part must be avoided. It is probable that 
the lung, in that place, is fastened by adhesions to the costal pleura. Of course 
you would not thrust in a trocar where you saw or felt that the heart was beating. 

The object to be kept in view is that of making the opening in the situation 
which will allow the most free and perfect vent for the liquid. The intercostal 
space between the sixth and seventh true ribs, where the digitations of the serratus 
major meet those of the obtiquus externus muscle, is the place usually recommended. 
Laennec prefers the space between the fifth and sixth ribs. He observes that, on 
the right side, an enlarged liver frequently reaches as high as the sixth, or even as» 
the fifth rib. When the diaphragm is pushed as high as this (and I believe that 
Dr. Edwin Harrison, who has paid much attention to this point, will tell you that 
it is often pushed up even higher) there is an obvious risk of penetrating it with 
the trocar. In fact, Laennec committed that error himself. After making an 
incision between the fifth and sixth ribs, he thrust the instrument, as he supposed, 
into the thorax ; and was a good deal surprised to find that no gush of liquid fol- 
lowed its introduction. The patient died ; and dissection showed that the trocar had 
entered the cavity of the abdomen after transfixing the diaphragm, which, having 
been forced upwards by a large liver, had contracted firm adhesions to the seventh 
rib. I have myself witnessed a similar mischance, on the other side of the chest. 
The integuments of the side were cedematous ; and it was thought that a little 
serum issued upon the passage of the grooved needle. The serum must have 
come from the infiltrated areolar tissue. No liquid was evacuated by the trocar. 
The patient died a day or two afterwards of peritonitis. The instrument had per- 
forated the diaphragm, and entered the spleen, which was unusually large. 

I am tempted to relate the particulars of one of the prosperous cases that I 
before briefly adverted to. It occurred in a lad of nineteen ; a patient of my col- 
league, Dr. Wilson. On his admission into the hospital he bore all the marks of 
copious effusion into the left pleura; the side enlarged and motionless, and dull on 
percussion ; the intercostal spaces tense, and even with the ribs ; the heart beating 
to the right of the sternum ; respiration puerile on the right side, inaudible on the 
left; urgent dyspnoea; a tendency to coma, marked by drowsiness and blueness 
of the cheeks and lips. In short, the boy was on the very verge of suffocation. 
He had been ill about a month ; and had been bled, and cupped, and brought under 
the specific influence of mercury. Dr. Wilson judiciously directed that the liquid 
should be let out. 

A grooved needle was first passed between the fifth and sixth ribs ; and some 
serum following the puncture, a trocar was then introduced by Mr. Tuson, and 
nine pints of a clear fluid were drawn off. During the operation the patient became 
faintish at times, and then the orifice of the canula was stopped for a moment by 
the finger. The immediate effect of the tapping was most interesting and grati- 
fying. Even while the liquid was flowing, the heart was observed gradually to 
move over from beneath the right mamma towards its natural situation; and his 
difficulty of breathing was signally relieved. At the beginning of the operation 
he respired fifty times in a minute; at its conclusion thirty-eight times only. A 
good deal of air entered while the liquid was escaping : and for some days after 
the operation a splashing sound was audible on succussion of the chest; and one 
part of that side was unnaturally resonant, when struck, and another part unnatu- 



PLEURISY. 



611 



rally dull ; and whatever was the posture of the patient, the hollow sound was 
uppermost, and the dull sound was undermost; and when he sat up and spoke, 
or coughed, a brazen resonance was heard by the ear applied to the scapular 
region. This lad got quite well, without the recurrence of a single bad symptom. 
He afterwards presented himself at the hospital ; and I understand that the left 
side was found to be in a very slight degree smaller than the right. 

The liquid evacuated in this case was clear and transparent. It separated, on 
cooling, into three parts : one of quite watery consistence, one more viscid, and 
a third which constituted a soft, transparent, jelly-like mass of fibrin. 

In this instance no injurious consequences resulted from the free admission of air. 

It may sometimes be necessary to puncture the cavity for mere pneumothorax : 
when, for instance, the pulmonary pleura has been pricked by a fractured rib, 
and air passes from the lung into the pleural sac faster than it can be absorbed; 
fast enough to compress the lung, and to threaten death by apnoea. The diagnosis 
of such a state cannot be difficult. The existence of the fracture, the tympanitic 
sound yielded by the chest on the injured side, the absence of respiratory murmur 
in the tympanitic part, and the increasing dyspnoea, all point to the same conclu- 
sion. Now a trocar of the smallest size — or even an acupunclure needle — may 
suffice to give vent to the imprisoned air, which will escape with an audible 
hissing noise. In some cases it must have existed in very large quantity, for the 
stream of issuing air has been strong enough to blow out a candle several times in 
succession; the flame being each time immediately re-lighted. 

The same necessity for puncturing the cavity of the pleura from without may 
arise in cases of pneumothorax depending on specific disease in the lungs : but 
we cannot regard the operation as curative in such cases. Its value is very dif- 
ferent from that which experience has shown to belong to it in empyema from 
acute or chronic (but simple) pleurisy. Yet if it saves life for the time, if it pre- 
vents impending suffocation, and relieves existing distress,, and postpones the fatal 
event, it is not without its value ; and it has many times been done, and been 
followed by very gratifying results ; but it has never, that I know of, been fol- 
lowed by entire recovery. Dr. Davies had superintended the operation in nine 
instances of pneumothorax with effusion : and all the patients died from tubercular 
complications. 

There are, indeed, on record examples of recovery after the operation, when 
pneumothorax had existed, and under very unpromising circumstances. I should 
have stated before, that as the pus, in empyema, sometimes finds its way out- 
wardly, penetrating between the ribs, and forming an external swelling, which, 
if not opened by the scalpel, will at length burst; so it also, sometimes, escapes 
by making a road into some part of the air-passages, and being expectorated. 
Now the operation of paracentesis, in such a ease, there being no tubercular dis- 
ease, has been successful. Le Bran relates an instance in which he operated for 
empyema, where " the injection of a small quantity of mel rosarum and barley- 
water through the wound excited coughing, and partof it was coughed up through 
the mouth, mixed with pus ;" thus clearly proving the existence of a fistulous 
passage through the lung ; notwithstanding which the patient recovered com- 
pletely. The effusion was probably circumscribed. But you will find other 
cases of a similar kind referred to by Dr. Townsend, in the Qyclopxdia of Prac- 
tical Medicine. 

This concludes what I have to say, not only of pleurisy, but also of pneumo- 
thorax, and of empyema, which are often treated of as separate and independent 
disorders. They are more frequently connected with pleurisy than with any 
other form of disease, and they are almost always consequences of disease or of 
injury. But I believe I have omitted nothing of importance in respect to either 
of them.* 

* [Typhoid P^eumostta. — A state of congestion, or of inflammation, more or less intense, 
of the lungs, accompanied by that impairment of the sensorial powers, and morbid condi- 
tion of the circulation and of the organism generally, which characterize the more grave 



612 



PLEURISY. 



forms of typhus fever, has repeatedly prevailed in different portions of the United States, 
as an epidemic, often of wide extent, and, in its earlier visitations, producing an amount 
of mortality truly appalling. 

The first notice we have of the appearance of this form of disease, remarks Dr. Dickson, 
(Essays on Pathology and Therapeutics, vol. i. 435), " was in the year 1806, in Medfield, a 
town of the State of Massachusetts, whence it spread gradually — extending itself, winter 
after winter, throughout New England, into Canada, and the Middle States, progressing 
from village to village, and from one portion of the country to another, until, in 1813, it 
had reached Philadelphia. In the winter of 1815 it first prevailed in South Carolina, and 
was then, and more widely in 1816, epidemic; since which time its ravages in this state 
have been slight. It continues to show itself, sporadically, everywhere, I believe, where it 
has once found footing. In South Carolina we scarcely pass a winter without meeting 
with instances of it, especially among the blacks." 

The disease is of frequent occurrence in other portions of the United States, and maybe 
considered, to a certain extent, as endemic in several localities. 

We are informed by Dr. Gibbes, (America?! Journal of the Medical Sciences, Oct., 1842,) 
that it prevails extensively during the winter months, on the rivers, swampy plantations, 
in the neighbourhood of Colombia, South Carolina, and destroys more negroes than all the 
other maladies combined to which they are ordinarily liable. 

According to Dr. Dickson, it has not been observed farther south than the State of Geor- 
gia, nor is it of very frequent occurrence beyond the latitude of Charleston. 

Typhus pneumonia, as it prevails in the United States, is very similar in character to, 
and is probably the same affection as that described by Sydenham, Huxham and others of 
the older writers as peripneumonia notha. Sauvages has very accurately portrayed the 
disease under the denomination of peripneumonia typhoides. An account is given by the 
late Dr. John Bard, of New York, of an epidemic that prevailed on Long Island, in the 
winter of 1749, which he terms a malignant pleurisy, that in all its essential features 
corresponds exactly with the disease under consideration; a similar affection is also no- 
ticed by Dr. Hugh Williamson, as prevailing in North Carolina in 1792. 

Typhoid pneumonia is described by Dr. Stokes as not uncommon in Ireland, while Dr. 
Burne, of the Westminster Hospital, mentions that a great number of cases of what he 
calls "the spotted fever," were brought into that institution in the year 1838. He describes 
the affection as "an adynamic or typhus fever, combined with a latent and dangerous 
pneumonia, and exhibiting on the surface a very regular and uniform spotted eruption — 
not petechia?." This is evidently the same disease as the typhus pneumonia of this country, 
which, when it first attracted attention, was so frequently attended with an eruption upon the 
skin, that it was very generally designated by the popular name of spotted fever. The erup- 
tion, however, soon ceased to attract attention; it was seldom observed as a phenomenon of 
the disease south of the Potomac, and even in the northern and middle portions of the 
United States, the eruption ceased early to present itself. 

Dr. Mackintosh, of Edinburgh, describes a form of pneumonic inflammation, attended by 
symptoms that are generally denominated typhoid, and which, in consequence, has obtained 
the name of pneumonia typhoides, as very prevalent among the British troops stationed in 
exposed situations along the coast, and, in large garrisons where the duty is severe. Dr. 
Mackintosh, however, objects to the adjunct typhoides, as expressing erroneous ideas of 
the pathological condition of the body; — and the objection is not without foundation — for 
although that peculiar form of pulmonary engorgement quickly followed by inflammation 
and hepatization, to which the term typhoid pneumonia has been applied, does very fre- 
quently occur in connection with genuine typhus, it is likewise a very common complication 
in certain seasons and localities of the bilious remittent fever, while it is also met with in 
cases of gastro-enteritis, of ambulent and erratic erysipelas, of diffuse cellular inflammation, 
and of other diseases by which the thoracic affection is more or less modified, and often 
completely masked; hence to denominate the pneumonic disease as essentially and invari- 
ably typhoid in its character is evidently a misnomer, and very liable to lead to serious 
errors in practice. 

In the United States the disease is known by various names, according to the predomi- 
nance of particular symptoms. In the more violent cases, the patient being suddenly 
.seized with a very severe chill, accompanied with marked coldness of the surface, it is, 
according to Dr. Gibbes, frequently denominated the cold plague. The head being almost 
invariably affected, before the pneumonic symptoms are developed, it is often called head 
pleurisy. In the autumn or spring when, in particular districts of country, it is frequently 
attended by the symptoms of ordinary bilious fevers, it is called bilious pleurisy. From the 
symptoms of prostration by which the disease is so generally attended throughout its whole 
course, and the rapidity with which the patient sinks in the more violent cases, the term 
typhoid pneumonia has become, however, the one by which it is most frequently designated. 

In its mode of attack, and the general symptoms by which typhoid pneumonia is ordina- 
rily attended, there is no uniformity. Usually, however, the disease is ushered in by a 
chill, which is often of great severity and of long continuance— the heat of the whole sur- 



PLEURISY. 



613 



face being to the touch much below the standard of health. The cold stage is not unfre- 
quently so intense as to destroy the patient before the slightest reaction occurs. Where 
the disease is violent in its attack, Dr. Gibbes states, that the patient may suddenly become 
cold and pulseless, lethargic, and often insensible without previous complaint; he has 
known instances in which the patient was found dead, or died within three or four hours 
after being apparently well. 

During the cold stage, the respiration is short and oppressed, and a pain on one or other 
side of the chest is generally complained of; pain of the head is also present in most cases ; 
and not unfrequently the patients experience severe pains in the back, limbs, and other 
parts of the body — similar occasionally to those of rheumatism. The muscular strength 
is greatly prostrated, and there is a sense of general uneasiness and great restlessness. 
After a period, longer or shorter in different cases, but usually protracted, reaction ensues, 
and the heat of the surface is restored — it is seldom, however, increased much above the 
ordinary standard of health. The heat is often unequally diffused over the surface — por- 
tions being decidedly hot while others are comparatively cool. Occasionally, the skin, 
becomes hot, dry and harsh, while, at other times, it is relaxed, cool, and clammy. The 
pulse, when reaction ensues, becomes somewhat fuller, and more quick and frequent, but 
in very few cases does it acquire any degree of tension, excepting, perhaps, when the 
disease attacks young subjects and those who retain some degree of vigour. Most com- 
monly the pulse is soft, or it yields to the slightest pressure. During the febrile s^tage, the 
pain, oppression of the chest, and difficulty of respiration are increased, and, very generally, a 
cough comes on within the first twenty-four hours, by which the pain in the thorax is greatly 
aggravated. When the cough is attended with expectoration, the pain in the side is con- 
siderably relieved, and the oppression of respiration diminished. When, however, the cough 
continues dry, or the expectoration is slight, all the more serious symptoms become aggra- 
vated. The matter expectorated is a thick, tenacious mucus, often tinged with blood, but 
at other times of an ash or dark-brown colour. The respiration besides being oppressed is 
usually hurried, and irregular — the patient's spirits are greatly depressed — he often utters 
deep and heavy sighs, and complains of a sense of weight, or of constriction at the prsecor- 
dia; he is often affected with nausea, and occasionally with vomiting. 

Dr. Mann (Med. Sketches, page 308), notices, as a common symptom of the disease, a 
remarkable pink-coloured suffusion over the whole face, distinct from the usual febrile red- 
ness of the cheeks — the face becoming, at the same time, puffed or bloated. This appearance 
is most conspicuous in individuals of a light complexion; it is present, also, upon the body, 
but to a less extent. In many cases it is not observed even on the face, or in a very slight 
degree and for a short period. 

The tongue, in the first period of the disease, is often clean but red, particularly at its 
edges ; in other cases, and perhaps most commonly, it is thickly coated with a yellowish 
mucus, which, in the progress of the disease, changes to a dark-brown — the tongue be- 
coming, at the same time, dry, hard, and rough — often chapped. Upon the separation of 
the crust, the tongue presents, not unfrequently, a bright-red colour, which colour occasion- 
ally pervades also the fauces. 

In many cases, the patient exhibits from the very commencement of the attack, particu- 
larly where there is much pain of the head, more or less delirium, and great restlessness. 

As the disease advances, the teeth and the whole interior of the mouth become coated 
with a dark-coloured sordes; the breathing becomes shorter and more oppressed — the 
strength more prostrated, the pulse smaller and weaker — the patient sinks into a state of 
low muttering delirium or of coma, more or less complete, and the fatal event takes place 
as in the ordinary cases of typhus fever. 

The duration of the disease is very variable. Death, as we have seen, may occur within 
a very few hours from the commencement of the attack. Dr. Mackintosh has seen the 
disease, in the strongest subjects, run its course to a fatal termination in from forty-eight to 
sixty hours; while Dr. Gibbes has known patients to be destroyed by it in from three to 
twenty hours. In other cases, the disease may continue for several days before a fatal 
event occurs. 

In cases where, under an appropriate treatment early commenced with, the nervous 
power is quickly aroused, the activity of the circulation is excited and a free action of the 
peripheral capillaries restored, according to Dr. Gibbes, the attack may be cut short, with- 
out the occurrence of any symptoms of pneumonic disease. 

When symptoms of pneumonra become developed, these will often yield to a proper 
treatment, within the first thirty-six or forty-eight hours, though they will occasionally con- 
tinue for six or seven days, or even longer. The pulse increasing in volume and in firm- 
ness, the surface becoming, throughout, warm, soft, and moist, the tongue cleaner and le.-s 
red, the delirium diminishing, the expectoration becoming more free and copious, the cough 
less frequent and annoying, the pain of the thorax less intense, the respiration more full and 
easy, and the occurrence of a quiet sleep, from which the patient awakes refreshed and 
with greater cheerfulness, are the certain indications of amendment — recovery, however, 



614 



PLEURISY. 



is in general very slow — the period of convalescence being protracted, while relapses 
readily occur from slight exposure or the least imprudence of any kind. 

Dr. Gibbes states, that he has frequently known patients who were convalescent and 
able to walk about, complaining, in fact, of nothing but debility, to " yield suddenly to a cold 
change of weather, and die in a few hours, or linger several days with pneumonic symp- 
toms." Symptoms that were before mild and favourable, will often become aggravated 
upon a change in the atmosphere to cold and damp. If a patient has been much enfeebled 
by a first attack, a second is very likely to prove fatal. 

In many cases of pneumonia typhoides, instead of a gradual decline of the symptoms 
of thoracic disease taking place, these cease suddenly, and a severe pain is immediately 
experienced in some other and perhaps remote part of the body, as in the region of the 
liver, in the bowels, or in the head, attended with the other symptoms of inflammation in 
these parts. According to Dr. Gibbes, when upon the cessation of the thoracic symptoms, a 
hemorrhage from the bowels ensues, it is generally critical — when inflammation of the 
brain or peritoneum takes place, the case usually terminates fatally. 

The foregoing is the description of pneumonia typhoides as it most frequently presents 
itself. In the different epidemical visitations of the disease, at different seasons, and in 
different localities, or even during the same periods and in the same places, it not unfre- 
quently, however, assumes a very different form. Thus, in some cases, the only symptoms 
which ihe patient exhibits are extreme prostration and wandering pains of the back, loins, 
shoulders or legs. In other cases, after a severe and protracted chill, the patient is seized 
with severe pain of the head and back, and great gastric distress — delirium soon sets in, 
which quickly gives place to coma, and death ensues within a few hours. 

"Occasionally," remarks Dr. Gibbes, " an acute pain in the back part of the eye, in the 
ears, or side of the neck, with stiffness of the muscles, is present. In severe cases the 
tonsils, the submaxillary and sublingual glands are swollen, with acute pain in swallowing; 
these are usually the worst cases." In a few instances the symptoms of genuine erysipelas 
present themselves on some portion of the skin, and invade successively almost every part 
of it. 

In these irregular forms of the disease, the symptoms of the thoracic affection are often 
very slight, or they may be entirely absent. There is usually, however, some sense of 
tightness about the chest, some difficulty of respiration, and a slight, occasional cough — 
with or without expectoration ; and it is remarked by Dr. Stokes, that the physical signs of 
pneumonia may frequently be detected in cases unattended with dyspnoea, pain, cough or 
expectoration. 

A very common form of the disease under consideration — and which at certain seasons, 
and in particular districts, is even more prevalent than that to which the appellation typhoid 
is ordinarily applied — is the one usually known as bilious pleurisy or bilious pneumonia. 

In this, the attack commences with symptoms differing but little from those which usually 
usher in an ordinary case of bilious remittent fever — there is, perhaps, in general, a more 
severe and protracted chill, and a sense of distress and oppression about the chest, which 
is not usually observed in the latter disease. Occasionally, the attack is preceded, for a day 
or two, by a sense of fullness and weight in the right hypochondrium, and, in a few cases, 
by symptoms of a dysenteric character. Very generally there is severe pain of the back and 
extremities, and often of the head also. Almost invariably, the attack is accompanied by an 
acute pain of the forehead — well-marked febrile symptoms, with, usually, decided exacerba- 
tions in the morning and remissions towards evening. — During the exacerbations the face 
is flushed, and as the skin, from the commencement of the disease is more or less tinged 
with bile, the mixture of red and yellow gives to the countenance a very peculiar, sickly 
aspect. The eyes are red and watery, the conjunctiva having often a deep yellow hue. In 
many instances, it is only after the fever has continued for several days that pain in the 
chest is complained of: this is sometimes very severe and acute, more commonly, however, 
it is obtuse — of an aching rather than of a lancinating character — there is, at the same 
time, a sense of weight and oppression of the chest, with more or less difficulty of respiration 
and cough. The cough is at first dry, and its repeated paroxysms cause an increase of the 
pain in the thorax and head. The expectorated matter is frothy and of a yellowish colour, 
often streaked with blood, and of variable consistence. The tongue is, at first, coated on 
its sides with a whitish mucus, while at the centre it is covered by a dark-yellow or brownish 
crust — the edges of the tongue are ordinarily of a decided red. As the disease advances, 
the tongue becomes dark-brown, dry, and hard. The pulse is usually small, frequent, and 
quick, with a slight degree of tension. 

There is always more or less gastric distress, and very commonly vomiting, the matter 
discharged from the stomach being often bile or a thick ropy mucus mixed with bile. In 
many cases the epigastrium is hot, and painful upon the slightest pressure. The urine is 
always of a deep yellow colour from the presence in it of the colouring matter of the bile. 

The stage of excitement in bilious pneumonia is ordinarily of short duration, and, unless 
the disease is arrested by an appropriate treatment, great muscular prostration speedily 
supervenes, and the same train, of symptoms ensue as in the typhoid form of the disease. 



PLEURISY. 



615 



In the affection we have described, under whatever form it may present itself, the period 
of convalescence is always slow, irregular, and for a long while imperfect. " Chronic he- 
patization, with or without hectic fever, or a lurking congestion, may continue for weeks; 
and although, under appropriate management, the disease may be ultimately removed, 
atrophy of the lungs, with or without ulcerative disease, is often established. In certain 
cases, months may elapse before the respiratory murmur is heard, and, in many instances, 
it is never re-established. On the other hand, it has been known to cease in a single day, 
on the supervention of an attack of gastritis or enteritis." (Dunglisori 's Practice of Medicine, 
vol. i. 313.) 

The principal exciting cause of pneumonia typhoides is unquestionably protracted ex- 
posure to a damp and cold atmosphere, while the predisposition to its attacks is promoted 
by all those causes which tend to reduce the vital energies of the system — as bodily or 
mental fatigue, intemperance, improper or deficient diet, insufficient clothing, mental dis- 
tress or anxiety, long watching, previous disease, &c. Nothing, remarks Dr. Mann, pre- 
disposes to its attack in so high a degree as an intemperate use of intoxicating drinks. The 
soldiers, says Dr. Mackintosh, were often seized with the disease who were exposed at 
night as sentinels — " instead of walking about they frequently stand shivering in their 
sentry boxes, the surface continues long chilled, and with a view to fortify themselves, and 
to produce warmth, they are in the habit of drinking ardent spirits in considerable quantity.'' 

It is a common complaint among the poor and labouring classes in many parts of this 
country, during the prevalence of long-continued cold and damp weather, such as frequently 
occurs during the spring and autumn, in the more northern states, as well as during the open 
winter of the middle states. In the south, according to Dr. Gibbes, it is rarely met with on 
highland plantations, and if at all, is confined to such negroes as are more or less exposed 
to work on low or wet ground. On the swamp plantations the disease is endemic. 

As we have already stated, the disease occasionally occurs as an epidemic, but generally, 
during seasons when the temperature of those districts in which it prevails is marked by 
sudden and considerable vicissitudes from heat to cold, and by extreme and long-continued 
moisture. 

Typhus pneumonia more frequently attacks males than females, and adults than chil- 
dren — this is a statement in which nearly all who have written upon the disease concur. 
The predisposition of adult males to its attacks, is very readily explained by the amount of 
exposure and fatigue to which they are usually subjected being much greater than that of 
females and children — and probably, also, from the fact that their habits, generally speak- 
ing, are much less temperate. The disease is not, however, confined to any age, nor are 
females and children entirely exempt from it, particularly when it prevails as an epidemic. 
It is usually, however, most severe in individuals over fifty years of age, and is very seldom 
seen in children under ten years. The negro race is peculiarly liable to its attacks. 

In the treatment of pneumonia typhoides much must necessarily be left to the judgment 
of the practitioner. In the selection of his remedies, more perhaps than in any other dis- 
ease, must he be guided by the particular character of the symptoms present in each case. 
It is all important that the true nature of the disease be carefully investigated in its earliest 
stages — it being then, in its ordinary form, readily controlled by an appropriate treatment, 
and, even when marked at its onset by symptoms of very considerable severity, it may often 
be arrested by prompt and judicious management. 

In this disease, Dr. Gibbes remarks, and a similar observation is made by others, if the 
cases are immediately attended to, it is found quite manageable, as much so as an ordinary 
catarrh; but when neglected for twelve or twenty-four hours, and the symptoms are at all 
aggravated, the patients are very apt to die." 

We shall often succeed, when the patient is seen during the first period of the attack, or 
during the cold stage, as it is not improperly termed, in rousing the nervous energy — pro- 
ducing a free and equable circulation, and a due degree of heat and moisture upon the sur- 
face, by resorting at once to moderate doses of opium, camphor, calomel, and ipecacuanha, 
in conjunction with the milder class of diffusible stimulants internally, and the application 
of heat and rubefacients externally. By this treatment, early and judiciously pursued, and 
carefully watched so as to prevent a state of over-excitement being produced by it, the en- 
gorgement of the lungs may often be prevented or removed, and a speedy restoration of 
health secured to the patient. 

In the more open form of the disease, known as bilious pneumonia, the early adminis- 
tration of an emetic will often be found beneficial. Richter states, that in the bilious form 
of the disease, emetics will often remove the pain and affection of the chest as by a charm, 
and Stoll makes the same observation (Ratio. Meden., i.). In the few cases Dr. Eberle had 
seen of bilious pneumonia, he states that the utility of emetics in its treatment was strik- 
ingly evinced. They in general, bring on an uniform diaphoresis, promote expectoration, 
and allay the pain in the thorax, often almost immediately. Dr. Dickson also remarks, 
that he has been much pleased with the effects of the early administration of an emetic, 
or an emetico-cathartic. A combination of ipecacuanha and calomel may be given, or the 
sulphate of magnesia dissolved in a strong infusion of seneka or serpentaria, with the addi- 



616 



PLEURISY. 



tion of twenty grains of ipecacuanha. Dr. Mann, likewise, speaks favourably of the effects 
of an emetic of ipecacuanha. In the more decidedly inflammatory cases, the emetic was 
not administered by him until after bleeding and cathartics had been employed; especially 
where the head or chest was affected with severe pain: — when after the occurrence of ex- 
pectoration 1 , this had become arrested from any cause, small emetics, he states, were found 
beneficial, and in many cases had to be frequently repeated. The emetico-cathartic or even 
the emetic alone, is, however, a remedy of very doubtful propriety in cases attended with 
early symptoms of prostration and extreme muscular debility. 

The propriety of blood letting in any of the forms of typhus pneumonia, has excited not 
a little controversy. By some practitioners, the use of the lancet is condemned in every 
case, as a remedy fraught with danger, from its liability to induce speedily a state of pros- 
tration from which the patient is with difficulty roused ; while others of equal celebrity insist 
upon the necessity of full and even repeated venesection — considering it to be an important, 
if not an indispensable remedy in the treatment of the form of pneumonia under conside- 
ration. This discrepancy of opinion is satisfactorily accounted for by the very different 
characters under which the disease presents itself in different localities, and at different 
periods — often, indeed, during the same epidemic visitation; south of the Potomac, we are 
informed by Professor Potter, that the disease is seldom so inflammatory as along the shores 
of New Jersey, Delaware, and Maryland; and the farther south, the more it is said to assume 
a middle typhoid complexion. In the winter epidemic of 1815-16, along the northern 
frontier of the United States, we are assured by Dr. Mann, that in many districts "the 
disease was highly inflammatory from its commencement to its final resolution," and that, 
u . it was as idle to administer stimulants for its cure, as it would have been to have poured 
oil on fire to extinguish the flame." " Its cure," he adds, " depended upon the assiduous 
administration of the antiphlogistic regimen : evacuants, expectorants, and diaphoretics, 
with the aid of blisters." 

It is very certain that in the ordinary cases of typhoid pneumonia, the use of the lancet 
will seldom be demanded, and in many, would be altogether inadmissible. Cases, it is 
true, will not unfrequently occur, in which the detraction of a moderate quantity of blood 
from the arm, during the early period of the febrile stage, will be productive of the best 
effects. General blood-letting, however, should always be resorted to with the utmost cau- 
tion — perhaps it would be better, in every instance where symptoms of a typhoid character 
early set in, and the loss of blood is considered advisable, to apply cups to the chest in 
preference to resorting to the lancet. In cases of bilious pneumonia, blood-letting will be 
much more frequently demanded than in the typhoid form of the disease; but even in these 
it should be resorted to only in the early period of the attack, and it is more safe to take 
away a sufficient amount at the first bleeding, than to trust to small and repeated bleedings. 
In the bilious form of the disease, when much pain or tenderness of the epigastrium is pre- 
sent, leeches or cups to this part are always proper, and will often be found to afford very 
decided relief. 

The bowels should be early evacuated by some mild but effective laxative — the best is 
unquestionably calomel in moderate doses, followed by castor oil or magnesia — active or 
watery purging should always be cautiously avoided. 

In the cases marked by early prostration, and extreme muscular debility, we should 
resort at once to moderately stimulating diaphoretics; of these, according to Dr. Dickson, 
camphor, nitrous ether, the carbonate and acetate of ammonia are the best; and they are 
rendered more beneficial by combining them with Dover's powder. "The efficacy of all 
these," he adds, "will be much aided by the pediluvium, and by the application of warm 
fomentations, poultices, and heat in various forms to the surface of the patient. Cata- 
plasms with mustard must be laid over the chest, if pain or dyspnoea is present, and applied 
also to the wrists and insteps. Ephspastics are also of use, by their double power as 
stimulants and revulsives: the back of the neck, if the head be affected, the sternum and 
the epigastric region, if the lungs or heart or stomach suffer, should be selected for- their 
application. There has been some dispute as to the preference due to the dry or moist 
form of heat, as the best to be resorted to in this disease. It is, I think, easy to decide. 
If the skin be dry, I prefer fomentations, or even the vapour-bath; if moist, I prefer bottles 
of hot water, heated bricks, bags of hot salt, chaff, &c. Sweating will in the greater number 
of cases, come on readily, but must be regulated. If too profuse, and kept up for too long 
a time, it may prove injurious and debilitating. You restrain it by substituting dry for 
moist applications, and removing some of the bed clothes, and changing cautiously the 
body linen of the patient; dry garments carefully and well-aired, being put on in the place 
of those moistened by the cutaneous discharge." 

In cases where a tendency to sinking is early evinced, Dr. Gibbes recommends small 
doses of calomel as a general excitant of the secretions, with camphor, opium, carbo- 
nate of ammonia, and free vesication. 

In nearly every form of the disease, whether typhoid, bilious, or more openly inflam- 
matory, the effects of small doses of calomel, combined with ipecacuanha and opium are 
spoken of as particularly beneficial. Large blisters over the chest will also, in most cases, 



PULMONARY HEMORRHAGE. 



617 



be found of the highest importance, from the very commencement of the attack. In obstinate 
cases, Dr. Mann directs them to be renewed daily until the pain of the chest is removed. 

Where the patient's strength rapidly fails, and he is sinking into that low typhoid condi- 
tion which marks the second period of the disease, stimulants must be freely resorted to: 
of these Dr. Dickson prefers " the volatile alkali in large doses, from five to ten grains 
every half hour or hour, with wine whey or brandy toddy; spts. nit. dulc, spts. of turpen- 
tine, the tincture of cantharides." " I can set," he remarks, " no limit to the administration 
of this class of remedies, but the excitement of a notable degree of reaction, which being 
observed, will guide you in the future quantities to be exhibited; taking care, however, that 
the patient shall not suffer by their timid or inefficient amount, nor be allowed to retrograde 
by any sudden subtraction of dose." 

"It is well to be reminded," observes the same writer, " that in this strange disease it is 
never permitted to despair of your patients, recoveries being in considerable number re- 
corded, from circumstances the most deplorable, and, indeed, to all reasonable anticipations, 
absolutely hopeless." 

During the whole period of convalescence the patient will require to be watched with 
care. — " You must abstract gradually from the amount of stimulants which have been given 
him, and substitute in their stead the more permanent tonics. Of these each practitioner 
has his favourite. Arsenic is preferred by many of the New England physicians, and is, 
according to Dr. Dickson, without doubt, highly serviceable." The muriate of iron is also 
spoken of as well adapted to this period of the disease— and is certainly preferable in all 
respects to the arsenic. Dr. Mann states, that the only stimulant employed by him in the 
convalescent state, was a mixture of spts. nit. dulc, and aqua ammonise; a teaspoonful of 
this proved a cordial and expectorant, at the termination of the disease, when repeated 
every two or three hours; as did, also, a mixture of equal parts of the camphorated tinc- 
ture of opium and antimonial wine, where the cough was troublesome. Other practitioners 
prefer, as a tonic, at the close of the disease and during the period of convalescence, the 
cinchona or the sulphate or muriate of quinia. Dr. Dickson gives the bark in infusion, 
combining it with serpentaria, adding to each dose a small proportion of carbonate of 
potass, and camphorated tincture of opium. The patient should be supplied with a light 
diet of nourishing and easily digested food — and should be guarded sedulously from the 
slightest amount of exposure to cold or damp, and should be guarded from sudden alterna- 
tions of temperature for a considerable time after recovery — he should to that end wear 
flannel next his skin, and adapt his clothing not only to the season, but to the temperature 
of each day and each portion of the day. — C.J 



LECTURE LIV. 

Pulmonary Hemorrhage ; its varieties ; its connection with pulmonary consump- 
tion, and ivitk disease of the heart. Pulmonary apoplexy. Prognosis in 
Hsemoptysis. Symptoms. Treatment. 

Having gone over the inflammatory affections of the organ of respiration ; 
having brought before you inflammation of the membrane which lines the air-pas- 
sages, or bronchitis ; inflammation of the membrane which invests the lungs, or 
pleurisy ; and inflammation of the ivhole substance of those organs, ox pneumonia ; 
I proceed next to the subject of pulmonary hemorrhage. 

You may remember that, in an early part of the course, I drew your attention 
to some general facts respecting internal hemorrhages. I showed you that the 
blood does sometimes proceed from visibly ruptured vessels, but that it is much 
oftener poured forth from unbroken surfaces, in the way of exhalation; and that 
hemorrhage of this kind takes place from the mucous membranes far more fre- 
quently than from any other natural surface of the body. I observed also that 
such hemorrhage is almost always preceded by congestion ; either by active con- 
gestion, which is less common, or by passive and mechanical, which is extremely 
common : and we speak, accordingly, of active and passive hemorrhage. Hemor- 
rhage is also sometimes primary, or idiopathic, and then constitutes the whole 
disease ; while at other times it is merely a symptom, direct or indirect, of some 
other disorder, in which case we call it secondary. 



618 



PULMONARY HEMORRHAGE. 



Now ill the lungs we find examples of all these varieties of internal bleeding ; but 
pulmonary hemorrhage is secondary much more often than it is primary. 

In speaking, therefore, of some forms of pulmonary haemorrhage, I must touch 
upon certain diseases of which the bleeding is a symptom : but I shall not go fur- 
ther into the consideration of those diseases at present, than may be necessary to 
elucidate the hemorrhage. Bleeding from the lungs is a thing of most fearful 
interest ; and it will be useful to take a general view of that phenomenon, whether 
it be a substantial disease in itself, or merely a sign of other pre-existing diseases. 

The blood, then, in pulmonary, as in all other hemorrhages, may issue through 
a breach in the walls of some considerable blood-vessel ; or it may proceed from 
innumerable points in the mucous membrane of the lungs, by the process of exhala- 
tion : and the latter mode of hemorrhage is much the more common of the two, 
although it is the popular belief that the " breaking a blood vessel in the lungs" is 
of very frequent occurrence. 

The particular vessels injured in the first class of cases, and the nature and 
origin of the breach made in their sides, are matters of infinite variety. Some- 
times the blood is extravasated through apertures, the results of a disorganizing 
process which has commenced in the coats of the vessels themselves; as when, 
for example, aneurisms of the thoracic aorta, or of its primary divisions, burst, 
and pour their contents into the air-tubes. Having pointed out this accidental and 
hopeless form of pulmonary hemorrhage, I shall postpone any further account of 
the disease that gives rise to it, to a future lecture. 

Sometimes, again, a large blood-vessel is laid open by the encroachment and 
extension of disease from contiguous structures. Here is represented (Carswell, 
fasc. vi. plate iii. fig. 5) the perforation of a large branch of the pulmonary artery, 
and of a neighbouring bronchial tube, by the extension of tubercular ulceration. 
The blood escaped so abundantly in this case, that the patient was dead in less 
than a quarter of an hour. And here I show you a preserved specimen of a similar 
opening made in the pulmonary vein. 

It will be necessary that I should anticipate somewhat ; and in order to include 
in one view all that relates to pulmonary hemorrhage, that I should speak cursorily 
of its connection with tubercular phthisis. No one here can be ignorant that in 
that terrible disease portions of the lung are liable to be hollowed out by the 
softening and expulsion of tubercular matter, into what are called vomicae. Now 
seeing that haemoptysis occurs very frequently in persons labouring under consump- 
tion, and that the expectoration of blood is often copious, and takes place when it 
is evident that there are tubercular excavations in the lung, it would be very natural 
for you to suppose that the bleeding in such cases proceeded from large vessels 
which had been laid open during the softening of the tubercles, or by the subse- 
quent extension of the ulcerating cavities. But in point of fact, this is very rarely 
the case. I shall explain to you hereafter how it happens that this hemorrhage 
from the larger vessels is generally prevented ; still it does sometimes happen. 

But in a far greater number of instances the blood in haemoptysis is exhaled 
from the mucous membrane that lines the air-passages. For when this surface is 
examined in the dead body, and immediately after the occurrence of pulmonary 
hemorrhage, it is very often found to be perfectly entire, from the commencement 
of the trachea to the remotest divisions of the bronchial tubes ; as far, at least, as 
minute dissection can follow them. The membrane in these cases is usually red, 
as in simple bronchitis; but it is sometimes pale, or with scarcely any traces of 
vascularity. The former of these appearances results from the continued tume- 
scence of the capillary vessels ; the latter is the consequence of their having been 
completely emptied of blood by the last hemorrhage. We shall meet with analo- 
gous conditions when we come to examine the hemorrhages that proceed from 
other mucous surfaces ; and especially from that of the alimentary canal. 

When blood is thus exhaled from the mucous membrane of the air-passages, 
the hemorrhage may be strictly primary or idiopathic, i. e., it may be independent 
of any discoverable alteration of texture, either in the mucous surface itself, or in 



PULMONARY HEMORRHAGE. 



619 



any other part which, by reason of some intelligible connection of structure or 
relation, seems capable of influencing the capillary circulation of the membrane. 
But the occurrence of pulmonary hemorrhage strictly idiopathic has been more 
frequently affirmed than proved. Active hemorrhage from the lungs is stated by 
systematic writers to be the hemorrhage of adolescence, as epistaxis is that of 
childhood. I believe, however, that idiopathic active hemorrhage from these 
organs is very rare indeed ; unless we may consider as such, certain forms of 
vicarious bleeding, which I shall presently advert to. Andral tells us that in one 
instance only, in which hemorrhage from the surface of the air-passages had been 
the immediate and apparently the sole cause of death, had he ever found the 
substance of the lungs free from tubercles, and perfectly healthy. He does not, 
however, state whether in this one instance the heart also was in its natural con- 
dition : an important omission, as we shall hereafter perceive. He relates, indeed, 
as an example, of idiopathic haemoptysis, the case of a young man who suffered 
profuse hemorrhage from the lungs on four several occasions, between the ages 
of twelve and eighteen, without any apparent detriment to his health, which 
remained excellent. It is consistent, however, with much experience to suppose 
that crude tubercles might have been scattered in the lungs of this person, and 
have sufficed, on the application of some exciting cause, to determine the hemor- 
rhage, although as yet their presence was not indicated by any other sign. Almost 
every systematic writer quotes, as an example of idiopathic hemorrhage from the 
lungs, the story of the Roman governor, mentioned by Pliny, who lived to the 
age of ninety, though he was afflicted with habitual haemoptysis. Now the fre- 
quent citation of this supposed instance is of itself a sufficient proof that sponta- 
neous pulmonary hemorrhage is far from being common. 

Cseteris paribus, the disposition to pulmonary hemorrhage is increased by what- 
ever tends to diminish the capacity of the thorax, and to compress the lungs, or 
the heart and great blood-vessels. The mechanical congestion thus produced may 
become a very intelligible cause of the exhalation of blood from the mucous mem- 
brane. And it is partly on this principle that we may account for the frequency 
of haemoptysis in persons with crooked spines ; in tailors, who sit continually in 
a stooping posture: in young women who lace their stays too tightly ; and even 
in those who labour under dropsy, or other cause of distension of the belly. 
Haemoptysis accompanying ascites has been known to cease at once upon the 
performance of the operation of tapping, and to recur upon the reaccumulation of 
the dropsical fluid ; and this is not on one occasion only, but so often and regu- 
larly as to preclude all notion of accidental coincidence. There can be little 
doubt, however, that in this class of cases, or at least in a vast majority of them, 
the haemoptysis is mainly to be ascribed to organic disease of the heart or of the 
lungs ; and that the pressure which precedes and determines the bleeding is simply 
a concurrent cause. 

If we cannot properly rank that pulmonary hemorrhage as idiopathic, which 
is constitutional and vicarious of some other natural or morbid discharge, — and 
most frequently of all of the menstrual discharge in females, — it may be consi- 
dered as forming a link of connection; as lying midway between secondary and 
primary hemorrhages. There are a great number of very curious and well- 
authenticated facts upon record concerning this singular form of hemorrhage by 
deviation. I will give you one history of the kind by way of sample ; it is related 
by Pinel, who held that there was no supplemental hemorrhage more common 
than the haemoptysis that is vicarious menstruation. 

A female, 58 years old, born of healthy and robust parents, of strong constitu- 
tion, of a sanguine and plethoric temperament, and of great sensibility, lived in 
the Salpetriere, and was therefore, under constant observation from the age of 14. 
She enjoyed excellent health till she was 16 years old. In her 16th year the 
menstrual discharge commenced without mishap or difficulty ; but this, hex first 
menstruation, was suddenly suppressed, in consequence of the fright and agitation 
produced by the sight of an epileptic patient in strong convulsions. From that 



620 



PULMONARY HEMORRHAGE. 



time the catamenia never reappeared, nor did any kind of discharge take place 
from the genital organs ; but at the next period, when regular menstruation ought 
again to have come on, the girl was attacked with violent haemoptysis. The 
hemorrhage was preceded by vague pains in the uterus and loins, and by other 
symptoms which frequently announce the catamenia. It lasted two days, during 
which time the girl expectorated nearly a quart of blood. With one interval of 
exception only, this female continued to menstruate through her lungs at each 
monthly period, from her 16th to her 58th year, i. e., during 42 years of her life. 
The coming on of the hemorrhage was sometimes a little accelerated by strong 
mental excitement; sometimes a little retarded by causes of a contrary nature. It 
was suspended during one whole year, without any serious impairment of the 
general health, or the occurrence of any other hemorrhage: during this interval, 
however, the patient suffered most severe headaches. Occasionally the haemo- 
ptysis was complicated with hsematemesis. The symptoms by which the pulmo- 
nary hemorrhage in this instance was generally preceded or accompanied were 
the following: — a sensation of weight and uneasiness in the loins and in the situa- 
tion of the uterus, soon followed by chilliness of the surface, general lassitude, 
and a feeling of oppression and heat in the chest, with some dyspnoea. The face 
became red, and she had intense headache. Then she began to have a distinct 
sensation of pricking, and of a sort of bubbling, in the trachea and about the com- 
mencement of the bronchi ; then followed sharp cough, and the expectoration of 
blood, often bright-coloured and frothy, sometimes of a darker hue. The duration 
of the haemoptysis was generally confined to a single day, and it never exceeded 
three days. It recurred with tolerable exactness at monthly periods; sometimes 
the interval was longer, and then the hemorrhage continued longer, but was less 
abundant; and upon the whole, about the same quantity of blood was lost on each 
occasion. This woman continued plump, and otherwise healthy, though liable 
to some thickness of the breath upon unusual exertion. 

Cases of this kind are not at all uncommon ; although the vicarious hemorrhage 
seldom persists so long and so steadily. They are not usually attended with any 
peril to life. 

It is, however, a melancholy truth, that the hemorrhage which takes place by 
exhalation from the mucous membrane of the air-passages, is dependent, in a very 
large proportion of instances, upon incurable disease. The hemorrhage is second- 
ary ; and the disease of which it is symptomatic is usually a fatal disease. And 
the complaint of which haemoptysis is by far the most frequently symptomatic, is 
tubercular phthisis. When the tubercles are found upon* dissection to be yet 
crude and entire, and no breach can be detected in the membrane, then no doubt 
can be entertained about the source and manner of the bleeding ; and even when 
cavities exist, especially if they are found to contain no blood, it is probable that, 
in most cases, the hemorrhage has had a similar origin. 

When haemoptysis is thus actually symptomatic of tubercular disease of the 
lungs, it is liable to considerable variety in regard to the period of its first occur- 
rence, and the symptoms by which it is succeeded. There are many persons in 
whom the first attack of haemoptysis precedes, even for years, the primary symp- 
toms of unequivocal phthisis. There are others in whom the first attack of 
haemoptysis is immediately followed by all the signs which announce the pre- 
sence of tubercles in the lungs. Many, again, do not spit blood until the tuber- 
cles have acquired a considerable degree of development, and the phthisical 
symptoms have been for some time clearly marked; and occasionally, in these 
cases, the first hemorrhage proves fatal. Lastly, it is far from being an uncom- 
mon thing" to see pulmonary consumption run its whole course, and terminate in 
death, without having been attended with any spitting of blood. 

Andral gives the following statement as the result of his own observation, 
in regard to the relative frequency of these several modes of connection between 
haemoptysis and consumption. 

Of the persons whom he had known to die of that disease, one in six never 



PULMONARY HEMORRHAGE. 



621 



spat blood at all. Three in six (or one half of the whole number) did not spit 
blood until the existence of tubercles in the lungs was already made certain by- 
unequivocal symptoms. In the remaining two-sixths the haemoptysis preceded 
the other symptoms of tubercular disease, and see?ned to mark the period of its 
commencement. 

By this comparative statement you will see how very frequently haemoptysis 
occurs as one of the symptoms connected with tubercular phthisis. Under this 
physician's observation it happened in five cases out of six. In the experience, 
however, of M. Louis, the proportion, though very large, is not quite so great as 
Andral found it. Among eighty-seven instances of consumption, there were fifty- 
seven, or four in every six, in which haemoptysis had been present. 

It has, however, been made a question, whether the spitting of blood which 
thus occurs in connection with tubercular phthisis, is always to be considered as 
indicative of the existence already of tubercles in the lungs; or whether it may 
not sometimes precede, and give occasion to, their formation in those organs. 
This question has evidently been suggested by those cases (constituting, accord- 
ing to Andral, one-third of all that happen) in which the ordinary signs of phthisis 
begin to manifest themselves immediately upon the occurrence of the first haemo- 
ptysis, or within a short time afterwards. Morton, who has noticed this kind of 
pulmonary hemorrhage, includes among his species of phthisis, the «« phthisis ab 
haemoptoe;" and Cullen held that spitting of blood was often the cause of pul- 
monary consumption. It is a very important question, and I shall revert to it 
again hereafter. 

Next to tubercular disorganization of the lungs, the most frequent source of 
pulmonary hemorrhage is to be found in organic disease of the heart. It has been 
stated by Chomel, Bouillaud, and others, both in this country and abroad, that the 
disease in these cases is most commonly situated in the right chambers of the 
heart. But certainly this is a mistake. The error has arisen from arguing upon 
erroneous analogies, instead of attending to matters of fact. However, the state- 
ment is just as little supported by reason as it is by the result of general experi- 
ence. The only alteration in the right cavities of the heart which we could 
suppose likely, a priori, to cause pulmonary congestion, and thereby haemoptysis, 
would be increased strength and thickness of their muscular parietes : hypertro- 
phy ; a morbid condition which is comparatively rare on that side of the heart, 
and which, perhaps, would not suffice for the production of haemoptysis, even if 
it did oftener exist. The direct effect, on the other hand, of any obstacle to the 
free passage of the blood in the right chambers of the heart, would be to gorge 
the liver, and the system of the vena portse; and to prevent the lungs from 
receiving their due proportion of blood. But any material obstruction existing in 
the left auricle or ventricle will impede the return of blood from the lungs, lead 
to its accumulation in those organs, give rise to mechanical congestion, and so 
dispose strongly to pulmonary hemorrhage. And, in point of fact, we find that 
haemoptysis is very frequently the result of disease in the left side of the heart; 
and this leads me to speak here of one very remarkable morbid condition of the 
lungs, which is often directly connected both with pulmonary hemorrhage and 
with cardiac disease ; though it is not always, or necessarily, associated with 
either. 

The morbid state to which I allude is far from being infrequent ; yet it had been 
scarcely noticed by or known to pathologists, until Laennec described it under the 
title of pulmonary apoplexy. It appears under two forms. In the one form we 
find an uncertain number of hard knobs, or compact masses, situated here and 
there in the substance of the lungs, chiefly in their lower lobes, and towards their 
posterior surface. Their size varies from that of -a marble to that of a hen's egg. 
When cut through they are seen to be very exactly circumscribed, the cut surface 
being more or less circular, of a uniform and very dark colour throughout, and 
exhibiting a strong contrast with the surrounding tissue. Careful examination 
shows that these masses aje composed of blood that has coagulated in the pulmo- 

4 



622 



PULMONARY HEMORRHAGE. 



nary vesicles. Occasionally the pulmonary substance seems broken down, or 
torn, by the extravasated blood ; and in these cases, perhaps, the resemblance 
between the injury done to the lung, and that which is inflicted on the substance 
of the brain in cerebral hemorrhage, is tolerably close. Generally, however, 
there is no such laceration of the pulmonary tiss ues j but one, or more, of the 
lobules of the lungs are gorged and crammed with blood, which has been poured 
out from the surface of the mucous membrane. These lobules, it is well known, 
have no direct communication with each other; but are isolated (except where 
they severally open into the bronchial tubes from which they spring) by a distinct 
investment of areolar tissue ; and it is to this peculiarity in their structure and 
disposition, that the exact circumscription of the dark-red indurated masses is to be 
attributed. 

In the other form of pulmonary apoplexy, there are fewer of these solid spots ; 
perhaps one only, large, diffused, occupying sometimes nearly the whole of one 
lobe, its limits obscurely defined, and its colour gradually deepening to the centre, 
which is obviously formed by little else than a black clot of blood. 

Now the principal symptom attending the formation of these masses is haemo- 
ptysis ; and the principal, though not the only cause is disease of the heart. The 
hemorrhage is often severe and copious in the first, or circumscribed form : some- 
times slight and scanty, but commonly slow, oozing, and persistent, in the second 
or uncircumscribed form. The heart disease is in its left chambers, and very 
often consists in contraction of the mitral orifice. No example of pulmonary 
apoplexy, or of pulmonary hemorrhage, even apparently dependent upon hyper- 
trophy of the right side of the heart, has ever fallen under my notice. 

In truth the morbid condition of the lungs which I am now speaking of, has 
been badly named. The application, by Laennec, of the term apoplexy to the 
kings was singularly unfortunate : for it suggests an analogy between two things, 
which, though resembling each other in the appearances which they leave behind 
them in the organ affected, are yet, essentially, unlike. I have shown you, in a 
previous part of the course, that cerebral hemorrhage depends almost always upon 
the giving way of a blood- vessel, in consequence of the morbid brittleness of tts 
coats : while what is called pulmonary apoplexy can very seldom indeed be so 
caused. The notions which I have been led to form upon this subject differ 
materially from those which you will find expressed in the works of almost every 
writer on pulmonary apoplexy. The opinions I entertain were stated several 
years ago, in some lectures which I was appointed to deliver before the College 
of Physicians ; and I have constantly been in the habit of mentioning them to the 
pupils of the Middlesex Hospital, and to my medical friends. It is a matter of 
satisfaction to me to find that they are esteemed to be correct by so sound a pa- 
thologist as Dr. Carswell, who has alluded to them in one of his fasciculi on the 
Elementary Forms of Disease. Laennec speaks of the pulmonary apoplexy, 
as if it were the cause of the haemoptysis. But this is surely a very incorrect 
view of the matter. The partial engorgement, and the haemoptysis, are not 
mutually connected with each other as cause and effect, but they are concurrent 
effects of the same cause ; of that cause which gives rise to the extravasation or 
exhalation of the blood in the first instance. A part of the blood so extravasated 
passes outwards by the trachea and mouth ; while a part is forced in the contrary 
direction, into the ultimate divisions of the bronchi, so as to fill and block up the 
whole tissue of a single lobule, or of a bunch of contiguous lobules, and thus 
arises the circumscribed variety. Andral conceives that the sanguine effusion 
takes place in the ultimate air-cells ; and he applies to this form of disease the term 
pneumo -hemorrhage, to distinguish it from ordinary haemoptysis, which he calls 
broncho- hemorrhage ; and this I believe to be the true pathology of the uncircum- 
scribed variety. But it seems to me vastly more probable than in the other form 
of the complaint the seat of the effusion is in one or more of the larger branches 
of the air tubes ; and that the blood, a part of it at least, is driven backwards into 
certain of the pulmonary lobules, by the convulsive efforts to respire which the 



PULMONARY HEMORRHAGE. 



623 



patient makes when threatened with suffocation by the copious explosion of 
blood, or by a paroxysm of cough and extreme dyspnoea : especially if the blood 
is poured out from the membrane while the chest is in the state of expiration. It 
is easy to understand how certain portions of the lungs, without undergoing any 
actual change of texture, may in this manner be so choked up, and crammed with 
blood, which afterwards coagulates, as to preclude any subsequent admission of 
air. 

This view of the formation of circumscribed pulmonary apoplexy affords an 
easy explanation of some of the phenomena attending it, which it would be diffi- 
cult to account for on any other supposition : I mean, first, the occurrence of 
several of the clots or masses of blood, in different, and sometimes in distant parts 
of the lung at the same time ; and secondly, the exact manner in which they are 
commonly bounded and limited to certain lobules. And if (as is sometimes, 
though seldom, the case), even the texture of the lung be lacerated, it is easier to 
conceive that this may happen in consequence of the violence of regurgitation 
during the struggle of impending suffocation, and that the mere impulsion of a 
thickened muscle at the centre of the circulation should be capable of driving the 
blood through the walls of an artery with sufficient force to tear and break down 
the substance of the lung around it. 

In the diffused or uncircumscribed form of pulmonary apoplexy, the congested 
lung is not relieved by a sudden and copious gush of hemorrhage, but the im- 
peded and stagnating blood oozes slowly through the vessels containing it into the 
neighbouring interstitial and vesicular tissues, clogs up a larger and larger space, 
and is partly expectorated in separate dark-red sputa, combined with a certain 
quantity of mucus. A similar condition of the lung sometimes occurs in purpura 
hemorrhagica, without any mechanical impediment to the passage of the blood 
into and through the heart. 

The belief that the dark-coloured, circumscribed spots seen in the lungs, and 
spoken of as pulmonary apoplexy, are often, if not always, produced in the manner 
I have just been describing, was suggested to me by the observation of a case, in 
which these appearances existed, and in which they certainly were so occasioned. 
I told you, when speaking of cynanche tonsillaris, that I had seen one person, 
and one only, die in consequence of that complaint ; and that his death was occa- 
sioned by the laying open of the lingual branch of the carotid artery in the progress 
of ulceration. The phenomena attending that patient's dissolution were of deep, 
though of painful interest. I described them to you before. He had been taken 
out of bed, and laid upon a table in the ward, in the middle of the night, in order 
that Mr. Mayo might more conveniently place a ligature upon the carotid. Sud- 
denly the bleeding burst forth afresh : and he expired, before our eyes, in the 
course of two minutes : not from syncope or exhaustion, but evidently suffocated. 
The blood entered and choked up the trachea, and he had not strength enough 
left to expel it by coughing. I felt his heart and the artery at his wrist pulsate 
firmly for some little time after the last attempt to dilate the chest had been made. 
This you know is what always happens when death takes place from the sudden 
denial of air to the lungs. • We found the upper surface of the glottis covered by a 
clot of blood. There was blood also in the windpipe ; and scattered through the 
substance of the lungs there were numerous hard, and dark, but not very large 
masses, precisely resembling those described by Laennec as constituting pulmonary 
apoplexy. This man had shown no symptoms of any pulmonary complaint; nor 
was there any morbid appearance in his lungs except those which resulted from the 
presence of the blood that had been poured into them through the trachea, and 
rammed home into some of the air-cells, in his convulsive attempts to breathe. All 
that I have observed since this case happened, has tended to confirm my belief, that 
what has been erected into a distinct form of disease, under the objectionable name 
of pulmonary apoplexy, is simply an accident of pulmonary hemorrhage. When 
haemoptysis has occurred, to any amount, in consumption, it is by no means un- 
common to find pulmonary apoplexy after death ; and Dr. Latham has mentioned 



624 



PULMONARY HEMORRHAGE. 



to me, in conversation, one remarkable instance of that disease, strongly corrobora- 
tive of the doctrine I have been endeavouring to support. A young female patient 
of his, labouring under confirmed phthisis, was attacked, for the first time, with 
haemoptysis. The bleeding was so profuse as to cause almost immediate death 
by suffocation. Her lungs were found riddled with small tuberculous cavities ; 
and each of these little cavities contained a little clot of blood. Surely it is more 
credible that the blood should have reached each cavity by regurgitation from the 
larger air-tubes, than that each should have been the seat of an independent hemor- 
rhage at the same moment. It is by a similar reflux of blood that the appearances 
are produced which characterize the circumscribed form of pulmonary apoplexy. 

Upon the whole, the occurrence of haemoptysis, considered in reference to 
the probable duration of life in those who are the subjects of it, is of melancholy 
omen. 

I have long arrived at this conclusion : — that if from any given number of per- 
sons who have been known to spit blood, we subtract those in whom that symptom 
was connected with irregularity in the uterine functions, there will remain but few 
in whom the haemoptysis did not depend upon disease, incurable and progressive 
in its nature, of the lungs, or of the heart ; and that if we still further subtract those 
persons in whom the hemorrhage was symptomatic of cardiac disease, there will 
be very few indeed left, in whose lungs the existence of tubercles may not be con- 
fidently predicated. 

Among these few may be reckoned persons who have suffered haemoptysis 
dependent upon the detachment and expulsion of "bronchial polypi;" and who 
exhibit no other indication of cardiac or of pulmonary disease. 

You will, of course, understand that I do not include in this estimate of haemo- 
ptysis as a prognostic symptom, those cases in which (as in simple bronchitis) 
the expectoration is merely streaked with blood : — nor those in which small quan- 
tities of blood are intimately combined and amalgamated with the bronchial mucus, 
and form the rust-coloured sputa so indicative of the presence of pneumonia: — 
nor those in which the hemorrhage is a consequence of mechanical injury to the 
chest. 

Of those individuals whom Andral had known to spit blood at some period or 
other of their lives, there was only one in five whom he did not also know to have 
tubercular phthisis. On the other hand, Louis states that for three years he asked 
all the patients who came before him, in the practice of a large hospital, and who 
were not affected with phthisis, whether they had ever spat blood ; and the answer 
was always in the negative, excepting only a few instances in which the patients 
had received violent blows upon the thorax ; and the cases of females in whom 
the menstrual discharge had been suddenly suppressed. 

The quantity of blood which is brought up in different cases of pulmonary 
hemorrhage, is extremely variable. Sometimes it is so copious and overwhelm- 
ing that the patient either dies suffocated, or he dies of syncope, outright: but 
this is not very common. Sometimes, on the other hand, a small quantity of blood 
finds its way into the mouth, the patient scarcely knows how. And between 
these two extremes there is every gradation in respect to quantity. 

" When blood is thrown out by the mouth (says Cullen), it is not always easy 
to determine from what internal part it proceeds ; whether from the internal sur- 
face of the mouth itself, from the fauces, or adjoining cavities of the nose, from 
the stomach, or from the lungs. It is, however, very necessary to distinguish 
the different cases." 

Now the diagnosis between hemorrhage from the lungs and hemorrhage from 
the stomach, in other words between haemoptysis and hsematemesis, I shall not 
enter upon, until I have described the latter disease. And the diagnosis between 
hemorrhage from the fauces or cavity of the mouth, and hemorrhage from the 
lungs, can never be very difficult, if once the doubt suggests itself, and the neces- 
sary examination of the mouth be made. And I would advise you not to omit 



PULMONARY HEMORRHAGE. 



625 



that inspection. I could tell you of cases in which the neglect of this simple pre- 
caution has led to needless activity of treatment, and to the ultimate discredit and 
disadvantage of the practitioner. Blood may ooze into the mouth from spongy 
gums, or drip from the posterior nasal orifices, and be at length spat out in con- 
siderable quantity. Etymologically speaking, these are cases of haemoptysis ; 
but theydo not constitute the particular disease or symptom to which alone nosolo- 
gists have agreed to restrict that term. The sources of the bleeding are manifest 
as soon as they are carefully looked for. 

Patients who are subject to haemoptysis generally know by experience when it 
is about to happen. It is frequently preceded by some uneasy feeling within the 
thorax — pain, or a sense of weight, or of heat or of pricking, beneath the sternum, 
with anxiety; and they tell you that they taste the blood in their mouths before 
it comes up, L e., they perceive a saltish taste; and just before the blood appears, 
a tickling sensation is experienced about the top of the larynx. To relieve this 
sensation, the patient coughs or hawks a little, and a certain quantity of frothy 
and florid blood is expectorated. 

In a person disposed to pulmonary hemorrhage, the bleeding may be deter- 
mined by a variety of causes ; which ought to be pointed out to him, in order that 
he may avoid them. Any thing which hurries the circulation will, of course, 
have a tendency to excite the hemorrhage. Straining of any, kind ; great efforts 
of the body ; active exercise; much talking; and more especially public speaking, 
or singing, or playing on wind instruments. A diminution in the superincumbent 
weight of the atmosphere is supposed to be, in some cases, sufficient to bring on 
haemoptysis ; and blood is said to have been forced even from sound lungs, ia 
persons who have ascended very high mountains, where the atmosphere is rare, 
and where the pressure upon the surface of the body is sensibly lessened. Per- 
haps the labour of the ascent may have shared in the production of the hemor- 
rhage; for I am not aware that any such effect has ever occurred to persons who 
have much more rapidly reached a very great altitude in balloons. 

Auscultation and percussion do not stand us in much stead in cases of haemo- 
ptysis, so far as that symptom itself is concerned. Indeed, if they were capable 
of affording us information, it would in most cases be superfluous ; for we see the 
blood, and we can generally satisfy ourselves that it comes from the lungs. 

But pulmonary hemorrhage may occur without haemoptysis. In what is called 
pulmonary apoplexy there is extravasation of blood : and it is not always attended 
with the expulsion of a portion of the extravasated fluid through the mouth. Laca- 
nec and others pretend to say, that when there is blood in the bronchi, they can 
distinguish, by the peculiar character of the crepitation to which it gives rise, that 
it is blood, and not mucus ; that the bubbles, passing through a thinner liquid, are 
larger, and break oftener, than those produced by the passage of air through viscid 
mucus. This distinction is too subtle for me. If, indeed, there has been haemo- 
ptysis, and especially if the haemoptysis has been sudden and copious, and if, after 
it, you hear large crepitation in one or more isolated parts of the lung, it will be 
reasonable to conclude that the air-tubes contain blood in those parts. Those 
lobules that are plugged up with blood, to the entire exclusion of air, will not, of 
course, be the seat of any sound during respiration ; but this limited absence of 
sound will be scarcely appreciable unless the infarcted portion lies near the sur- 
face of the lung. Around the spot thus rendered solid the sound of crepitation 
may be audible. 

Yet, although the method of auscultation furnishes but little help towards the 
detection of pulmonary hemorrhage, it will often afford us most precise and valuable 
information respecting the disease of which the hemorrhage is a consequence, and 
an index. Thus, it will frequently teach us, with absolute certainty, that the 
heart is diseased, or that the lungs are occupied by tubercles. The precise sounds, 
or deficiencies of sound, which supply the key to this knowledge, I shall describe 
when I come to those disorders. 

Whatever may be the source and organic cause of the haemoptysis, the bleeding 
40 



626 



PULMONARY HEMORRHAGE. 



should be stopped as soon as possible : not, however, merely by suppressing it, 
but by relieving the necessity on which it depends. The longer it is suffered to 
continue, the more likely is it to add to the damage which already, in too many 
cases, exists in the lungs. If it leads to the formation of blocks of pulmonary 
apoplexy, the portions of lung so filled up are rendered useless for a long period, 
and probably for ever. Now as in most cases the hemorrhage is a hemorrhage 
by exhalation, and depends upon congestion, active or mechanical, we shall stay 
the hemorrhage if we remove the congestion. 

The congestion may be either mechanical or active when it results from the pre- 
sence of tubercles in the lungs; it is almost always mechanical when it depends 
upon disease of the heart. The tubercles may press upon the blood-vessels, and 
so lead to mechanical engorgement ; or ihey may provoke by their presence an 
active determination of blood to those organs, just as we know that they often 
provoke inflammation, which is congestion and something more; and just as any 
foreign body lodged in the lung may cause either the one or the other of these 
conditions. 

Frequently there is a distinct febrile movement accompanying the hemorrhage : 
the heart beats with increased force and frequency, the cheeks are flushed, and 
the skin is hot; sometimes the pulse is quite hard, and full, and bounding, and 
people speak of such a pulse as a hemorrhagic pulse. Now I mentioned in a 
former part of the course, that hemorrhage occurring under such circumstances as 
these often works its own cure; but it is better, when an organ so vital and im- 
portant as the lung is the seat of the effusion of blood, that we should cure the 
bleeding than_that it should cure itself — that we should diminish the congestion 
with which it is linked, through the safer channel afforded by the veins of the 
arm. The patient is to be surrounded with cool fresh air. His head and shoulders 
should be elevated. He should be restricted to the most meagre diet; and be 
forbidden to exert himself, or to speak more than is absolutely necessary. His 
bowels should be freely purged, in the first instance, and then kepi lax and open, 
both with the view of deriving (as it is called) from the thorax, and of preventing 
costiveness and straining. And, in conjunction with these measures, he should 
lose blood from the arm. The amount and the repetition of the bleeding must be 
determined by the circumstances of the case, i. e., by the cessation or continuance 
of the hemorrhage, and especially by the condition of the pulse. It would be idle 
to attempt to lay down precise rules on this matter. We do not bleed, however, 
so resolutely and perseveringly in haemoptysis as we are often obliged to do in 
acute inflammation. 

A prejudice has been taken (such, at least, I think it) against local blood-letting 
in pulmonary hemorrhage. Inasmuch as leeches applied to the groins in ame- 
norrhoea appear sometimes to restore the catamenia, so they have been thought 
likely, when applied over Ihe surface of the chest, to attract the blood somehow 
to that part of the body, and even to cause hemorrhage when none before existed: 
Now I have so many times taken blood from some part or other of the exterior 
of the thorax by leeches, or cupping-glasses, without observing any such effect, 
of causing haemoptysis, or of increasing it while already present, that I cannot 
help considering the objection rather a fanciful one. 

When the fever and congestion are abated ; or when there has been no consti- 
tutional disturbance, and the hemorrhage has shown a passive character from the 
beginning, and when a continuance of it, so far from being curative in its nature, 
is likely to be injurious ; then we are to employ those remedies which have been 
found efficacious in restraining and suppressing hemorrhages. 

Now of the substances which are held to possess more or less of a specific 
virtue, when taken internally, in arresting the efflux of blood, the sugar of lead, 
the plumbi acetas, enjoys in this country the highest reputation. And it certainly 
is a very serviceable remedy. Dr. Paris speaks of it as one of the most valuable 
resources of physic : and says that in respect to its power over internal hemor- 
rhage there is nothing simile aut secundum. He states also that its use is equally 



PULMONARY HEMORRHAGE. 



627 



safe and manageable. There is, in fact, no doubt of its efficacy : but most other 
writers use very cautious language in recommending its employment. Physicians 
have been deterred from giving it by the fear of its poisonous qualities; by the 
dread of producing the disease called colica pictonum. Cullen observes, that the 
preparations of lead are certainly powerful in controlling hemorrhage, but that 
they are otherwise of a character so pernicious as to forbid their use except in 
cases of the utmost danger. Of late years this drug has usually been adminis- 
tered in small doses, and guarded by opium ; and it is to this combination that 
Dr. Paris refers when he declares it to be a safe and manageable remedy. More 
recently, however, a statement has been made by Dr. A. T. Thomson, which 
must be considered of much importance if further experience shall show it to be 
well founded. He was led, it seems, by some accidental circumstance, to sus- 
pect that lead acted as a poison upon the animal body, only in the shape of its 
carbonate. And the result of a series of experiments upon brutes satisfied him 
of the correctness of this notion. He holds, that when the acetate of lead pro- 
duces the well-known symptoms of the painter's colic, it does so in consequence 
of its being somehow converted, afier its reception into the body, into the car- 
bonate: that this conversion may be obviated by a very simple expedient; and 
that the remedy may then be given with perfect safety in large and efficient doses. 
The expedient is merely that of administering the lead in draughts containing 
some dilute acetic acid, which prevents the decomposition of the acetaie by any 
carbonic acid that happens to be present in the intestinal canal. In this way he 
tells me he has given as much as fifteen grains daily for ten days together, with- 
out any inconvenience, and with most excellent effect upon the hemorrhage. I 
have often exhibited lead in this manner ; and I have never known it to give rise 
to any unpleasant consequences. At any rate this method of administering it 
deserves further and careful inquiry.* 

In slight cases of haemoptysis, the mineral acids, with or without alum, are 
often sufficient or, if there be feverishness, the saline draught with nitre and 
digitalis. Of the numberless other drugs which have been vaunted as specific in 
hemorrhage I have very little personal experience ; at least in pulmonary hemor- 
rhage. In certain other forms of internal' bleeding there are some of them that 
are worth trying. But in haemoptysis there are none I can venture to recommend 
but such as I have now mentioned. You may sometimes be urged to give a 
celebrated quack medicine — Ruspinfs styptic, which has obtained a high repute, 
and sells at a high price. This nostrum seems for a long while to have baffled 
analysis. The late Dr. Wollaston told Dr. Maton that it contained no- metallic 
substance ; Dr. Thomson has since announced that it mainly consists- of a solution 
of gallic acid in alcohol diluted with rose-water. But I believe that all the reme- 
dial agents which contain gallic acid are more effectual in another form of internal 
hemorrhage, to be considered hereafter. 

Of mercury, as a remedy for pulmonary hemorrhage, I have already mentioned 
both my own insufficient experience, and the very favourable report of some ex- 
cellent judges who have much employed it. 

* [We have also administered acetate of lead very extensively in cases of hsemoptysis, 
and in tolerably large doses, continued, at short intervals, for one or two days, and have 
never known any injurious or even unpleasant effects to be produced by it. As a means 
of controlling tbe hemorrhage from the lungs we know of no remedy so certain, in its 
effects. In the disease under consideration, we have very generally combined a sm|U 
portion of ipecacuanha with the acetate of lead. — C] 



PULMONARY EMPHYSEMA. 



LECTURE LV, 

Pulmonary Emphysema ; vesicular and interlobular. Anatomical characters 
of vesicular emphysema ; physical signs ; general symptoms ; causes ; treat- 
ment. Interlobular emphysema : its anatomical characters, symptoms, cause, 
and cure. (Edema of the lungs. Phthisis Pulmonalis. 

I have yet one or two morbid conditions of the lungs to consider and to de- 
scribe, before I go .to that which is the most common and most extensively fatal 
of all its morbid conditions — tubercular phthisis. 

There is a state of the lung, or rather there are two or three different states, to 
which Laennec has applied the name emphysema. A very injudicious name it 
was for him so to impose. We are infinitely indebted to Laennec for the entirely 
new light which his able researches have thrown upon the morbid anatomy and 
the pathology of the lungs : but we have to regret that he should have employed, 
in several instances, a vicious nomenclature. Emphysema is a term that had 
long been familiar among medical men in a eertain sense. It was used to express 
the inflation of the areolar tissue of the body with air; and surgeons still make 
much of it as an indication, in cases of fractured rib, that the bone has' grazed the 
pleura, and allowed air to pass into the areolar tissue, and to diffuse itself over the 
chest and neck, and other parts ; so that these parts, when pressed, convey a 
curious sense of crackling to the finger. But emphysema of the lung., as that 
term is employed by Laennec, includes dilatation of the air-cells of the lungs, and 
^rupture of the partitions which separate them from each other ; and also the infil- 
tration of air into the interlobular areolar tissue, or into the subpleural areolar tis- 
sue. In strictness of language these last conditions alone should have been called 
emphysema of the lung. Laennec has distinguished the two species in this way. 
To the dilatation of the air-cells, with or without a breaeh of their partitions, he 
gives the name of vesicular emphysema: " the vesieular, (I quote the words of 
Dr. Forbes' translation) or pulmonary, properly so ealled. Now in truth this is 
emphysema improperly so called. To the infiltration of the areolar tissue in or 
around the lung with air, i. e., to emphysema of the lung in the old sense of that 
word, he applies the title of interlobular emphysema. We cannot change these 
denominations now. They have fastened themselves upon medical language. 
But it is very fit that you should be aware of their inconsistency with the ancient 
signification of the same word, and have clear notions of what in Laennec's no- 
menclature they are intended to express. 

The change ealled vesicular emphysema was not unknown, as a mere morbid 
condition, before the time of Laennec ; but it had been noticed by very few 
writers, and practically it was wholly unattended to. Yet it is extremely common ; 
much more so than you would suppose •: and when rightly studied it is of great 
interest, too, in relation to the general pathology of the chest. But it is still so 
new, and may so readily escape observation^ both in the dead and in the living 
body if it be not looked for, that I shall devote a somewhat more minute atten- 
tion to it, on those accounts. 

Laennec was undoubtedly the first to put emphysema pulmonum upon the list 
of definite and cognizable diseases ; to point out its frequency ; and to collect its 
symptoms. But when he affirms that, before his time, the pulmonary change 
which constitutes the disorder was misunderstood by nearly all those persons 
who had noticed it, he scarcely does them justice. "All of them (says he) seem 
to have thought that the derangement in question consisted in the infiltration of the 
cellular substance of the lungs with air." He inconsistently adds, " Ruysch and 
Valsalva are the only authors, as far as I know, who have observed in individual 
cases, the dilatation of the cells and with still greater inconsistency he pro- 
ceeds to quote, from Morgagni, the following passage in which this dilatation is 



PULMONARY EMPHYSEMA. 



629 



very clearly described: "Sinistri pulmonis lobus superior, qua claviculam spec- 
tabat, vesiculas ex quibus constat mirum in modum auclas habebat; ut nonnullae 
avellanae magnitudinem aequarent ; caeterae raulto minores erant." You will find 
the same change noted by Dr. Baillie, in his Morbid Anatomy : and by earlier 
writers than he. 

Vesicular emphysema then, (to adopt Laennec's phraseology,) consists in dila- 
tation of the air-cells. The enlarged cells become misshapen also in many cases. 
They vary in magnitude from that of a millet seed to that of a swan-shot : nay r 
the cavities may even reach the size of a nutmeg or of a hen's egg: but when* 
they are as big as this — and a fortiori if they are still bigger — the distension and 
vacuity are, no doubt, the result of the union of several air-cells, broken into one, 
by the stretching or destruction of the partitions that naturally divide and isolate 
them. You may see the dilated vesicles very plainly through the pleura if you 
carefully examine the surface of the lung. They appear to the naked eye as the 
healthy vesicles appear when seen through a magnifying glass. Sometimes all 
the vesicles belonging to one lobule are enlarged, while those of the adjoining 
lobules are of the natural size. In that case the emphysematous lobule is con- 
spicuous both by its peculiar colour, and by its protrusion. The surface of the 
lung is often rendered quite irregular and uneven by projections of this kind. 
Sometimes one large globular prominence is seen, like a bubble on the water, or 
like a little bladder springing from a footstalk : but if you examine it closely you 
will generally find that the footstalk is merely a constriction at the surface, and 
that there is as large a cavity beyond it, in the lung, as there is without. These 
bullae you cannot slip about by pressure from one part of the pleura to another. 

The unevenness produced by vesicular emphysema upon the outside of the lung 
is manifest enough, when looked for ; but the same condition of the air-cells exists 
also within, and there it is not so readily perceptible. The fluids which the lung 
contains obscure all distinction of parts when the organ is cut. The best way of 
getting a fair view of the dilated cells as they appear in the substance of the lung, 
is to inflate the emphysematous portion, by blowing air in at the bronchial trunk 
which belongs to it, and then tying that trunk to prevent the escape of the air. 
The inflated lung should be hung up in a current of wind, so that it may quickly 
dry ; and during the drying process, it should, from time to time, be reinflated : 
for else the included air gets out somehow, and the piece of lung shrinks and 
shrivels up. When it is quite dry, if a section of it be made with a thin sharp 
knife, the altered state of the air-cells, some of which are more and some less 
dilated, will be very conspicuous. 

No part of the lung is exempt from liability to these morbid changes; but 
generally they are limited to certain portions of the organ, and they are much 
more common and more pronounced at its loose anterior borders, and near its 
summit, than anywhere else. Both lungs appear to be alike obnoxious to the 
disease ; which seldom affects the one without affecting, in a greater or less 
degree, the other also. 

The parts that are emphysematous are usually paler than the rest, and some- 
times they are quite white. In extreme cases the surface of the lung presents a 
sort of piebald appearance ; large patches of it looking as if they had been bleached. 
This pale colour is oftenest seen towards the free edges of the lung. Sometimes 
those edges are rounded and thick ; sometimes thinner, and folded back ; while 
sometimes the margin is blown out, as it were, into an irregular fringe ; some of 
the inflated portions remaining connected with the lung by slender pedicles, and 
thus forming appendices to it of a light yellow colour. 1 presume that what was 
thought and called a fringe of fat, garnishing the edges of the lung, in the body, 
of King George IV., was of this kind. At least I have never seen, nor heard 
of, any other example of fat deposited in those organs. If you hold the emphy- 
sematous border between your eye and the light, you perceive that it is trans- 
lucent: if you prick it with a pin, the puffy part surrounding the puncture 
collapses ; which shows that the dilated vesicles communicate together. 



630 



PULMONARY EMPHYSEMA. 



An emphysematous lung is not only paler, but drier also than ordinary: and for 
the same reason. It possesses fewer capillary blood-vessels, less blood, and con- 
sequently less moisture. It is dry and light, and floats high upon water, like a 
bladder filled with air. 

If you take such a lung out of the body, having its surface embossed with irre- 
gular groups of enlarged air-cells — and if you inflate that lung, by blowing into 
the bronchi — the emphysematous portions will seem to sink in, and flatten, and 
return to the ordinary level as the lung becomes distended. In point of fact, how- 
ever, these portions remain permanently dilated, and the other parts of the surface 
^ise, as the air enters them, until the whole is smooth and even. Air is shut up 
in the emphysematous portions, which do not subside, as the adjoining portions 
do, when left to the agency of their proper elasticity. Hence you will see how 
it is that, when the vesicular emphysema is extensive, so as to occupy nearly the 
whole of the lung, the lung becomes apparently too big for the case in which it 
is contained. Not only does it not collapse when the sternum is raised, and the 
pressure of the atmosphere is admitted to its external surface, but it even pro- 
trudes, the moment that the opening is made. When you handle such a lung, it 
gives a very different sensation to the fingers from that produced by pressing a 
healthy lung. It feels like a down pillow. It crepitates less ; the air is less easily 
forced out .of it, and escapes slowly, with a slight hissing noise. 

Such being the state of the lung, as discovered after death, you will naturally 
be inquisitive to know by what signs the existence of a condition so remarkable 
is revealed during life. First, then, when the emphysematous distension is con- 
siderable in amount, and extensive, it produces alterations in the shape and move- 
ments of the chest. The lung having lost much of its elasticity, does not subside 
as a healthy lung does. The act of expiration is arrested and incomplete. Con- 
sequently the thorax remains nearly in that position which it assumes after inspir- 
ing. It is prominent and rounder on the diseased side; or on both sides, if both 
lungs be affected; but it is apt to be irregularly prominent, and unsymmelrical ; 
to bulge here and there in correspondence with the bulging of the lung within. 
The ribs are less oblique than they should be, and the chest is, therefore, more 
cylindrical. The clavicles are ill-defined in such persons. They are so, as you 
know, in fat persons : wherefore this aid to the diagnosis is of most value in those 
who are spare. In them it is a valuable sign, for it is simple and obvious. The 
distended lung presses upwards, as well as in other directions, and tends to efface 
the depressions which naturally exist both above and below the collar-bone. This 
symptom is the more to be depended on if it presents itself on one side only. The 
manner of breathing is instructive also. The ribs, never receding within their 
proper limits after expiration, can move but little during inspiration : and the 
breathing is in a great measure abdominal. 

Now all these signs are physical signs. But what, in the second place, are 
the auscultatory physical signs ? Why, in the emphysematous regions, which 
commonly are also the most bulging, percussion yields an unnaturally clear and 
resonant sound, while auscultation discovers a very indistinct vesicular murmur? 
The two modes check and explain each the information afforded by the other. 
Percussion ascertains that there is air beneath the part struck : auscultation ascer- 
tains that there is little or no air in motion beneath that part. It follows, there- 
fore, that there is stagnant air; air shut up in the enlarged air-cells, or air inter- 
posed between the ear and the lung in the cavity of the pleura : air at rest, in fact. 
I say the respiratory murmur is very feeble. This partly depends upon the 
limited play of the ribs, partly and chiefly upon the circumstance that the air is 
imprisoned in the dilated cells. When none enters or leaves them during respi- 
ration, no vesicular breathing can be heard : and then we must call in the aid of 
other considerations to determine whether the air be contained in the cavity of the 
pleura, or in the emphysematous lung. 

Pure pneumothorax is extremely rare. Pneumothorax with liquid effusion is 
easily recognized by its proper signs. If these be absent, we conclude that the 



PULMONARY EMPHYSEMA. 



631 



stagnant air occupies the lung, and not the pleura : and this conclusion is strength- 
ened if the unduly resonant part be prominent also. Almost all writers on this 
subject follow Laennec in stating that dry crepitation may be heard in the em- 
physematous parts. It may be so; but if so, I cannot distinguish it. I mean 
that I know no crepitation, but that which is moist, and which proceeds from the 
formation and rupture of bubbles, as air passes through liquids in the bronchial 
tubes. But other people believe that they can hear a dry crackling, such as may 
be produced by inflating a portion of dry areolar tissue out of the body, or a dry 
bladder. You will try this by your own experience. I do not deny that such 
a sound exists : I only say that if it does exist, I cannot tell when I hear it, and 
when I hear large moist crepitation. But I more than suspect that no such sound 
is given out by an emphysematous lung; and that the sound heard is really large 
crepitation in the neighbourhood of the dilated cells ; for emphysema is very often 
accompanied by catarrh; and the sounds in question, authors agree, are not per- 
manently audible. 

So much for the physical signs of emphysema pulmonum. The general signs, 
when the change is extensive, are an habitual shortness of breath, with occasional 
paroxysms of extreme dyspnoea ; cough which, however, is far from being a 
constant symptom ; palpitation in most instances as the disease advances, and more 
or less oedema of the ankles. Usually the appetite remains unimpaired, and the 
patient does not lose flesh. The disorder is unattended with fever; and is essen- 
tially chronic. 

The paroxysms of urgent dyspnoea are frequently concurrent with, and appa- 
rently excited by attacks of smart bronchial catarrh ; but they sometimes arise 
without any obvious cause. They are apt to come on suddenly, in the night, and 
the patient is obliged immediately to sit up, and even to open the doors and win- 
dows of his bed-room, that he may breathe more freely. In one word he under- 
goes a paroxysm of asthma. These attacks become more frequent and more 
severe as the patient and the disorder grow older. They are attended with much 
wheezing ; and in the lower posterior part of the lungs crepitation is generally 
audible. At first the palpitation of the heart, and oedema of the feet, abate and 
cease as the violent dyspno?a goes off* : but at length these symptoms become 
permanent. 

We see a reason, in the physical condition of the thorax, why the breathing 
should be more oppressed, and why the paroxysms of orthopncea should occur 
more frequently in the night. Whenever the respiration is principally abdominal 
it is apt to be embarrassed by the recumbent posture, which throws a part of the 
weight of the viscera of the belly upon the diaphragm. The horizontal position 
is always ill borne by these patients ; and, for similar reasons, flatulence or fullness 
of the stomach, however caused, distresses them. 

Cough, as I observed befoce, is an occasional, but by no means an essential 
accompaniment of vesicular emphysema : the expectoration, where there is any, 
is thinnish, like gum-water, and full of foam. 

- Louis, who has analyzed, with his accustomed care and exactness, a considera- 
ble number of cases of emphysema, states that the disease is seldom complicated 
with tubercles in the lungs. We may suspect that complication, if haemoptysis, 
or emaciation, occur ; which are otherwise rare symptoms. 

To what cause can we ascribe this dilatation of the pulmonary vesicles, whereby 
the proper function of the lung, in the part affected, is impaired, or annulled ? 
Mainly, I think, in the outset at least, to the imprisonment of air within them, 
under circumstances of disease. You may often trace back the shortness of breath 
to the period of infancy. Patients will tell you that from their earliest recollection 
they have been easily put out of breath: that they never were able to engage 
heartily, and to the same degree with their companions, in theactive sports of child- 
hood. It is easy to conceive that under chronic inflammation, or other disease of the 
raucous membrane, air may enter the vesicles more readily than it can escape 
from them again. The act of inspiration is voluntary and strong; the tubes are 



632 



PULMONARY EMPHYSEMA. 



made patent by it, and air rushes in and finds its way to their extremities. But 
the act of exspiration is passive, and comparatively feeble. Slight tumefaction of 
the membrane, or a little plug of viscid mucus, may so close up a small bronchial 
ramification, that the air cannot pass through it in expiration : and more and more 
air may thus be accumulated and incarcerated in certain air-cells, which yield to 
its distending force, and losing their elasticity become permanently large. And 
this process will be accelerated if the original disorder which gives rise to it is 
attended with violent cough; with forcible efforts, that is, of expiration. Em- 
physema is always (in my opinion) a consequence of pre-existing disease or dis- 
order of the chest. There are some who believe it to be occasionally a congenital 
and idiopathic affection. They build this notion upon the fact that the complaint 
is traceable, from one generation to another, in certain families ; and as it often 
is present at an early age in children born of emphysematous parents, they con- 
clude that the emphysema, in such cases, is a vice of the original bodily forma- 
tion. I am not convinced by this mode of reasoning. The facts upon which it 
rests show simply that the disorder runs much in families, and that the tendency 
to it is sometimes inherited. The lax or weak fabric, which favoured the produc- 
tion of the disease in the parent, is repeated in the offspring, and imparts the 
same predisposition. Children are very liable to severe coughs, such as are cal- 
culated to strain and overstretch the cells of their delicate lungs. What can be 
more likely to do so than the reiterated and violent paroxysms of coughing which 
occur in pertussis ? After the cough has ceased, however, the shortness of breath 
which it leaves behind is easily overlooked, until with the increase of the emphy- 
sema, it forces itself into notice. For when once the morbid process has begun 
it tends, slowly often, but surely, to its own augmentation. As the cells dilate, 
the capillary blood-vessels distributed over their parietes are gradually compressed 
and emptied: and many of them are, at length, completely obliterated. Hence, 
not only an exsanguine condition of the pulmonary tissue, but atrophy also of 
the intervesicular partitions, which become first thin, then tattered and imperfect. 
In dried specimens of emphysema you see very plainly the remains of the former 
walls of separation between the vesicles. 

It is this interference with the nutrition of the lung which causes vesicular 
emphysema to be always a progressive disease. We see why it is that, speak- 
ing generally, the extent of the morbid change is proportioned to the age of 
the patient: why paroxysms of severe dyspnoea at length supervene; and become 
more and more frequent and trying. The function of the lung becomes year by 
year more limited; until it can no longer bear, without a struggle of distress, that 
further encroachment upon its office and capability which a slight catarrh, rapid 
movements of the body, a distended abdomen, or even the recumbent posture, 
may be sufficient to produce. 

Laennec attributes the dilatation of the air-cells, in the first instance, to what 
(with a curious infelicity of diction) he terms dry catarrh, which is characterized 
by its tendency to recur, and by the expectoration of small pieces of hard, pearly 
phlegm. But doubtless the disorder may be produced, and aggravated when pro- 
duced, by any cause that impedes the free exit of the air from the lungs during 
expiration : by blowing on wind instruments of music, by pressure made on parts 
of the lung; by tumours therefore in the thorax, a large heart, aneurism of the 
thoracic aorta, deformity of the chest from crookedness of the spine, tight lacing, 
and even the presence of tubercles ; although lungs that are full of tubercles are 
not, in general, much affected by emphysema. This last fact has led to the 
absurd project of attempting to prevent phthisis by producing emphysema. It is 
the same disease which exists in broken- winded horses; and Sir John Floyer, in 
his Treatise of the. Asthma, published in 1(598, sets forth, in the quaint language 
of that olden time, both the alteration which Laennec thought he had been the 
first to describe, and the mode in which it takes place. His observation respect- 
ing the lungs of horses are equally applicable — and he no doubt intended to apply 
them—to the human lungs. , After speaking of " the broken wind, from the 



PULMONARY EMPHYSEMA. 



633 



rupture or dilatation of the bladders of the lungs, by which the air is too much 
retained in the bladders or their interstices, and thereby produces a permanent 
flatulent tumour" — and stating that " these horses wheeze much after filling their 
stomachs, by water or food, because that keeps up the diaphragm" — he goes on 
thus. As it happens in external flatulent tumours, they at first go off and return, 
but at last fix in permanent flatulent tumours ; so it is in the flatulent asthma, the 
frequent nervous inflations induce at last a constant windy tumour or inflation ; and 
it ought to be considered how far holding the breath in hysteric fits, or the violent 
coughing in long catarrhs, or the great distension of the lungs by an inflammation 
in the peripneumonia, may strain the bladders and their muscular fibres, and 
thereby produce the same rupture or dilatation or hernia as happens in the broken- 
winded. This must be observed by the help of the microscope; and if the air 
blown into any lobe will not be expelled thence by the natural tone or muscle of 
the bladders, that the lobe may again subside of itself, 'tis certain some injury is 
done to the ventiducts ; the bladders are either broken, and admit the air into the 
membranous interstices, or else they are over-distended like a hernia in the peri- 
toneum ; and this will produce an inflation of the whole substance of the lungs, 
and that a continual compression of the air and blood-vessels, which will produce 
a constant asthma." Really this is a capital piece of pathology for the seventeenth 
century. 

It is, at first sight, a matter of surprise that vesicular emphysema of the lung, 
and dilatation of the bronchi, do not more often go together. Sometimes, indeed, 
the smaller branches of the air-tubes do partake of the dilatation of the cells: but 
this is not commonly the case. Still the mechanism of both diseases appears to 
be, in the first instance, the same. The detention of mucus in them leads to 
dilatation of the bronchial tubes : the incarceration of air in them to enlargement 
of the pulmonary vesicles. 

Vesicular emphysema may arise then, and receive increase from, various dis- 
ordered conditions that precede or accompany it, and of which it is the effect. 
On the other hand, it is often itself the cause of subsequent disease, not merely in 
the lung, but in other parts; and above all, of disease in the right chambers of the 
heart. The smaller blood-vessels, as I have shown you, are gradually effaced as 
the dilatation of the air-cells proceeds: the emphysematous lung is evidently in a 
state of comparative anaemia, and incapable of admitting all the blood which is 
due to it from the pulmonary artery. In other words, the right side of the heart 
does not empty itself with its accustomed ease. Hence increased muscular con* 
tractions of the right ventricle: and a yielding of its walls to the augmenting pres- 
sure of the contained blood. And this embarrassment of the circulation in the 
right side of the heart is aggravated at those periods when the paroxysms of urgent 
dyspnoea occur. Now nothing is a more sure cause of anasarca than a permanent 
dilatation of the right cavities of the heart: and this influence of the emphysema- 
tous lung upon that organ is clearly seen in the palpitations to which such patients 
are liable, and in the oedema of the feet and ankles which often becomes manifest 
at the same time. 

I must beg you to bear in mind that emphysema of the lung is one, and a very 
common, cause of asthma. The asthma so arising is less perilous than that 
which proceeds from certain other organic changes, to be described hereafter. 
Vesicular emphysema, indeed, in its simple uncomplicated form, is seldom attended 
with much danger. When it proves fatal, it is so in consequence of the superad- 
dition of some other disease. Laennec states very truly, that of all the varieties 
of asthma, this is the one which affords the patient the best hope of a long life. 

The condition that I have been describing, when once it has fairly been estab- 
lished, can scarcely admit of a cure. We shall do our patients good, not by any 
treatment addressed to the existing emphysema itself, but by guarding them 
against those circumstances which are likely to aggravate it; and by mitigating or 
removing those other disorders with which the emphysema is apt to be combined. 
Whatever is calculated to put the patient out of breath is bad for him. It is or> 



634 



PULMONARY EMPHYSEMA. 



served that they who, having emphysema, are obnoxious also to catarrhs, during 
which the dyspnoea is singularly increased, are much more free from such attacks 
in the warm weather of summer, than in the winter. This explains the beneficial 
influence of a judicious change of climate upon such persons, and it points to the 
necessity of warm clothing in the colder seasons for those who are obliged to 
remain in this country. The feet especially should be kept dry and warm; and 
the liability to catarrh may be sometimes diminished by the use of the cold 
shower-bath, in the way I formerly recommended. During the fits of extreme 
dyspnoea, you may hear the expiratory wheeze remarkably loud and protracted ; 
and if,, withal, you hear any small crepitation, indicative of pneumonic inflamma- 
tion, you will do well to cup the patient between his shoulders. This will always 
give relief to loaded lungs, whether there be inflammation present or not. But 
the great assuager of the dyspnoea in this disorder is opium ; and especially opium 
combined with aether. Half a drachm of Hoffman's anodyne, with a third of a 
grain of the acetate or muriate of morphia, in camphor julep, will operate like a 
charm often, in quieting the whole system, and removing the difficulty of breath- 
ing. This circumstance would lead us to suppose that the access depended, in 
part at least, upon a spasmodic state of some of the muscles concerned in respira- 
tion. To this question I shall revert when I speak of asthma as a separate dis- 
ease. At any rate you will find that some such formula as I have just mentioned 
will stand you in good stead when you have to deal with asthma engrafted on 
emphysema. And I may add, that this is a case of exception to a rule I formerly 
laid down. You need not be deterred from giving a full dose of opium by the 
blueness, which is temporary, of the patient's lips and countenance. 

The interlobular and sub-pleural emphysema of the lungs is a species of true 
emphysema, the air being contained in the meshes of the common areolar tissue. 
When it appears on the surface of the lung, it may be distinguished from the 
bladder-like prominences which sometimes form there by the dilatation of the air- 
cells, in this way: the bullae which are situated in the areolar tissue connecting 
the pleura with the lung, maj'- be made to move hither and thither under pressure; 
whereas those which result from the protrusion of an enlarged cell or cells cannot 
be made thus to change their place. This sub-pleural effusion of air is sometimes 
enormous. I have seen it as large as a hen's egg. Bouillaud mentions a case in 
which the bladder or pouch was equal to the size of a stomach of ordinary dimen- 
sions. It proceeds, I presume, from the rupture of a superficial air-vesicle. 
Sometimes, as I mentioned before, the pleura also gives way, and air is poured 
into the cavity of the thorax. More commonly the membrane remains entire, 
and then these large bubbles of air may be seen upon the surface of the lung. 

Of interlobular emphysema I can give you but little account except from the 
observations of others. I have never seen more than one well-marked example 
of it. The lobules of the lungs cohere together by means of areolar tissue, which 
is dense and close in the natural state, but which admits of considerable expansion 
when it is inflated with air. If the emphysema be slight in degree, the lozenge- 
shaped spaces visible on the surface of the lung are defined by little bubbles of 
air, that look like beads strung upon a thread. But in extreme cases the lobules 
are fairly blown asunder by the air; the partitions between them increase in width, 
and are said to be sometimes as much as an inch broad. They are broadest 
towards the surface of the lung, and narrower towards its roots ; and exhibit some- 
what of the arrangement seen in the section of an orange, the septa radiating and 
diverging from a centre. If the areolar tissue could be taken out, there would be 
left cracks and clefts in the lung. When {he interlobular emphysema penetrates 
to the roots of the lung, the air readily passes into the areolar tissue of the medi- 
astinum, and thence to the subcutaneous tissue of the neck and chest — and then 

we have the genuine emphysema of authors who wrote prior 1o Laennec. 

There is this material difference between vesicularand interlobular emphysema ; 

that the one is slow and gradual in its formation, the other sudden. The perma- 



INTERLOBULAR EMPHYSEMA. 



635 



nent dilatation of the air-vesicles is the work of time. They yield, and lose their 
elasticity, and break into one another, only by degrees. The interlobular effusion 
of air maybe effected in a few minutes or seconds. It is caused by violent strain- 
ing efforts ; such as those made by a woman in childbirth, or by any one who 
exerts himself to lift a weight which is too much for him. A deep inspiration is 
taken ; then the glottis is voluntarily closed, and a strong expiratory effort is made. 
Some rupture must take place and form a communication between the air-vesicles 
and the areolar tissue; but such rupture has never been (raced, nor is it likely 
that it should be. 

They say that this form of emphysema is revealed also by large dry crepita- 
tion ; why it should, is not evident. I can only say of that sound, as T said 
before : it may exist, and it may be distinguishable from large moist crepitation, 
but my ear is not delicate enough to distinguish it : and to speak the truth, I doubt 
exceedingly whether any such sound really occurs at any time. But <lo not let 
my doubts infect you : try for yourselves ; and till you have had opportunities of 
investigating this point, consider it as adhuc sub jv dice. 

Again, they say that the noise of friction denotes the existence of interlobular 
and subpleural emphysema. On this point I can give you no information of my 
own knowledge. That you may sometimes hear the costal pleura rub against 
the pulmonary during inspiration and expiration, I know ; I have often heard that 
sound (as I mentioned to you before) when the membrane has been roughened 
by pleurisy ; but that a soft, smooth, moist lung, though embossed by emphysema, 
will give rise to a rubbing sound, I do not know. It may be so, but it has never 
occurred to me to hear it. 

We may be more certain that interlobular emphysema has arisen when, im- 
mediately after some violent straining effort, considerable dyspnoea and oppression 
ensue, and presently the subcutaneous areolar tissue becomes emphysematous. 
Yon will understand how rapidly the inflation of the areolar tissue may take 
place if you ever saw a butcher blow up that of a calf which he is in the act of 
skinning. 

As interlobular emphysema differs from vesicular emphysema in its seat, and 
in the suddenness of its formation, and in some sort also in its cause, so does it 
differ in its curability. Under favourable circumstances it will soon cure itself — 
the air will be reabsorbed, and the dyspnoea cease. I do not know that we can 
do much by art to accelerate that process. If the dyspnoea be extreme, it will be 
relieved by blood-letting ; and if the air makes its appearance, and can be felt, 
crackling, beneath the skin, you may let it out by making a few punctures with a 
lancet, and the deeper-sealed emphysema will be lessened as the air escapes. I 
believe that this interlobular emphysema is more common in infancy than in any 
other part of life ; on account, I suppose, of the greater delicacy and tenderness 
of all the tissues at that age. 

The interstitial areolar tissue of the lungs, as well as the air-cells, is liable to be 
filled not only with air, but with serous fluid ; and this constitutes oedema of the 
lungs ; a condition which is by no means uncommon, and one of which you 
ought therefore to be aware ; but it need not long occupy our attention at present. 
When a lung, or a portion of lung, is anasarcous (and you will often find that the 
oedema is limited to the most depending part of those organs), it is generally of a 
pale gray or yellowish tint ; is heavier than healthy lung, and less crepitant ; and 
pits more on pressure — is doughy. And if the oedema is extensive, the lung 
does not collapse when the chest is laid open. When incisions are made into the 
lung in this state, a thin watery fluid flows out, more or less spumous ; and if the 
lung be well squeezed, the whole of the liquid may be expressed ; and then it 
will be obvious that the texture of the organ is sound, but that it had previously 
contained less air than usual, in consequence of the presence of the watery fluid. 

This condition of the lung seldom takes place except as a part of general ana* 
sarca : and we may discover its existence, first by noticing that there is dropsy 



636 



PHTHISIS PULMONALIS. 



of the areolar tissue in other parts ; secondly, that the patient has dyspncea ; and 
thirdly, by hearing crepitation, produced by large bubbles, at the lowermost por- 
tions only of the lungs. Into those portions the liquid gravitates; just as it sinks 
into the ankles when the patient sits up or walks about. There is still air in the 
oedetnatous portion ; so that percussion still gives a hollow sound : as hollow at 
least on the one side as on the other. With the air there is also liquid, which 
transudes, I suppose, from the areolar tissue, or is exhaled from the surface of 
the membrane: and the liquid is from time to time coughed up and expectorated. 
Sometimes, however, there is but little expectoration. What does come up is 
chiefly aqueous, with occasionally a piece or two of mucus floating upon it; and 
it is somewhat foamy also. 

This cedema or anasarca of the lung is symptomatic of other disease ; generally 
of disease of the heart or great blood-vessels : and it is capable of no other rational 
treatment than such as is suited to the original disorder : and therefore I have 
nothing further to say about it now. 

I proceed, in the next place, to that most prevalent and lamentable disease of 
the lungs, which is well known to everybody, under the titles of pulmonary con- 
sumption, and tubercular phthisis. And without pausing to make any general 
reflections, respecting facts which must be familiar to you all — the fatal and almost 
hopeless character of the disease, and the havoc it produces among the young, the 
most gifted, and the most beautiful, of the human race — I shall commence by 
inquiring into the morbid anatomy of tubercular phthisis : which will naturally 
introduce us to the consideration of its symptoms, causes, treatment, and general 
history. 

Phthisis, you know, means a wasting away, or a consuming; but of late years 
the term has been restricted to that species of wasting disease, which consists in 
the occupation of the lungs by tubercular matter, and the changes which that 
matter suffers and works. But it would be an error to suppose that the disease 
is restricted to the lungs in these cases. The lung disease would be sufficient at 
length to destroy life; but its mortal tendency is aided and accelerated, in most 
instances, by disease of a similar character, situated in other organs. " The pul- 
monary consumption (as Dr. Latham justly observes) is no more than a fragment 
of a great constitutional malady." But that malady plays its part most conspi- 
cuously in the lungs. I shall notice its complications as I go on,; but I am desi- 
rous of cautioning you in the outset against supposing that tubercular phthisis is 
exclusively a pulmonary disease. 

Before I proceed to a more particular description of the changes that, in the 
progress of consumption, are wrought in the lungs, I must briefly recall to your 
recollection certain points, relating to tubercular disease in general, which were 
brought before you in an earlier part of the course. The formation of tubercles 
is closely linked wiih the existence of the scrofulous diathesis. Tubercles them- 
selves are composed of unorganized matter, deposited from the blood, of a yel- 
lowish colour, opaque, friable, and of about the firmness and consistence of cheese. 
This is what all pathologists agree in regarding as the true tubercular matter. It 
is most commonly deposited on the free surface of mucous membranes; and not 
unfrequently amidst areolar tissue. You will remember that tubercles are not 
necessarily, as some have supposed, of a round shape. Their form depends upon 
the nature of the tissue in which the tubercular matter is deposited. Wherever it 
is laid down, it is liable to increase in quantity by the continual accretion of fresh 
matter of the same kind. Hence, when a speck of this peculiar matter is depo- 
sited in any soft uniform tissue — such as the brain, or the areolar membrane—- 
there being no inequality of pressure from any quarter, it preserves a spherical or 
globular form as it grows larger. But taking the lung, with which we are at 
present chiefly concerned, the round form is sometimes real, sometimes apparent 
only. It is real when the tubercular matter fills up, or lines, and therefore takes 
the shape of, the pulmonary vesicles. So it is when a number of these, conti- 



PHTHISIS PULMONALIS. 



637 



guous to each other, coalesce by the increase of deposit and compose one large 
globular mass. And you may often catch the tubercles, if I may so say, in the 
process of forming these large rounded masses ; i. e., you may see them arranged 
in circular groups or clusters, the interstices between them becoming gradually 
smaller and smaller. But when, as is often the case, the tubercular matter is laid 
down in the smaller ramifications of the bronchi, it assumes a cylindrical shape. 
This you may ascertain by carefully following the branching of the air-tubes : but 
in the manner in which the lung is usually divided by the scalpel, you see merely 
sections of these cylinders; and then the round form is apparent only. If the 
tubercular matter comes to fill one of these smaller air-tubes, and also all the 
vesicles to which that tube conducts, then the new substance, when fairly dis- 
played, represents a branch, with a cauliflower termination; like a twig with a 
bunch of leaves at its extremity. You may see these appearances delineated, 
from nature, in Dr. Carswell's admirable lithographic drawings. 

If this account of the formation of tubercles, as explained by Dr. Carswell, be 
the true one ; — of which I entertain little doubt ; — it will follow, as a matter of 
necessity, that no alteration can take place in the tubercular matter, after it has 
once assumed the solid form, except through the agency of the parts around and 
in contact with it. No change can originate in the organic tubercle itself. 

Besides this true and undisputed species of tubercle, you will often find the 
lungs more or less thickly studded with a number of small granules, of firmer 
consistence, almost as hard as cartilage, semi-transparent, and of a bluish-gray 
colour. Respecting the nature of these granules — which are sometimes called 
miliary tubercles, sometimes the granulations of Bayle, who first described them 
— many different opinions are entertained. Laennec considered them to repre- 
sent the incipient stage of the opaque yellow substance; and he calls them accord- 
ingly nascent tubercles. Andral believes that they are simply some of the pul- 
monary vesicles rendered solid and hard by chronic inflammation. Dr. Carswell 
explains their formation in this way. The membrane lining the air-passages 
secretes from the blood, not only the matter of tubercle, but its own proper fluid ; 
whence it sometimes happens that a dull yellowish point of tubercular matter 
becomes enclosed and set, as it were, in a small pallet of gray, tough, semi-trans- 
parent mucus. Whatever may be the true theory respecting these little bodies, it 
is certain that they acknowledge some intimate connection with the true cheesy- 
tubercle. They both occur in the same persons, in the same lungs, in the same 
parts of the lung. One very seldom occurs without the other. They both be- 
long essentially to the disease we are considering — pulmonary phthisis. Louis, 
a minute and faithful observer, states that the granules present, at a certain period 
of their development, a central opacity. Upon the whole, it seems probable, 
that Laennec's doctrine, in regard to the relation subsisting between the gray semi- 
transparent granule and the yellow opaque tubercle, was well founded. 

He was wrong, however, in some other points, especially in his statement that 
the softening of tubercles begins in their centres. Dr. Carswell has shown how 
the appearance of a central softening arises, first, in the smaller tubercles ; second- 
ly, in the larger agglomerated tubercular masses. The morbid secretion is depo- 
sited, principally, upon the mucous surface— upon the inner lining of the air- 
cells, and of the bronchial tubes communicating with them. Now it may so 
accumulate as to fill those cavities ; and then, sections of them will represent the 
crude tubercles of Laennec. But it may only line the cavities: it may leave a 
central vacuity, containing mucus or other secreted fluids ; and if the lung be cut 
across under these circumstances, the divided air-cells will look like rings of 
tubercular matter grouped together; and so also will the divided bronchial tubes. 
We then have the appearance of tubercles, with central depressions, or soft cen- 
tral points ; and Laennec was deceived by those appearances. 

But the larger masses begin also, he says, to soften at the centre. True : we 
do find the process of softening going on at several points within them at the same 
time. The masses, you must bear in mind, are formed by the growing together 



638 



PHTHISIS PULMONALIS. 



of many smaller tubercles ; and the areolar tissue, with the other tissues which 
originally separated these tubercles, still exists, though it ceases to be visible. At 
length, under the augmenting pressure, or some other influence, it suppurates; 
and in this way the tubercular mass is broken down. Now this is the very pro- 
cess by which the tubercles are at length, often, expelled from the body. They 
increase till the surrounding parts take on inflammation, either from the increasing 
pressure, or from some accidental cause. The inflammation thus excited, occur- 
ring in scrofulous persons, has the scrofulous character. The thin pus which it 
throws out pervades and loosens the tubercular deposit; a process of ulceration 
goes on in the surrounding textures; and, at last, the softened scrofulous matter 
is gradually coughed up and expectorated. 

This explanation of the mode in which the tubercles are formed, and increase, 
and soften, and are removed, has been given to the world within the last few years, 
by Dr. Carswell ; and it is much the most simple and probable of any that I have 
seen. It is moreover, perfectly consistent with the best ascertained facts concern- 
ing the progress of tubercular disease. You will find numberless theories broached 
by different authors on this subject, if you like to look for them ; but I do not 
think you will find any so satisfactory as Dr. Carswell's. And having recalled 
these things to your memory (for it is some time now since I mentioned them 
before) we may go on to the further consideration of the morbid anatomy and 
pathology of tubercular phthisis. 

It is a remarkable and very important fact, that tubercles, when they affect the 
lungs, are not deposited at random, or indifferently in all parts of those organs. 
It is in the upper lobes, and in the upper and back parts of those lobes, that, in 
nineteen cases out of twenty, and in more than that proportion, we meet with 
tubercles when they are few. It is in the same part that they are largest, and 
most numerous, when they are scattered throughout the whole lung. It is here, 
also, that they first ripen, and grow soft, and become ready for expulsion through 
the bronchi and trachea : consequently, it is here, that we have the most frequent, 
the most numerous, and the largest excavations in the lung — what are technically 
called vomicx. And the number and magnitude of the tubercles and of the 
vomicae gradually diminish from the summit of the lungs downwards. 

Now these are not merely curious facts : they have a most important bearing 
upon the diagnosis, in cases that might otherwise be doubtful. It is a rule which 
has but few exceptions — just enough to establish its claim to be a rule — that the 
favourite habitat of pulmonary tubercles is the upper part of the superior lobes of 
the lungs; and I may remind you that the converse of this is true (though with 
more numerous exceptions) of common inflammation of the lungs. Pneumonia 
affects by preference the lower lobes; it does sometimes commence in the upper, 
but that is comparatively rare. When it occupies the superior lobes it generally 
has arrived there by traveling upwards from the inferior. You will at once per- 
ceive the practical advantage of knowing these points of contrast. 

It is a curious fact also — less practically useful, perhaps, than the former, but 
still a valuable fact — that the left lung is much more obnoxious to tubercular dis- 
ease than the right. Modern observers have collected numerical statements show- 
ing that this really is so. Why it should be so, I know not. Thus Louis, whose 
volume is the result of immense labour in observing, and is full of the most 
instructive matter, had met with seven cases in which tubercles were confined to 
a single lung: in two of the seven cases it was the right lung that was thus exclu- 
sively affected, in Jive it was the left. Of 38 instances in which the upper lobe 
was totally disorganized by the disease on one side, 28 were of the left, and only 
10 of the right. Eight times he had known the pleura perforated by the exten- 
sion of tubercular disease; and seven times out of the eight the perforation hap- 
pened on the left side of the chest. So also Reynard met with 27 cases of pneu- 
mothorax on the left side, to 13 on the right. No less curious is it that here also 
the facts ascertained with respect to pneumonia are just the contrary of those 
which belong to phthisis. I mentioned, in a former lecture, Andral's conclusion, 



PHTHISIS. 



639 



derived from the observation and collation of 210 examples, that pneumonia is 
more than twice as common on the right side as on the left. M. Lombard, of 
Geneva, found the ratio somewhat less than this, but still great. Of 868 instanced 
of pneumonia, 413 occurred on the right side alone, 260 on the left alone, and 195 
on both sides at once. That is, there were three on the right side alone, for every 
two on the left alone. 

The tubercular matter then, being deposited on the mucous surface of the 
vesicles, and of the small bronchial tubes that conduct to them — groups of these 
diseased air-cells, lying contiguous to each other, become, more or fewer of them, 
amalgamated, or fused, as it were, into one large mass : and generally there are 
tubercles of various sizes, from that of a pin's head, to that of a pigeon's egg, in 
the same lung. And there is yet another disposition which the tubercular matter 
is apt to take : it sometimes is diffused uniformly over a considerable space, occu- 
pying all the areolar and interstitial portions of the part affected, and having no 
distinct circumscribing boundary. The part looks as if fluid tubercular matter 
had been poured into it, and there had hardened. This is what the French call 
tubercular infiltration of the lung. 

The tubercular matter, once deposited, may remain for a longer or shorter time 
in what is called the crude state; surrounded by perfectly healthy lung, under- 
going no increase in quantity, and no alteration of consistence. But in a vast 
majority of cases, scrofulous inflammation is sooner or later set up around the 
tubercles — or in the areolar tissue imprisoned within the agglomerated masses — 
and then the whole breaks down in the way I mentioned before; and the detritus 
is conveyed through one or more tubes into the primary divisions of the bronchi, 
and thence to the mouth, to be expectorated. Of course there is an excavation, 
cavity, cavern, or vomica, left. All these names are given to the void space which 
the tubercular matter previously joccupied. Now there are some curious particu- 
lars to be mentioned respecting these cavities ; but I must postpone them till our 
next meeting. 



LECTURE LVI. 

Phthisis, continued. Vomicae; adhesions of the pleurae; ulceration of the larynx 
and trachea — of the intestines ; fatty liver ; auscultatory signs of a vomica : 
gurgling, cavernous respiration, pectoriloquy ; general symptoms of phthisis : 
cough, expectoration, dyspnoea, pain, hectic fever, diarrhoea, wasting, oedema, 
aphthae. 

We were engaged, when we separated yesterday, in investigating the morbid 
anatomy of consumption. Bear in mind how and where the tubercular matter, 
which is the essence of that disease, is deposited in the lungs : that it occupies by 
preference their upper lobes, and the upper part of those lobes ; invading gradually 
the lower lobes, from above downwards, as the disease advances. Both lungs 
are, commonly, affected at the same time, though in unequal degrees. Among 
one hundred and twenty-three instances of phthisis, Louis found that the tuber- 
cles were limited five times to the left lung, and twice to the right. The tubercu- 
lar matter, once deposited, may remain quiet and unchanged for some time ; but 
in general it increases in quantity, until at length inflammation of a low and scro- 
fulous character, arises in the pulmonary substance in immediate contact with the 
tubercles — or in the areolar tissue involved in the larger agglomerated masses — 
in consequence of which inflammation a sort of suppuration takes place ; the 
tubercular matter becomes soft, and breaks down, and is ultimately expelled 
through the bronchi, trachea, and mouth. The vacuities left in the lung after this 



640 



PHTHISIS. 



process of expulsion are called cavities, excavations, caverns, vomicae. And I go 
on to consider certain points of practical interest connected with these vomicae. 

In the first place, as you may see by the specimens upon the table, they vary 
greatly in size. They may be no bigger than, or not so big as a pea: or they 
may be large enough to contain a pint or more of fluid. Sometimes the whole of 
the upper lobe is converted into a bag of this kind. These large cavities are never 
met with in the lower lobes. They are formed by the union of several that are 
smaller; so that they are often of very irregular shape, and divided, as it were, 
into chambers, by imperfect partitions, or by bands which cross them in various 
directions. Opening into the cavity there is always one, and there are generally 
several, pervious bronchial tubes, which seem as if they had been cut off just 
where they enter the cavity. But you never, or very seldom, indeed, find a 
blood-vessel thus opening into the cavity. And the reason of these differences is 
plain enough. It is not, as some modern authors have fancied, that the arterial 
or venous tissue possesses a low degree of vitality, and therefore resists or avoids 
the destruction in which the surrounding tissues are involved. That principle 
may be applicable to other cases, but it is not applicable to this. The opinion I 
am now referring to proceeds on the supposition that the bands which sometimes 
cross the cavities are really blood vessels that have escaped the disorganizing pro- 
cess. Such seems to have been the notion entertained by Bayle; and it has been 
more recently and more expressly advanced by Crnveilhier. But the truth is, 
that these bands rarely contain blood-vessels : and when they do contain them, 
the blood-vessels are mostly impervious. In one hundred and twenty-three cases, 
Louis found pervious blood-vessels in the bands no oftener than five times. 

The true reason why bronchial tubes open into these cavities, and blood-vessels 
do not, is to be found in the natural differences between the two sets of vessels, 
in respect to their structure, and in respect to the fluids that pass through them. 
The blood-tubes yield readily to external pressure. Many of them are pushed 
aside and flattened by the progressive increase of the tubercular matter around 
them ; some probably are obstructed by its gradual accumulation within. In either 
case the stagnant blood coagulates, and the vessel is obliterated to some distance 
from the place of the original obstacle ; just as you know a clot forms, and seals 
up an artery, which has been tied during life, for some little way anterior to the 
ligature. But the bronchial tubes are neither so easily compressed, nor do they 
carry any coagulable fluid. In the agglomeration of the tubercular masses, by 
the softening of which the cavities are formed, the air-tubes included within the 
mass are filled up by it; and when the whole breaks down in scrofulous suppu- 
ration, they are expectorated with the rest of the detritus. Meanwhile their open 
mouths, on the hither side of the point where the tubercular matter stopped, 
remain, and afford a channel through which the same matter, after it has become 
soft, finds its way towards the trachea. Occasionally, indeed — but that, I repeat, 
is a rare occurrence- — a considerable blood-vessel does get laid open during the 
formation of a vomica, and then copious and fatal hemorrhage ensues. Occasion- 
ally also an oozing or exhalation of small quantities of blood takes place from the 
inner surface of the cavity, tinging the matter expectorated. 

When the vomica is first formed, by the expulsion of the tubercular matter, its 
inner surface is soft and ragged ; and if other softening tubercles are in the imme- 
diate neighbourhood, the cavity goes on enlarging; that is, two or more vomicae 
coalesce. If, however, there happen to be no more tubercles thereabouts, the 
cavity may remain stationary. Its inner surface then becomes smoother; and 
something like a membrane forms upon it: and sometimes a puriform fluid is 
poured out by this surface, and sometimes not. Generally the pulmonary tissue 
around such a cavity is condensed and solidified ; partly perhaps by crude tuber- 
cular matter which it contains, partly in consequence of the inflammatory process 
of which it has been the seat during ihe softening of the tubercles. It is impor- 
tant to bear in mind this fact of the condensed, solid state of the lung immedi- 



PHTHISIS. 



641 



ately surrounding a vomica; for it explains certain peculiarities met with in the 
symptoms. 

There is another point of much interest connected with these vomicae. When 
they occur singly, without other tubercles or caviiies (which, though a very rare 
thing, does sometimes happen); and when occurring thus singly they have been 
completely emptied of the tubercular matter ; they may gradually contract, and 
ultimately become obliterated. This approach of their sides leads to a puckering 
of the pleura on the surface of the lung : and on the other hand, a puckering of the 
surface indicates that beneath it there is probably a collapsed vomica. Its inner 
surface becomes converted in that case into a substance resembling cartilage : and 
the appearance it presents is called a cicatrix : and really it deserves that name. 
The process which has gone on is a process of natural recovery : and the recovery 
would be complete, if no fresh deposit of tubercular matter took place. Too often, 
however, the tubercles multiply, until at length their number, or size, or effects, 
become incompatible with the further continuance of life. 

This, then, is one way in which tubercular disease, limited to one small por- 
tion of the lung, may be eliminated, and the part which it occupied undergo a 
kind of repair. But the disease, when so limited, may cease in another way. 
The more watery parts of the morbid secretion may be absorbed ; and the earthy 
salts it contains may concrete; and the whole be converted into a shriveled, hard, 
chalky mass, which sometimes is coughed up, sometimes, in favourable cases, 
remains for years in the lung, an inert and almost harmless body. 

Let me state, while I think of it, that the expectoration of these chalk-like con- 
cretions, denoting, as it usually does, the existence of pulmonary consumption, 
marks at the same time the chronic character of the case. I am acquainted with 
a gentleman who, though delicate, enjoys a very fair share of health, and who has 
for years been coughing up, at intervals, little branching fragments, like bits of 
white coral, consisting principally of carbonate and phosphate of lime, and evi- 
dently moulded in the smaller bronchial tubes. 

When the tubercles are numerous — or rather when they lie near to the surface 
of the lung, as, of course, they are likely to do when they are numerous — they 
very generally give rise to dry or adhesive pleurisy. So that in a person dead of 
consumption, it is a very rare thing to find the lungs free from adhesions to the 
ribs. I mentioned before that this attachment of the lung to the walls of the chest 
affords a protection against a much more formidable condition ; namely, perfora- 
tion of the pulmonary pleura, and the escape of tubercular matter and air into the 
serous cavity: producing that worst kind of pleurisy which constitutes pneumo- 
thorax. That the pleurisy and adhesion are consequences of the presence and 
irritation of the tubercles, appears from this : — that, for the most part, the extent 
and the situation of the adhesions correspond with the extent and situation of the 
tubercular disease. Thus, a single spot of adhesion has been seen to unite 
the costal and pulmonary pleura? exactly opposite a solitary tubercle which lay 
near the surface of the lung. As the summit and back part of the upper lobes are 
most thickly set with tubercles, so here also is the adhesion the most constant, 
and the most firm. You will often find the upper part of the lung invested with 
a thick cap of false membrane ; and the connection between the pleurae so tough, 
that the lung breaks down in the attempt to separate them. 

To show you that these statements — which have long been familiar to those 
much conversant with disease and with morbid anatomy — to convince you that they 
are strictly borne out by numerical or tabular facts, I may again have recourse to 
Louis. He tells us that in 112 cases which he himself examined of persons dead 
of consumption, and having therefore tubercles in their lungs, there was but one 
in which both lungs were free from adhesions. In eight cases the right lung was 
exempt from them ; and in seven cases the left. Again, in twenty-five other 
instances, there were either no cavities, or very little ones ; and the adhesions 
were accordingly of small extent, and easily broken down. In the remainder 
three were large vomicae, and the adhesions were extensive, dense, and firm. 
41 



642 



PHTHISIS. 



Such is a sketch of the changes which take place in the lungs, in consequence 
of the deposition of tubercular matter in them, and of the changes which 
that matter undergoes. But the air-passages that lead to the lungs are very liable 
to become implicated as the disease proceeds. The mucous membrane of the 
larynx and trachea ulcerate: and when the morbid condition of the larynx gives 
rise to prominent symptoms, and especially (as it is apt to do) to hoarseness and 
loss of voice, the disease is sometimes called laryngeal phthisis. But there is no 
such disease, that I know of, existing by itself. I mean, that scrofulous ulcera- 
tion of the larynx and trachea occurs only when the lungs are affected with tuber- 
cles. It is curious that when ulcers are met with in the trachea, they are often 
found on one side of it only; on the side, viz. which corresponds with the dis- 
eased lung, or with that lung which is most diseased. In like manner, when 
some of the bronchi are found red internally, and even ulcerated, these appear- 
ances are confined to those bronchi which communicate with cavities ; and do not 
occur in the bronchial canals leading to crude tubercles. It is towards the back 
part also of the trachea that the ulcers, especially when large, are most commonly 
observed ; the floor of that channel when the patient lies supine. And when the 
epiglottis is involved in the mischief, the ulcers are situated, almost always, on 
its laryngeal surface alone. We have strong reasons therefore for believing that 
their formation is influenced by the contact of the matter which is expectorated, 
in its frequent passage over the mucous membrane. Moreover the little mucous 
glands wherewiih the membrane is provided, are most numerous at the posterior 
part of the trachea and bronchi ; and these glands are especially prone to ulcerate. 

In respect to these points also Louis has made comparative observations. 
Among 180 persons who died of some chronic disorder, not phthisical, he once 
only met with ulceration of the larynx ; whereas of those who perished with con- 
sumption, nearly one in every Jive had ulceration of the epiglottis and larynx, and 
nearly one in three had ulceration of the windpipe. Hence it would appear that, 
if we except the effects of the syphilitic poison upon the larynx, ulceration of that 
part is almost peculiar to phthisis pulmonalis. 

I have told you that consumption is not merely a long disease. Its local ravages 
are most obvious indeed in the thorax : but it leaves in the abdomen also traces of 
its destructive agency not less definite and scarcely less constant. You know that 
the surface of the intestinal canal is strewed, throughout, with separate mucous 
follicles ; and that the lower portion of the ileum is furnished with other follicles, 
collected together in oval or circular groups. When I come to speak of continued 
fever I shall have much to say about the changes which these little glandular 
bodies undergo, in one form at least of that disease. These same glands are the 
frequent seat of tubercular deposit in phthisis. Here and there you may see a 
solitary yellow tumour, not larger than a hemp-seed, projecting from the surface 
of the bowel. In other places the ripened little tumour has burst, the tubercular 
matter is gone, and a ragged roundish ulcer remains. More frequently the aggre- 
gated glands are affected; and the ulceration, in them, varies much in form and 
extent. It often involves the whole patch, and then the shape of the ulcer is 
more or less elliptical. Louis met with ulceration of these glandulae agminatae 
in five-sixths of ali the fatal cases of phthisis that he examined. Ulcers, of 
greater magnitude, were very nearly as common in the large intestines. And it 
is worthy of notice that, the disorganizing process being in these cases slow, 
nature has time (if I may use such metaphorical language) to provide against the 
threatened perforation of the gut. The tissue that forms the base of the ulcer, 
whether it be the muscular or the peritoneal coat, is thickened and vamped : or 
the bowel becomes adherent to some contiguous surface. Once only in my life 
have I known scrofulous ulceration, in phthisis, penetrate the serous tunic, and 
allow the contents of the intestine to escape into the sac of the peritoneum. 

It is fitting you should know — although the facts possess, as yet, no practical 
value — that the stomach is often much enlarged and thinned in those who die of 
consumption ; and that the liver is very apt to undergo a remarkable change, 



PHTHISIS. 



643 



almost peculiar, I believe, to that disease. It, too, enlarges, and becomes full of 
adipous matter, greasing the hands and scalpel of the anatomist, and yielding when 
heated an oily substance, which makes a grease-spot on paper placed in contact 
with it. The whole gland partakes in the alteration, is of soft consistence, loses 
its natural red tint, and assumes a pale fawn colour. No profession contributes 
so much as ours to the introduction of new, barbarous, and dissonant words into 
the English language. We have accordingly invented an epithet for this kind of 
liver. We call it (not \hefat, but) the fatty liver. In three years Louis met with 
this fatty liver forty-nine times ; and forty-seven of the patients died phthisical. 
It occurred in one-third of the whole number of the victims to consumption ; 
whereas, among two hundred and twenty-three cases, not phthisical, there were 
two examples ' only of this hepatic change. Its presence is revealed during life 
by no symptoms, except that the enlargement belonging to it may sometimes be 
ascertained by percussion and pressure with the fingers. 

Let us now inquire what modifications of the healthy sounds arise from the 
altered conditions of the lungs in phthisis. Most of them are such as you would 
naturally expect. Whether a portion of lung be rendered solid by common 
inflammation, or by the presence of tubercles in it, the result, so far as the auscul- 
tatory signs are concerned, will be the same. In such a piece of lung, supposing 
the solidification complete, no vesicular breathing can be heard ; but bronchial 
breathing and bronchophony will be audible, in each case, if the solidified portion 
encloses a considerable bronchus, and comes near the surface of the chest. And 
percussion will give a dull sound, whether the lung lying beneath the part struck 
be hepatized, or blocked up by tubercular matter. On these points, therefore, 
after what was said in a preceding lecture, I need not dwell. But the excavations, 
the empty or half-empty vomicae — these are something new. We have hitherto 
met with no condition exactly similar to that of a large cavity. And accordingly I 
have to make you acquainted with two or three new sounds : or sounds which are 
modifications of those formerly described, and in most instances sufficiently dis- 
tinct from them to have acquired peculiar names. You will remember that what 
we have called large crepitation depends upon the passage of air through liquids; 
the liquids being contained in tubes; those tubes the bronchi and their ramifica- 
tions. But when pus or vitiated mucus, or liquid of any kind, is collected in a 
vomica, which communicates freely with the trachea through pervious bronchi, 
the bubbles produced by the entrance and exit of air will be still more numerous 
and large ; and a sound is then produced which the word gurgling expresses well. 
Laennec calls it gargoidllement. This sound is heard, too, in a circumscribed 
space ; and not diffused, as large crepitation usually is. Wherever, therefore, we 
hear gurgling during respiration, or during the act of coughing, there, we conclude, 
exists a cavity. But the cavity is not necessarily a vomica. In ninety-nine cases 
out of a hundred it will be so ; but in the hundredth case perhaps it will not. Bear 
in mind what was formerly stated of dilatation of the bronchi : how sometimes 
they terminate in a considerable globular expansion; sometimes belly out and 
contract again several times alternately : and yon, will see that cavities containing 
liquid, or liable to contain liquid, belonging equally to the one condition and to the 
other, and the sound in question depending solely on the intermixture and agita- 
tion of air with liquid in a cavity, we cannot be sure from mere gurgling respira- 
tion, or gurgling cough, that we have a tubercular excavation beneath our ear; or 
that the case is one of consumption. Gurgling may also proceed from that very 
rare morbid condition, abscess, the result of common inflammation of the lung. 
These constitute the only sources of fallacy in the matter. The fallacy seldom 
interposes; but it does sometimes interpose; and therefore it must qualify out 
conclusion from this symptom of gurgling, in respect to cases otherwise doubtful. 

Again, the vomica may be empty of liquid; and then we hear, as the patient 
respires, not vesicular breathing of course, nor yet exactly bronchial breathing ; it 
is something more than that when the cavity is large, something different in cha- 
racter from it when the cavity is small ; but whatever the character of the sound* 



644 



PHTHISIS. 



as we believe it to take plaee in a vomica or cavern, we call it cavernous respira- 
tion. It is a hollow sound, especially when the cavity is of considerable size; 
an exaggeration of mere bronchial respiration. But the cavity may be small. The 
moment a portion of tubercular matter is separated and discharged through a 
neighbouring bronchial tube, the cavity has commenced; and the sound produced 
in these little cavities during the breathing may be of various kinds. It may be, 
and it often is, a cliek, like the opening and shutting of a valve; or a chirp; or a 
creaking ; or like many other well-known sounds : but, as all these sounds, under 
certain circumstances, denote the formation of a vomica, it is best for simplicity's 
sake, to call them all by the same name — cavernous respiration. 

Dr. Latham explains in a few words the causes of these differences. " The 
varieties of cavernous breathing are doubtless owing to different sizes, and forms, 
and situations of cavities, and to different conditions of the surrounding lung. A 
cavity may be very large or very small. Several bronchi may open into it, or 
only one. It may be a simple cavity, or it may have many chambers. Its sides 
may be condensed and equal, or rough and ragged. The lung around it may be 
solid and indurated, or pervious and vesicular. It may be near the ribs, or far 
from them : adherent to, or separate from the pleura. It is quite obvious that 
these different circumstances are calculated to modify the sound, which will, never- 
theless, be always such as indicates a cavity." 

A tubercular cavity may be so large, and of such a kind, as to yield the metallic 
sounds which are apt to be heard in pneumothorax. I show you a cavity in which 
those sounds were actually heard, most distinctly, by many persons, during the 
patient's life while he was under my care in the Middlesex Hospital. I was 
certain beforehand that these sounds proceeded, not from the cavity of the pleura, 
but from a tubercular excavation. Once subsequently, in a patient who was dying 
of phthisis and diabetes, I have heard the same sounds ; also, I am sure, in a 
tubercular cavity. The patient insisted on leaving the hospital, and I lost sight of 
him before he died. 

I promised, when speaking of these metallic sounds as arising (as they much 
more commonly do) from pneumothorax — a collection of air, or of air and fluid, 
in the sac of the pleura — I promised to point out the circumstances whereby you 
may tell which of the two conditions in question the sounds denote. Both of the 
conditions imply, in general, the existence of tubercular phthisis; and therefore 
the observation of the ordinary symptoms of phthisis will not help us much. 

Now, in the cases seen by me, there were two circumstances that stamped them 
as being cases in which the sound proceeded from a cavity in the lung, and not 
exterior to it. One was the situation in which the sound was invariably heard. 
The other was, the absence of excessive resonance when that part was percussed. 
You know that when air is contained within the pleura itself, the sound yielded 
on percussing the chest in the corresponding spot is quite tympanitic, like that of 
a drum. But it is a well-ascertained fact, (though contrary perhaps to what you 
would suppose,) that the sound is duller over tubercular cavities, in nine eases out 
often, than over sound lung. The explanation of this fact is simple enough. It 
is that the layer of lung which still remains in such cases, thick or thin, is dense 
and solid, and damps the sound which the vomica might otherwise make resonant. 
But then again the situation- of the metallic sounds was a guide. They occupied 
the upper part of the chest: the very part where vomicae are wont to be the most 
common, and the largest: and moreover a part where pneumothorax seldom or 
never exists. The summit of the lung is generally covered in phthisis with a cap 
of false membrane, which binds it to the ribs : and this, as I observed before, is 
the main reason why perforation of the pleura pulmonalis is so rare in that dis- 
ease.; and it is also the reason why, when it does take place, it seldom takes 
place at or near the apex of the lung. In truth it is found by experience that 
(though the rupture of the pleura may happen in any part) the place where it 
usually occurs is in the lower and back part of the upper lobe of the lung, oppo- 
site the angle of the third or fourth rib ; that is, just beneath the edge of the false 



PHTHISIS. 



645 



membrane by which the summit of the lung is generally adherent. But the sound, 
in the cases I refer to, was invariably heard at the very top of the chest. It did 
not shift, as that of pneumothorax may often be made to shift, when the patient 
changed his posture. Attention to these points will always lead you to an exact 
diagnosis. You may say, perhaps, " The complaint being in each case a mortal 
one, what is the use of so much refinement?" Why, there is this utility in it. 
We may sometimes, as I stated before, give great relief to the patient, and save 
his life for a time, by tapping the chest in pneumothorax. The air may get in 
with each inspiration, and threaten immediate suffocation; and the thorax being 
punctured it will issue in a blast. But no one would think of tapping a tubercu- 
lar cavity. 

To give out the amphoric resonance and the metallic sounds, the vomica must, 
I presume, be a large one. That which is before you, the only one I ever saw 
in which those sounds had been heard, is very large. Its inner surface is smooth : 
it adheres to the ribs externally by at least two-thirds of its cireumferenee : and 
the medium of adhesion is very thin. Quite low down, a single bronchial tube, 
of about the third division, may be seen to enter it. 

So much, then, for the modification by a tubercular cavity, of the sounds "heard 
during respiration. But the voice will also be modified, if the cavity be of con- 
siderable size, and near the surface, and have dense walls, and be empty. Then 
we hear, in that part, when the patient speaks, the sound which is called pecto- 
riloquy; as if the voice proceeded from the chest. The words are distinctly 
articulated into the ear of the listener. But I need not trouble myself or you by 
attempting to describe pectoriloquy. You may any day hear the exact sound 
that word is intended to denote, by placing a stethoscope over the trachea of one 
of your friends, applying your ear to the other end of it, and getting him to speak: 
just as you may obtain an exact notion of bronchial respiration by listening then 
to his breathing. 

For some time after the first appearance of Laennec's great and original work 
on the diseases of the chest, pectoriloquy was deemed to be the pathognomonic 
and infallible sign of a vomica. "Oh," the young auscultator would say, "I 
detect pectoriloquy beneath the clavicle. There can be no further doubt about 
the nature of the disease. My patient has not only tubercles, but a cavity, in his 
lung." So I long thought; and so some, I fancy, think still. Yet the evidence 
afforded by mere pectoriloquy of the presence of a vomica, or even of the presence 
of tubercles, is far from being certain or trustworthy. Experience had taught me 
this before I knew that many others, studying under the same schoolmaster, had 
learned the same truth. Among my hospital patients some years ago was a 
man who laboured under phthisis. Percussion gave a dull sound under his right 
collar-bone, and in the same spot loud and distinct pectoriloquy was audible. I 
well recollect inviting the particular attention of the pupils to this case, as affording 
an exquisite specimen of pectoriloquy ; and I predicted very confidently that after 
the patient's death, which was obviously at hand, a large excavation would be found 
in the summit of his right lung. My prediction did me no credit. The left lung 
indeed was hollowed by cavities, but there was nothing like a cavity in the right. 
The upper part of the lung was thoroughly and uniformly solid ; filled with hard, 
gray, tubercular matter. The large bronchial tubes were pervious, and the voice 
descending into them had been conducted by the solid lung with perfect and 
almost painful distinctness to the listeners ear. This was a useful lesson to me: 
and I mention it that it may be a lesson to yon. Remember that solidification of 
the summit of the lung will modify the sound of the patient's voice, very much in 
the same manner as a large vomica there situated. It is stated, indeed, and per- 
haps truly, that a practised ear can discriminate between the loud, diffused, 
though articulate, resonance of the voice produced by solid lung, and the circum- 
scribed, whiffing, pectoriloquy of a cavity. But the distinction is too nice for the 
average of practitioners, Now since the pulmonary tissue may be rendered dense 



646 



PHTHISIS. 



and solid by other causes than tubercles, pectoriloquy does not always indicate 
the existence of consumption. The fallacious condition does not often occur; 
for common inflammation is seldom limited to the upper part of the lung ; and the 
whole of that part is seldom completely hardened by crude tubercles. But when- 
ever it does occur, it is apt to mislead or puzzle. I was consulted last year about 
a gentleman in whom this phenomenon of pectoriloquy was strongly marked. 
Two excellent auscultalors had been led, by this symptom, to the belief that a 
cavity existed in the lung. Remembering the case I have just mentioned, and 
learning that the patient had been ill for a few days only, and had not previously 
suffered cough, nor any apparent pectoral complaint, I was of opinion that the 
summit of his right lung had become hepatized by acute pneumonia. And it was 
so. The patient died ; and the diagnosis I had formed was verified upon the 
inspection of the lung. Dr. Latham relates one or two examples to the same 
purpose. Dr. Stokes goes so far as to consider pectoriloquy the least important 
and most fallacious of all the physical signs of phthisis. Taken alone (he says) 
it is absolutely without value. Dr. Forbes has come to similar conclusions. 
Certainly cavernous respiration is a much more alarming sound. 

Wherever actual pectoriloquy from a cavity is heard, there also will be heard 
cavernous respiration. But the converse of this is not necessarily true. There 
may be, and there often is, cavernous respiration and a cavity, yet no pectoriloquy. 
The cavity is not large enough, or not near enough to the surface of the chest, or 
not of such a kind as to reverberate the voice. 

Often when pectoriloquy is absent, and cavernous respiration is doubtful, and 
gurgling even cannot be heard (because the communication with the bronchi is 
not free), a slight splashing sound will occur when the patient coughs : nay, you 
may sometimes hear it, if he holds his breath, with every beat of his heart, which 
causes a little succussion in the cavity : but its contents must then be thin. 

Now when the sounds I have been engaged in describing are well marked, they 
denote the existence of a vomica. The only source of fallacy is that which I 
formerly mentioned : the same sounds may arise from a cavity in the lung, what- 
ever be its nature ; and therefore they may arise when the bronchi are expanded 
into cavities. But I repeat that this is a deceptive condition which you cannot 
calculate upon meeting with often. 

When the sounds are not well marked, take time before you pronounce a de- 
cided opinion respecting them. Strong bronchophony comes very near to weak 
pectoriloquy : bronchial respiration may closely resemble some varieties of ca- 
vernous breathing : large crepitation, confined to a small spot, may simulate gurg- 
ling. It is better, when the sounds are thus equivocal, and when they may denote 
conditions so very different in their nature and tendency, to suspend one's judg- 
ment, and to give a guarded opinion. A little time in such cases will clear away 
the doubt. 

I am afraid of being tedious about4hese sounds ; but really they are of immense 
importance. Upon their exact appreciation, and correct interpretation, will de- 
pend the opinion you will be called upon to express ; and that opinion will, in 
many cases, be a sentence of life or death in respect to the dearest friends of those 
who hear it. A correct diagnosis is also very important, in the early periods of 
the disease especially, for another reason. It is in those early periods alone that 
we can hope to arrest the progress of the complaint by art, or by change of cli- 
mate. 

I must now consider the general symptoms of this most afflicting disease : and 
while doing so, I shall point out how the physical signs confirm or confute their 
language, in cases which might otherwise be doubtful. 

The general symptoms of phthisis are cough, dyspnoea, expectoration, hae- 
moptysis, wasting, hectic fever, hoarseness, or loss of voice, diarrhoea; and 
there are some other symptoms which mark often some of its stages, and to 
which I shall incidentally advert. I shall speak of them all as briefly as is con- 
sistent with clearness. 



PHTHISIS. 



647 



Cough is one of the earliest symptoms of consumption; and it is that which 
commonly first attracts the attention, and awakens the fears of the patient, or the 
patient's friends. Generally at first it is slight, occasional, and dry : it occurs 
upon the patient's getting out of bed in the morning ; or if he makes any 
unusual exertion in the course of the day. It feels to him as if it was caused by 
irritation about the throat. Sometimes it will cease for a while, as in the warm 
weather of summer, and recur in winter when the external temperature is lower. 
By degrees it begins to be troublesome in the night : and to be attended with 
more or less mucous expectoration. 

Now when such a cough steals upon a person gradually, and when no reason 
can be assigned for its occurrence, that circumstance alone is enough to excite 
suspicion as to its true nature and cause. But chronic cough may. exist without 
any tubercular disease of the lungs ; as you well know. It may depend upon a 
disordered state of the stomach ; the pneumo gastric nerve may be irritated there. 
It may be the cough of chronic catarrh ; it may result from disease of the heart; 
it may be the nervous, barking, importunate cough which I formerly mentioned 
as of frequent occurrence in hysterical girls. And bearing these circumstances 
in your mind, you will inquire and you will generally make out without much 
difficulty, whether there be any unnatural or deranged state of the digestive 
organs ; or chronic catarrh ; or cardiac disease ; or hysteria. These are points 
on which I need not further insist. 

I may observe, here, that as chronic cough may exist when there is no con- 
sumption; so consumption may sometimes exist, and even prove fatal, and large 
portions of the lungs may be disorganized, without there having been any cough; 
or at least without the occurrence of cough enough to draw the notice of the 
patient or his friends to it. This is not common, however : cough is usually 
present more or less, during all the stages of phthisis, and it is often that symp- 
tom which most distresses and harasses both the patient and his family. 

Great attention used to be paid to the expectoration in eases of suspected 
phthisis. It was thought that if a patient spat pus, he was in a state of con- 
firmed consumption: and whole volumes have been written, and prizes awarded 
to their authors, respecting the means of distinguishing pus from mucus. But 
we now know that, so far as the diagnosis of phthisis is concerned, this is a very 
idle inquiry. The inflamed bronchial membrane may secrete pus ; so that the 
presence or absence of pus in the sputa is no test at all of the presence or absence 
of tubercles in the lungs. If you are, nevertheless, curious to know how pus 
may be recognized, one easy criterion is that proposed by the late Dr. Young. 
You are aware that pus, like the blood, contains globules ; and these globules, 
when examined through transmitted light, will exhibit prismatic colours ; appear 
surrounded by rings of colours, somewhat resembling those of the rainbow, but 
differently arranged, and often beautifully brilliant. Mucus having no such globules, 
affords no such coloured rings. The way to make the examination is, to put a minute 
quantity of the fluid between two small pieces of plate glass; to hold the glass 
close to the eye ; and to look through it at a distant candle, having a dark object 
behind it. A yet readier, and I believe a better test is furnished by the liquor 
potassse, which converts pus into a viscid stringy mass, while it liquefies mucus. 

Whether the expectoration be puriform or not, has ceased, however, to be a 
question of much importance as regards the diagnosis of phthisis. A portion of 
the matter expectorated comes from the surface of the bronchi, and consists of 
altered mucus : and therefore the sputa brought up in phthisis, and the sputa 
brought up in bronchitis, are, in a great degree, the same. These are partly 
composed of a stringy transparent fluid, in which opaque masses of a yellow or 
greenish colour are seen to float; and intermixed also with which there may be a good 
deal of froth. The froth is a measure of the difficulty with which the mucus is 
brought up : and it is usually less abundant and conspicuous in phthisis than in 
bronchitis. The heavy sage-leaf sputa that we sometimes see, belong to both 
diseases. 



648 



PHTHISIS. 



You may occasionally find portions of tubercular matter in the expectoration ; 
a circumstance quite decisive, when we are sure of it, of the nature of the case: 
dull yellow streaks, or little curd-like fragments involved in the mucus. But small 
opaque specks of that character are sometimes formed in the follicles of the tonsils ; 
and this makes the appearance more equivocal. The sputa most characteristic of 
tubercular disease consist of globular flocculent masses, which look like little por- 
tions of wool more than any thing else. Nummular sputa the French call these, 
because when spat into a vessel not containing water, they assume a flat circular 
form, like a piece of money, and remain separate and distinct from each other. 
When they are spat into a glass of water, you perceive that some of them sub- 
side to the bottom — some float on the top, suspended, apparently, by healthier 
mucus in which they are entangled, or by bubbles of air — and some remain sta- 
tionary at different depths. When stirred and agitated in the water, they render 
it slightly milky. This kind of expectoration commonly marks a confirmed and 
advanced state of the disease ; but it will continue for weeks sometimes. It is not 
perfectly pathognomonic, but nearly so. On one occasion I found expectoration 
of this nature from a man whom I did not very diligently examine by my ear; and 
I set the case down as one of phthisis chiefly on the observation of that symptom. 
The patient evidently had not long to live. Our apothecary at the hospital, Mr. 
Corfe, had more time to explore the condition of the chest: and he came to the 
conclusion, that the disease was not tubercular phthisis, but extensive chronic 
bronchitis: and sure enough he was right. When we came to examine the lungs 
after the patient's death, not a tubercle could be found. I am satisfied that there 
is no kind of expectoration which indicates phthisis with perfect certainty; but 
that which I have just been describing very seldom occurs except there is phthisis. 
Louis appears to have noticed these round, separated, woolly masses twice only 
unconnected with tubercles; and once the same thing has occurred to Chomel : 
so that, when the other symptoms are obscure and doubtful, this will materially 
augment the gravity of the prognosis. Flies appear to be more attracted by the 
sputa of phthisis than by any other. 

Haemoptysis is a kind of expectoration; the expectoration of blood. I have 
already spoken of this symptom as connected with phthisis, and have stated my 
belief on that subject; viz., that if a person spits blood who has received no in- 
jury of the chest, in whom the uterine functions are healthy and right, and who 
has no disease of the heart, the odds that there are tubercles in the lungs of that 
person are fearfully high. Excluding cases of amenorrhcea, and of mechanical 
injury to the thorax, Louis did not meet with a single example of haemoptysis 
among twelve hundred patients, except in such as were phthisical. 

I touched, at the same time, upon the question, whether haemoptysis, which 
sometimes precedes for a while the manifestation of any other symptoms of con- 
sumption, is ever really the cause of it, as the old authors maintained. You will 
understand my persuasion to be that, occurring in connection with tubercles, pul- 
monary hemorrhage is always the consequence, and never the cause, of their 
presence in the lung. Andral relates a curious case, from which the contrary 
opinion might be argued. "A man, ill of chronic peritonitis, had been for nearly 
two months in La Charite, and had never presented any morbid symptom which 
had relation to the organs of respiration. He had no cough, and he breathed easily. 
One evening, for the first time, he suffered some dyspnoea: and in the course of 
that night he spat up a large quantity of florid and frothy blood. For the five 
following days the haemoptysis continued abundant, then it diminished by degrees, 
and at length stopped. But the patient continued to cough, and to breathe with 
difficulty, and at length he died. In the right lung there were found several 
masses of a brownish-red colour, exactly circumscribed, and constituting, in short, 
that condition which Laennec has called 'pulmonary apoplexy/ One of these 
masses contained a considerable number of granulations of a yellowish-white 
colour, and having all the characters of minute tubercles in an early state. Two 
other of the red masses contained each a very small number of these white gra- 



PHTHISIS. 



649 



nules ; and in the remaining masses no tubercles at all could be discovered, nor 
was there any trace of them in other parts of the lungs; but they were numerous 
in the false membranes of the peritoneum." 

Andral argues, that in this case the partial collections of blood that were found 
in the lung could not have been occasioned by the presence of tubercles, because 
in the majority of these masses no traces of tubercular matter could be perceived. 
On the other hand, their existence appears connected with that of the apoplectic 
masses, because, except in the midst of some of these, no pulmonary tubercles 
could be seen. But such a case as this hardly bears out the conclusion that pul- 
monary hemorrhage is ever the cause of tubercles. There were tubercles in the 
abdomen before ; therefore, the disposition to tubercular disease pre-existed in this 
individual ; and then tubercular matter was deposited in the places where blood 
was extravasated ; just as we know it is deposited in the blood itself, in the spleen 
sometimes ; or, what I think more probable still, the cluster of granulations pro- 
voked the hemorrhage from the spot they occupied, and other lobules of the same 
lung became blocked up by the reflux of blood, in the manner formerly explained. 

Prior to the age of fifteen, haemoptysis, even in phthisical children, is extremely 
uncommon. 

Dyspncea is not a very important symptom in phthisis. It is seldom extreme 
till towards the termination of the disease, and not always then. Patients who 
fear, and yet are unwilling to believe, that they are consumptive, will fetch a deep 
breath, and bid you remark how thoroughly they can distend their lungs ; and 
they expect you to say that there can be no disease in those organs. I have been 
told that the late Dr. Baillie died of pulmonary phthisis; and that. even he was 
accustomed to delude himself by this test. However, though phthisical persons 
do not in general suffer much from dyspncea, their breathing, though they may 
not be aware of it, or choose to acknowledge it, is generally, in some degree or 
other, short, or hurried. You may wonder that a disorder in which so large a 
portion of the breathing apparatus is often effectually spoiled, should be attended 
by so little distress in respiration; so little dyspncea: but your surprise will be 
diminished if you consider the insufficient manner in which consumptive patients 
are nourished, in consequence of abdominal disease ; and the extent to which 
their blood is wasted by diarrhoea, and by perspiration. The mass of blood is 
thus kept down to that measure which, passing through the still pervious portions 
of the lungs, is capable of being arterialized without any great deviation from the 
ordinary mode and frequency of breathing. 

Neither is pain of the chest a very important symptom in consumption. In 
some cases severe pains are complained of, resembling those of rheumatism, in 
the sides, or beneath the clavicles. In others, no pain at all is experienced. 
When sharp pain occurs, it may be supposed that the pleura is inflamed and 
beginning to adhere in the painful part. 

There is, however, one contingency of which the two symptoms last mentioned 
are sometimes very significant. When, during the progress of phthisis, violent 
pain of the side, and extreme dyspncea and anxiety, set in suddenly, they denote, 
with much certainty, perforation of the pleura, and its serious consequences. 

The hectic fever which accompanies phthisis is of much greater moment. It 
often creeps upon the patient insidiously. He feels chilly, perhaps, towards even- 
ing ; and in the night his hands and feet are dry and burning ; and in the morning 
he perspires. The most marked symptoms of the hectic are to be found in the 
perspiration, and in the state of the pulse. The perspiration is usually out of all 
proportion to the previous chilliness and dry heat. It seems to have a close con- 
nection with the sleep of the patient: it seldom comes on while he continues to be 
awake; but after sleeping he wakes, and finds that he is sweating. The perspi- 
ration is generally most copious on the upper part of the body, the chest and head. 
Sometimes it is moderate ; sometimes the patient is drenched and drowned in it. 
There is a good deal of uncertainty about this symptom, and of obscurity as to its 
cause. Generally speaking, it belongs to the more advanced stages of phthisis ; 



650 



PHTHISIS. 



but occasionally it accompanies its early period. It will cease without any appa- 
rent cause; and recur again with the same capriciousness. A poor friend of mine, 
who died of phthisis, and was particularly harassed by the nocturnal perspira- 
tions, took it into his head that posture had something to do with them ; and slept 
for several nights in succession sitting in an easy chair: and during those nights 
he certainly did not sweat, though he had been doing so profusely before. Louis 
found that one patient in ten escaped this symptom. 

This is a symptom which is often very distressing to the patient, making him 
even dread to go to sleep; it tends also to the rapid exhaustion of his strength ; 
and betokens, it is believed, when copious or persistent, a short duration of the 
disease. 

Frequency of pulse is a symptom so generally present in tubercular phthisis, 
that too much importance has been ascribed to it as a diagnostic sign. I mean, it 
has been too much the opinion that the lungs are safe, when the pulse does not 
rise above its natural standard. Sometimes it remains steady nearly up to the 
period of dissolution. Such cases are, I believe, generally slow in their progress. 

Very recently I lost a friend whose lungs were full of cavities and crude tuber- 
cles. He had been a valetudinarian for years ; but the pulmonary disorder had 
been manifested by decided symptoms during a few months only. At no period 
did his pulse exceed sixty-eight beats in the minute. Commonly, however, the 
pulse is habitually above ninety ; and often it is much more. When there is 
nothing to account for this increased frequency of pulse it is a suspicious symptom. 

Diarrhoea is a common, and an ugly symptom in phthisis. When it occurs 
early, as it sometimes does ; when a patient having habitually costive bowels, 
becomes habitually relaxed ; and you suspect only, from other causes, that he may 
have incipient phthisis; this change often sets its seal upon the nature of his dis- 
order. Usually, however, diarrhoea does not become urgent until the disease is 
far advanced, and has already declared itself by other and unequivocal symptoms. 
When it so occurs, it is apt to harass the patient exceedingly ; and rapidly to 
waste his strength and flesh. He appears to melt away under the influence of the 
purging ; which is therefore said to be colliquative. It used to be held that the 
diarrhoea and the perspiration bore an inverse ratio to each other: that when one 
of them abated, the other always increased. But the more exact observations of 
Louis and others have proved that this is not so : that neither in phthisis, nor in 
other diseases, have these symptoms any such regular reciprocal relation. One 
reason, perhaps, for this error, may be found in the circumstance, that acids, which 
have the effect often of checking the perspiration, tend also, as is well known, to 
produce diarrhoea. Louis found that this symptom began early in the disease, and 
continued through its whole course, in one out of every eight patients; and in 
one case only in every twenty-two was it wholly wanting. It depends most com- 
monly, if not always, upon scrofulous ulceration in the small intestines and in the. 
colon. In Louis' experience, there were, invariably, large ulcers, whenever the 
diarrhoea had been chronic and abiding, and the stools had been numerous. In 
the small intestines the ulceration evidently commences in the mucous follicles; 
the glandulae solitariae, or the glandulae agminatse : and sometimes, though not often, 
the ulcer perforates the bowel. It is probable that in the large intestine ulceration 
begins in the same way, by the deposit of tubercular matter (which is subse- 
quently removed) in the solitary glands : but when once begun the ulcerating 
process extends itself indefinitely to the surrounding mucous membrane. 

I should have stated before that, with this disease of the intestinal canal, there 
is often found enlargement of the corresponding glands of the mesentery, which 
are frequently filled also with tubercular matter. 

Several of the symptoms thai I have been mentioning — the state of the digestive 
organs, which interferes with the due assimilation of the food ; the drain implied in 
the profuse sweats, and in the habitual diarrhoea ; — conduce to cause another 
constant accompaniment of phthisis; and that is emaciation. — You know that 
the wasting in this complaint, when it is not cut short by some accidental com- 



PHTHISIS. 

0 



651 



plication before it has reached what may be called its natural termination, is 
extreme. It often is one of the earliest, as it is one of the most alarming, of the 
symptoms which the patient presents : and it frequently becomes excessive 
before any perspiration or purging have taken place to account for it. If, without 
any apparent cause, a person grows thin and weak, and his pulse is quick, and 
his breath at all short — these are intimations which seldom prove unfaithful, that 
tubercular disease is at work in the lungs, and in the abdomen. 

(Edema of the ankles, and even some purfiness of the hands and face, are 
circumstances which seldom fail to appear in pulmonary consumption: but they 
are among the latest of the symptoms. (Edema does not tell us what the disease 
is in such cases. We have been satisfied as to that some time before. But (un- 
less there is some marked disease of the heart) it tells us that the disease is about 
to terminate. It is worth attention as a prognostic symptom merely. 

And the same may be said of aphthae. This is one of the last of the symptoms : 
but it does not always occur at all. I have lately described this morbid fe condition 
of the mucous membrane of the mouth and tongue, and have nothing more to say 
of it at present. It has the same relation to phthisis as to other chronic disorders : 
it marks, for the most part, the approach of their fatal termination. 

It is always interesting to couple changes of structure with their appropriate 
signs. I will therefore take this opportunity of telling you what Louis has ob- 
served of this relation, in respect to the larynx and windpipe. 

Ulceration of the epiglottis was often latent; gave no appreciable signal of its 
existence. The symptoms that belong to it are, a raw, or pricking, or burning 
sensation at the upper part of the thyreoid cartilage, with occasional dysphagia, 
and the rejection of liquids through the nose, while the tonsils and pharynx present 
no visible alteration. 

Ulceration of the interior of the larynx is marked, when slight, by trivial pain 
in that part, and some variation from the natural voice ; when deep, by severer 
pain, and abiding aphonia. 

Ulceration of the trachea is seldom revealed by any symptom. And this is 
worth remembering: for patients are continually persuaded by medical men who 
know no better, that their symptoms are all tracheal. 

There are still a few other circumstances which, when they occur, accumulate 
conviction as to the nature of the disorder. The catamenia are suspended in 
women : and the hair falls cfT. There are certain physical peculiarities too, which 
are strongly indicative of a tendency to consumption ; or perhaps I should say of 
the scrofulous diathesis. Largeness of the pupil, with a sluggish iris — in other 
words, a not very sensible retina- — constitutes one of these. A clubbed state of 
the ends of the fingers, with convex and adunque nails, forms another. Yet this 
last is not peculiar to tubercular consumption. I have heard of one case in which 
it was strongly marked : the patient died after a long illness- — chronic puriform 
discharge from the pleura after paracentesis thoracis : but there were no tubercles. 



LECTURE L V I I . 

Phthisis, continued. Diagnosis. Forms and varieties of Phthisis. Ordinary 
duration. Age at which it is most frequently fatal. Influence of sex; and 
of occupation. Question of Contagion. Treatment. 

In a former lecture, the twelfth of this course, I entered somewhat fully into the 
pathology of scrofulous and tubercular diseases in general. I pointed out the 
fact, that though such diseases affect vast numbers Of persons, and are most exten- 
sively fatal, yet that they affect almost exclusively certain classes of persons. That 
while some are so prone to tubercular disease, as to fall into it upon the operation 



652 PHTHISIS. 

of the slightest external causes, or even spontaneously — nay, in spite of every 
care to the contrary— others, again, who are constantly exposed to influences 
likely to call scrofulous disease into action, either do not suffer therefrom ; or if 
they do become scrofulous, it is only when the external circumstances most 
favourable to the production of such disease have been intense in degree and pro- 
tracted in their application. 

At the same time I showed you how commonly the disposition to scrofula 
descends in families : and I told you what observation has collected in respect to 
the causes which may excite scrofulous disease in persons hereditarily disposed 
to it. I shall not, therefore, go over that ground again. What I then said of 
scrofulous disease in general is true of tubercular consumption in particular. I will 
merely remind you that these exciting causes are essentially causes of debility. 
Whatever tends to depress the vital powers, and permanently to weaken the body, 
tends also, in a predisposed frame, to engender or to call forth this fearful and most 
destructive malady. 

With respect to the detection of tubercular disease in the lungs, it is sometimes 
very easy, sometimes extremely difficult. It is easy when the tubercles are 
numerous, large, or far advanced: difficult, sometimes, when they are crude, 
scanty in number, and thinly scattered, and individually small. In the latter 
case they may not cause any appreciable deviation from the natural resonance of 
the chest on percussion, or from the natural smooth equable rustle of the breath- 
ing. It would be tedious to travel over again all the auscultatory and other symp- 
toms, with the view of pointing out their bearing upon the diagnosis. I touched 
upon that point incidentally, when discussing the individual symptoms, in the last 
lecture. Many of the symptoms tell their story so plainly that any attempt to 
expound or interpret them would be quite superfluous. One or two cardinal 
points, however, which have rather been hinted at before than expressed, I may 
just advert to. 

The fact that tubercles occupy the upper part of the lung by preference, is of 
great moment in relation to the diagnosis. When the symptoms are equivocal ; 
when, as far as they are concerned, the case may either be one of chronic bron- 
chitis, or of tubercular consumption ; a careful examination of the superior regions 
of the chest will often decide the anxious question. The sound resulting from the 
first gentle tap upon or beneath the clavicle, often rings in the physician's ear 
the knell of his unfortunate patient. Even unusual distinctness of the sound of 
expiration, if heard at the summit of the lung, and a fortiori if at the summit of 
one lung only, warrants the terrible suspicion that tubercles are breeding in that 
lung. It may, indeed, be laid down as a rule, which is diversified with but few 
exceptions, that if you find dulness on percussion ; or coarse or insufficient breath- 
ing; or undue resonance of the voice; or a click or morbid noise of some sort 
when the patient respires, or speaks, or coughs ; if you find this day after day 
and always, between the clavicle and the mamma in front, or between the clavicle 
and upper edge of the scapula, over the top of the shoulder, and nowhere else; 
and more especially if these deviations from the healthy sounds be limited to one 
side, or greater on one side than on> the other, or different in quality on the two 
sides ; you may set the case down as a case of tubercular phthisis. On the other 
hand, if in the same parts you still distinguish all the natural sounds of the respi- 
ration, and can still obtain a clear sound on percussion, you are not to condemn 
the case, nor to despair of recovery, whatever its other circumstances may be. 
The worst symptom certainly, when auscultatory signs are wanting, is haemo- 
ptysis. 

Incipient consumption is most liable to be confounded with chronic bronchitis. 
Yet the leading features of the two are well contrasted. The morbid sounds 
belonging to chronic bronchitis are chiefly audible in the lower lobes of the lungs: 
those of phthisis in the upper. Some degree of expectoration attends the cough 
of bronchitis from the first : the cough of phthisis is often, for a long while, dry. 
Simple bronchitis is not accompanied by haemoptysis. The pain that occurs in 



PHTHISIS, 



653 



bronchitis is felt beneath the sternum : in phthisis pain most commonly affects the 
sides, and the space between the shoulders. It is enough, I trust, to have drawn 
your attention to these points, without dwelling upon them longer. 

Dr. Latham, in the little work which I have several times referred to, has laid 
down certain distinctions most deserving of your notice in respect to the various 
forms of phthisis. This portion of his book is quite original. The facts indeed 
have long been known ; but they have never before, that I am aware of, been 
made so instructive, by being clearly disposed, and exhibited in their proper 
bearings. 

He first divides phthisis generally into two forms, which he calls mixed phthisis 
and unmixed phthisis. And he illustrates what he means by those terms very 
simply and skilfully. He takes the case of an absorbent gland in the neck, 
affected with scrofulous disease. The changes which are liable to take place in 
it are wrought before our eyes: we have the privilege of watching them. Now 
such a gland will sometimes enlarge, in consequence of the deposition of tuber- 
cular matter in its substance : it will grow large and hard without there being any 
pain, or heat, or redness, observable ; and it may remain in that state for weeks, or 
months, or years. 

But in the majority of instances the absorbent gland, after remaining for a cer- 
tain time in this condition, will undergo, and cause, other changes. Pain, heat, 
and redness, will ensue; the hard gland will soften ; the integuments will grow 
thin, and at length give way ; the softened tubercular matter, mingled with pu -, 
will escape ; and then the pain and heat and redness — -the inflammation, in short 
— will disappear ; and the abscess will heal, leaving behind it nothing more than 
a slight scar. This process may happen to one such gland, or to more than one 
simultaneously ; or to several in succession. 

In this case there has been no more inflammation than was just enough to 
accomplish its purpose of removing from the body the tubercular matter. The 
inflammation has not transgressed what Dr. Latham has called its specific limit. 

But again it may go beyond that limit ; it may be both more severe and more 
extensive than is necessary for the removal of the tubercular matter in the dis- 
eased gland. It may pervade the whole neck, giving rise to diffused redness, 
and swelling, and pain ; and the whole of the subcutaneous areolar tissue between 
the angle of the jaw and the clavicle may be loaded with effused serum and pus. 

All this you may see almost any day in the wards or waiting-rooms of a hos- 
pital. And Dr. Latham has happily chosen this affection of the cervical glands 
to elucidate what happens when the tubercular matter is deposited in the lungs, 
where one cannot see the changes it is suffering or producing. 

Tubercles in the lungs may remain for an indefinite period of time, in their 
crude state ; never softening at all, or softening only at a very late period. Or 
they may give rise to just so much of inflammation, and no more, in the pulmo- 
nary tissue surrounding them, as is sufficient to bring about their own softening 
and subsequent expulsion. Or, lastly, the tubercles may excite much more in- 
flammation of the lung around them than is requisite for their elimination : inflam- 
mation of every degree, and of any extent. 

Now to the first two cases, when they occur, he gives the name of umixed 
phthisis : the third he calls, on the other hand, mixed phthisis. We learn from 
auscultation whether the case be one of mixed or unmixed consumption ; i. e., we 
hear, in the unmixed forms, the sounds or modifications of sound which result 
from the presence of tubercles or of vomicae ; and we hear these morbid sounds 
only : in every part of the lung where they are not audible, we hear the vesicular 
murmur of health. But in the mixed form we also hear these sounds. True, 
and we hear other morbid sounds beside. The tubercular disease is mixed with 
common inflammation ; and we hear the sounds that denote common inflamma- 
tion of the mucous membrane, or of the substance of the lung — sibilus, or large 
or small crepitation — we hear these sounds mixing themselves with the sounds 
which belong to the tubercular affection. 



654 



PHTHISIS. 



This distinction is of considerable importance, for it concerns the treatment of 
the malady. The tubercular disease, when established, is beyond our power. 
The inflammation which is incidental to it we may hope to alleviate or to remove. 
It is in the stage of vomicae that the disease commonly assumes the mixed cha- 
racter; and sometimes the bronchial or vesicular effusion upon which the added 
sounds depend, may be got rid of by the seasonable application of a few leeches, 
or of cupping-glasses, or of a blister, or by a moderate bleeding from the arm, 
and the disease be brought back again, for a time at least, within its specific limits ; 
and the patient be relieved from much distress, and imminent danger. It is upon 
this principle that Dr. Latham explains the fact that most consumptive patients 
improve considerably, soon after their admission into the wards of a hospital. 
The poor are necessarily much exposed to those causes which tend to complicate 
the tubercular disease. The tubercular disease may as yet be slight and limited; 
but the superadded mischief, the bronchial and vesicular effusion, may be immense ; 
and this being submitted, often for the first time, to treatment, upon their admis- 
sion to a hospital, is for a while removed. 

Now if we had not the advantage of the method of auscultation, we could not 
ascertain these differences, nor detect them when they existed. You will per- 
ceive, I am sure, their practical importance. 

Of course the more ready the surrounding lung is to take on inflammation — in 
other words, the stronger the disposition in the complaint to assume the mixed 
character — the more rapidly fatal is it likely to be. 

But of the unmixed form of phthisis Dr. Latham has made two interesting 
varieties : and the truth of the distinctions he has drawn will be more manifest to 
you, the more you see of this terrible disease. In one of these varieties ihe lungs 
are apparently tenanted by a multitude of tubercles, which remain crude and unal- 
tered for a considerable length of time. In the other, successive crops of tubercles 
appear to form : or at any rate the tubercles ripen and are expelled in successive 
crops : and there may be long intervals between each crop and the next. 

Dr. Latham thus describes the former of these two varieties: — "An individual 
loses the complexion of health, and becomes thin ; he coughs a little ; but perhaps 
he has no notable fever, and no constant acceleration of pulse." Upon auscultation 
of his chest it is found that there is dullness beneath one or both clavicles, or 
about one or both scapulas, and an indistinct respiratory murmur in those parts ; 
but the vesicular breathing is free and perfect in every other part of the lung. 
Here we have tubercles, crude, and in the upper lobe alone : and this state of 
things may endure for years, without variation; the patient remaining always a 
great valetudinarian. " To such a patient (says Dr. Latham) it is a continual 
puzzle why he does not get well. He consults an infinite number of medical 
men ; and it is remarkable that he gets no comfort or satisfaction from those who 
understand his disease the best, and the greatest comfort and satisfaction from 
those who understand nothing about it. Those who know what it is, out of 
kindness do not tell him the truth, and they cannot asseverate a falsehood stoutly 
enough to carry any weight with it: whereas they who know nothing about it 
affirm boldly and unhesitatingly that it is all stomach? really believing that the 
whole and sole disorder is in the stomach, and that it is within the reach of an 
easy cure." 

But at length — perhaps after a very long period — vomica? are formed ; and then 
the patient sinks rapidly, and his lungs after death are found riddled by cavities 
and stuffed with tubercles ; but every part of them not occupied by tubercles or 
vomica? is crepitant and healthy. In these cases disease lingers long in the crude 
stage ; new tubercles are added, probably, year after year ; but none of them soften. 
They do not excite inflammation in the lung around them. You recognize the 
presence of the tubercular matter by the ear; but there are no vomicae. At last 
vomicae are formed, many at the same time or in rapid succession, and the patient 
presently succumbs. 



PHTHISIS. 



655 



The othor variety of unmixed phthisis may be just as protracted as this; but 
its character and progress differ materially. In the former case the patient's con- 
dition was one of invariable ill health; in the one I am about to mention he has 
fiis of ill health, and fits of comparative good health. He spits for a time con- 
siderable quantities of puriform matter, and then ceases from expectorating alto- 
gether. He has hectic fever, and then throws it ofT, and then suffers it again : 
wastes, and recovers his flesh, and ao-ain loses it. You will find such cases 
common enough ; and in these cases the morbid sounds will be correspondent to 
the symptoms. During the fits of illness you will hear gurgling respiration or 
gurglingcough at the apex of one or both lungs : and during the fits of good health 
you will hear cavernous respiration or pectoriloquy in the same parts; but every- 
where else you will hear a clear sound of vesicular breathing. Here the tuber- 
cular matter excites just enough inflammation around it to achieve its own expul- 
sion, and no more. The lung is destroyed bit by bit. Fresh portions of tubercular 
matter are deposited; these ripen and soften, and are expectorated, and a vomica 
is the result: and then there is a period of quiet. And there being still a large 
portion of each lung to breathe with, the patient regains more health and strength 
in the intervals of his attacks, than the former patient possessed habitually. 

But in this form of unmixed pulmonary consumption, a period at length arrives 
when the patient does not revert to the former state of apparent health. The 
quantity of lung that has now been destroyed forbids it. You may hear the 
sounds proper to tubercular disease over a large space, between the clavicle and 
the mamma, or anywhere about the scapula, on one or both sides; yet still that 
part of the lung which is free from tubercles and vomica? is pervious and healthy: 
but the hectic continues, the emaciation increases, and the strength declines ; and 
the fatal consummation arrives. 

Of these two varieties of genuine and unmixed consumption, the first is the 
most hopeless. The tubercles are numerous; they probably go on increasing in 
number though they do not soften ; there is not, and there cannot be, any even 
temporary return to health, either real or apparent. 

Whereas where the tubercles come singly, or in successive crops, and rapidly 
sofien, and are expectorated; and where some long time interposes between the 
crops; the health and strength return, and there is just a chance that no more 
tubercles may form. It is in this variety of unmixed phthisis that a natural cure, 
by the contraction and cicatrization of a vomica, may by possibility take place. 
We cannot expect, and we must not permit ourselves to encourage hope, that the 
disease will cease in that manner: but if it ceases in any form of the malady, it 
is in this. 

This grouping of the different characters under which pulmonary consumption 
may appear, has been performed by Dr. Latham with perfect fidelity. There is 
nothing overstrained or fanciful about his sketch ; it is after nature; and it is by 
the hand of a master. And there is something very refreshing in original views 
of this kind. Vastly more instructive too they are, than those presented by a dull 
compilation. I therefore again recommend you to study his little volume. I am 
sure that / have derived much useful and usable knowledge from it; and so also 
may you. 

There is another form still of tubercular consumption which Dr. Latham has not 
omitted to notice; but his observations on this form are not so new. It is a 
striking, but not very common form ; and it is sure to arrest the attention of the 
practitioner when it does occur. I have met with three or four examples of it. 
The phenomena are of this kind. The patient has difficulty of breathing, cough, 
haemoptysis perhaps, night-sweats, and much hectic fever: the symptoms in short 
which constitute the acute phthisis of some authors. But if you listen to the 
chest, you do not hear the sounds that are peculiar to phthisis: yon do not find 
dullness confined to the upper lobes, or pectoriloquy, or gurgling respiration : but 
you rather find the superadded sounds which accompany mixed phthisis ; small 
crepitation all over the lungs, succeeded by an absence or deficiency of the proper 



656 



PHTHISIS. 



breathing everywhere. Meanwhile there will be none of the expectoration which 
is characteristic of phthisis. In short, you would not suppose that the disease 
was phthisis at all. Yet it must be called such, for after death you find the lungs 
thickly bestrewed everywhere with what I spoke of before as the granulations of 
Bayle ; nascent tubercles, myriads of them, gray and minute: what many per- 
sons call miliary tubercles. The tubercular matter, from some cause which we 
know nothing of, is thickly and uniformly sown over the whole of the air- 
passages, or throughout the entire extent of the lungs, and its sudden presence 
there in such abundance excites inflammation, which masks and conceals the 
specific disease ; and the true nature of the case is not suspected until after the 
patient's death. All the instances that I have seen — three or four only in number 
— were supposed by me to be cases of extensive inflammation of the lungs ; and 
so indeed they were, but they were something more. The tubercles, doubtless, 
were the cause of the inflammation ; and not the inflammation the cause of the 
tubercles. 

From what I have been slating you will perceive how difficult it is to say what 
is the ordinary duration of phthisis ; concerning which a question was put to me 
at the close of the last lecture. The disease may be present for some time with- 
out declaring itself by any marked or unequivocal symptoms ; and therefore with- 
out attracting attention. But taking the cases as they occur, and estimating the 
duration of the malady from the time when it first manifests itself in a decided 
form, we find there is quite enough of variation to warrant the distinction that 
has been made by authors between chronic and acute phthisis ; or, to use the 
more popular and more expressive phraseology, between slow and galloping con- 
sumption. The following tabular statement of the results observed by Bayle and 
Louis, will give you a somewhat more precise notion of the general progress and 
duration of the disease. The whole number of cases noted was 314. Of these 
24 died within three months ; 69 between three and six months ; 69 also between 
six and nine months ; 32 between nine and twelve months ; 43 between twelve 
and eighteen months ; 30 within from eighteen months to two years ; 12 between 
two and three years ; 11 between three and four years; 5 between four and five 
years ; 1 between five and six years ; 3 between six and seven years ; 1 between 
seven and eight years; 3 between eight and ten years; and 11 between ten and 
forty years. 

You will remark that, as far as this account goes, more than one-half of the 
whole number died within nine months from the time when the disease first 
became manifest. This agrees with the experience of the late Dr. Gregory, of 
Edinburgh. He used to state that the ordinary duration of phthisis was about 
six months ; that sometimes it lasted only two or three months ; and that he had 
seen one case which proved fatal on the seventeenth day after the symptoms were 
first observed. On the other hand, he had known one man who was at least 72 
years old when he died, in whom symptoms of phthisis first appeared at the age 
of 18, and who was never free from them during all the intervening period; being 
often hectic, and frequently spitting blood. The average or mean duration of 
consumption has been computed to be about two years. This is a different thing, 
you will please to observe, from its ordinary duration. 

There are many other points in the statistical history of phthisis well worthy 
of attention and inquiry ; but I have not time to go into them in any other than a 
summary manner. This part of the subject is very well worked up in Sir James 
Clark's lucid and sensible book upon Consumption: but you will have perceived, 
from the references I have so frequently had occasion to make to M. Louis, that 
his work is the great storehouse or treasury of tabular information, in respect to 
the facts of tubercular phthisis. 

It is an interesting question to determine at what period of human life consump- 
tion numbers the most victims. There are two short tables, one drawn up by 
Louis, containing observations relative to 123 cases, and the other by Bayle, re- 
specting 100 — which throw some light on the question. The two tables agree, 



PHTHISIS. 



657 



in the main, very closely. Thus, from the age of 15 to that of 20, Louis met 
with 11 deaths from phthisis, Bayle with 10; from 20 to 30, Louis met with 39 f 
and Bavle 23; from 30 to 40, Louis 33, Bayle 23; from 40 to 50, Louis 23, 
Bayle 21 ; from 50 to 60, Louis 12, Bayle 15; from 60 to 70, Louis 5, Bayle 8. 
You see from this account how erroneous the common notion is, that consumption 
does not occur at an advanced period of life: that a person who has reached his 
thirtieth or fortieth year is thenceforth safe from that disease. From these two 
tables, and others collected by Sir James Clark, it appears that, taking decennial 
periods, the greatest number of deaths from phthisis happens between the ages of 20 
and 30: the next greatest number from 30 to 40 : the next from 40 to 50 : and 
that, after these, it is a doubtful matter whether more perish of consumption between 
50 and 60, or between 15 and 20, which last is only one-half a decennial period. 
These calculations refer, as you will remark, to human life after the age of 
puberty. Before that age, tubercular disease is fearfully common, especially in 
infancy and childhood. Among 920 children (532 girls and 388 boys) who died 
from the age of 2 to that of 15 years, no less than 538 (nearly three-fifths of the 
whole) were affected, Dr. Papavoine tells us, with tubercles. 

As far as numerical observation has hitherto been extended, it would appear 
that more women than men die of consumption. Statistical researches are of still 
greater interest, perhaps, when they elucidate the influence of different trades and 
occupations in calling phthisis into existence. Sir James Clark has brought toge- 
ther much curious information on this point. There are certain occupations which 
appear to provoke pulmonary consumption by the direct application of local irri- 
tants to the lungs themselves : and there are others which tend indirectly to bring 
on phthisis, by lowering the tone of the general health : by producing debility and 
cachexia. But these two causes often go together: and it is difficult to estimate 
with accuracy their separate effect. The workmen whose employments have a 
directly irritating operation upon the respiratory organs, are stone-masons, miners, 
coal-heavers, flax-dressers, brass and steel polishers, metal-grinders, needle-point- 
ers ; and many others who of necessity inhale during their labour an atmosphere 
loaded with irritating particles of matter. But, then, most of these men work 
also in towns, and remain for many hours day after day in a constrained position, 
in crowded or in close apartments. Moreover, some of these occupations, being 
sedentary, and requiring no great muscular power, are unfortunately selected, for 
that reason, by persons who are naturally of feeble or delicate constitution. On 
the other hand, butchers, fishermen, and their families, and farm-servants, are said 
to be comparatively free from phthisis. Beddoes ascribed this exemption to the 
use of animal food by these classes ; but much of their better health is due, no 
doubt, to their habits of active exercise in ,the open air; and to the circumstance 
that such employments demand a certain amount of bodily strength and energy, 
and therefore are not likely to be adopted by weak and scrofulous individuals. - 
It is obvious that the whole inquiry is beset with sources of fallacy. We know, 
however, on the evidence of undoubted facts, that certain occupations do tend to 
induce pectoral complaints, and to shorten life. Dr. Knight, of Sheffield, informs 
us that fork-grinders, who are what are called dry grinders, die there of the grind- 
er's asthma, or grinder's rot, before they are thirty-two years old. Razor- 
grinders, who grind wet and dry, live a little longer: the moisture diminishes, of 
course, the number of floating particles of metal. Table-knife grinders work on 
wet stones, and survive till they are between forty and fifty. I must refer you to 
Sir James Clark's book for similar facts in respect to the inhalation of siiex, of 
the dust of mines, and so forth. Without pretending to assign to each alleged 
injurious influence its precise contribution of mischievous effect, we must be con- 
tent, at present, with the practical inference, that such employments should, if 
possible, be avoided by all those who show any tendency to scrofulous disease. 

Is phthisis contagious? No: I verily believe it is not. A diathesis is not 
communicable from person to person. Neither can the disease be easily (if at 
all) generated in a sound constitution. Nor is it ever imparted, in my opinion, 
42 



658 PHTHISIS. 

even by one scrofulous individual to another. Yet in Italy a consumptive pa- 
tient could not be more dreaded and shunned if he had the plague. And in this 
country the suspicion will now and then arise that the disease may be infectious. 
A girl dying of phthisis is nursed by her sister, who afterwards droops and dies 
of the same complaint. Here the presence of peculiar diathesis is strongly pre- 
sumable. But the parties may be different in blood. A wife watches the 
death-bed of her consumptive husband ; and presently sinks herself under con- 
sumption ; and there may be no traceable or acknowledged example of scrofula 
in her pedigree. Yet even here the latent diathesis may fairly be presumed to 
have existed. Very few families are perfectly pure from the strumous intermix- 
ture. The predisposition maybe slight; it may be dormant for a generation ; 
or, likfi other inherited peculiarities, it may light capriciously on some individuals 
only of the kindred. In both the supposed cases there have been other influences 
at work, more authentic than the alleged contagious property, in calling forth 
the fatal malady. Watching, the want of rest, confinement in the unwholesome 
air of a sick chamber, and, above all, protracted mental anxiety, than which no 
single cause perhaps has more power to foster and forward the inbred tendency 
to phthisis. The disorder, I am satisfied, does not spread by contagion. Never- 
theless, if consulted on the subject, I should, for obvious reasons, dissuade the 
occupation of the same bed, or even of the same sleeping apartment, by two 
persons, one of whom was known to labour under pulmonary consumption. 

The treatment to be adopted, and the plan of regimen to be observed, in 
respect to tubercular phthisis, resolves themselves into the methods of preven- 
tion when the disease is likely to occur; of arresting its progress when that 
disease is incipient or limited in extent ; and of alleviating the most distressing 
symptoms, when no hope remains of stopping its course, or averting its fatal 
close. 

With regard to the prevention of the disease, in those, who, by inheritance, or 
by circumstances, are predisposed to it, a great deal might be said ; but the 
subject belongs rather to the head of medical police, or hygiene, than to the 
practice of physic. We deem that a person has that predisposition, which is 
almost a necessary condition of the development of tubercular disease, when we 
observe those marks of the scrofulous diathesis which I pointed out in an earlier 
part of the course : or when we know that the parents possess that peculiarity of 
constitution; or when brothers or sisters have displayed it. It would be well 
indeed for society if the multiplication and diffusion of the strumous diathesis 
could be checked by a prudent avoidance of ill-assorted marriages. But we 
cannot say— no legislature could say — to a scrofulous man or woman, you shall 
not marry, and propagate scrofula. It is reasonable, however, to conclude, and 
the conclusion is amply borne out by the observation of facts that where both 
parents are strumous, the child will, in all probability, be doubly so ; or that, at 
any rate, its chance ®f escaping the scrofulous disposition will be small. It is 
very desirable, therefore, that correct notions on these subjects should be gene- 
rally prevalent: and that persons who are conscious that scrofula in any of its shapes 
exists in their family, and, a fortiori, they who know that it exists in their own 
corporeal frame, should avoid allying themselves with such as are in the same pre- 
dicament : and this prudence might be enforced if they could be made to foresee 
the suffering and misery its neglect is calculated to inflict upon their offspring. 
Intermarriages of persons of the same family, when that family is subject to 
tubercular disease, are earnestly to be deprecated. But on these points our advice 
is seldom asked. 

We are liable, however, to be consulted respecting the mode of warding off 
scrofulous disease in those who have derived an hereditary tendency to it from 
their ancestors. Now the first, and most effectual prophylactic in such cases, is 
residence in a warm climate: and next to that is the avoidance of all causes likely 
to foster the morbid tendency. I need not repeat what I formerly told you on 
this subject. Pure air ; nourishing, but unstimulating food ; moderate exercise ; 



PHTHISIS. 



659 



early hours ; cleanliness; warm clothing; and abstinence from excessive study, 
from severe bodily toil, and from vicious and exhausting indulgences of all kinds: 
these are the topics upon which we much insist, when our advice is sought for 
respecting the means of preventing consumption in children or others, who are 
in danger of contracting it. 

But when the disease is present — when tubercles actually exist, and are ascer- 
tained to exist in the lungs— may the progress of the disorder be ever suspended 
by a change of climate? Indeed I believe it may : but only in certain cases, and 
in certain stages of the disease. When phthisis occurs in either of its slow and 
unmixed forms, the question of a change of sky will be worth entertaining. In 
that form in which tubercles remain long in the crude state, I believe life may be 
preserved or lengthened by leaving this country, and residing under a higher and 
more equable temperature, provided that no softening of the tubercular matter has 
yet taken place. And in the other form — when a vomica or vomicae have occur- 
red, and the strength is apparently restored, and the remainder of the lungs gives 
out the sounds of health — in that case also I would recommend a voyage to a 
milder climate to those persons who could afford to migrate, and to whom it was 
a matter of importance that they should prolong their earthly existence. I 
believe there is no place to which such persons could go with more hope of 
benefit than to Madeira. There are, however, places on our own coast that 
offer no ineffectual substitute for warmer lands beyond the sea, to those who 
cannot so conveniently expatriate themselves. Hastings, for instance; the Isle 
of Wight; and more espesially Torquay on the coast of Devonshire; and Pen- 
zance, or its neighbourhood, in Cornwall. In those sheltered spots the patient 
may sometimes pass the colder weather of our winter and spring months in com- 
parative security. If, however, the lungs are already in a state of rapid disor- 
ganization, no benefit, but on the contrary much inconvenience and useless expense 
will result from change of place, unless that place in which the patient is 
residing be notoriously unhealthy. When I am asked about removal, either to 
another country, or to some distant part of our own, and the state of the patient 
is such as I have just alluded to, I always advise that he should not forego the 
comforts of his home — and leave his family and friends — to seek advantage 
which he will not find, among strangers, and amid the discomforts of a lodging 
perhaps, or an incommodious dwelling. I think it cruel and wrong to send 
people away merely to die : and that many are so sent to this place and that*, in 
the almost certain prospect of their never returning, no one, I think, can doubt. 

You wiil find a great discrepancy of opinion among authors, and among prac- 
titioners with whom you may converse, in respect to the regimen which con- 
sumptive persons should follow. One man gives all his phthisical patients beef- 
steaks and porter; another restricts all his to vegetables and asses' milk: and 
each will boast, and bring forward most triumphant examples, of the success of 
his system. Now it is quite obvious that for a sick person who receives benefit 
from the one of these plans of diet, the contrary plan could scarcely be otherwise 
than injurious; and reason at once suggests that there must be some distinction 
between the cases that get better under the one system, and those that improve 
under the other. Doubtless, we must have regard to the constitution and habits of 
the patient ; and sometimes trial alone will show which plan is the most beneficial ; 
but I believe the best clue to lead us out of the difficulty will be found in Dr. 
Latham's division of phthisis into mixed and unmixed. The object is, to sustain 
the patient's strength without exciting inflammation in his lungs. If, with the spe- 
cific disease, there be conjoined an inflammatory condition of the pulmonary sub- 
stance around the turbercles, or of the bronchial membrane ; in such cases an 
antiphjogistic diet is the proper one. On the other hand, when the disease mani- 
fests no tendency to transgress its specific limits, then the diet should be generous 
and full: and it may be so without being over-stimulant. Debility, however in- 
duced, adds to the disposition to the deposit of tubercular matter ; and therefore 
the debility arising from insufficient nutrition is to be avoided as carefully as is 



660 



PHTHISIS. 



compatible with the other indication, which is, to obviate inflammation of the lung. 
With these hints, you will be able, I trust, to strike the balance between the risk 
of augmenting the local mischief directly, on the one hand, and that of depressing 
the general strength, and so increasing the local mischief indirectly, on the other. 
Milk is a sort of animal diet, and it is both nutritious and unstimulating; therefore 
milk may, in many cases, form the staple of the food, if the patient likes it, and 
it agrees with him: but there is much variety in this respect in different persons. 
I repeat, that you will too often find prejudices entertained, on the one side or the 
other, in regard to the diet proper for consumptive persons: but the commonest 
error of the two is, I believe, that of reducing the patient's strength by a needless 
restriction of his nutriment, lest inflammation should ensue. 

Louis, should you refer to him, would be likely to lead you into the opposite mis- 
take; for he affirms, that neither bronchitis, nor pneumonia, nor pleurisy, have 
any effect in exciting tubercular phthisis. But this opinion is quite opposed to 
the general sense of most men of experience. Many a case of consumption can 
be traced back to a severe catarrh, and no further. Many, which ran a short 
course, were dated, within my own knowledge, from the last visitation of influ- 
enza. If M. Louis had meant that thoracic inflammation will not produce tuber- 
cles in the lungs of a person who has not the scrofulous diathesis, and that tuber- 
cles may and do arise without any previous inflammation, I should quite agree with 
him. But he draws his conclusions from cases of phthisis. I have no doubt 
whatever that the dormant predisposition is often awakened into actual disease, 
and that latent tubercles are often accelerated in their progress, by inflammation 
of the pulmonary tissues. Whether this happens directly from the local inflam- 
mation, or indirectly from its effects in lowering the vital powers, is a question 
which no one can solve, and of which the solution is not of much consequence. 
What we are sure of is, that every one who bears a real or suspected taint of 
scrofula in his frame, should scrupulously guard against every known and avoida- 
ble cause of catarrh, pneumonia, or pleurisy. I hold M. Louis's doctrine on this 
head to be unsound and unsafe: and I mention it only to admonish you against it. 

In offering you a few final observations on the remedies of phthisis, I shall take 
leave to abstain from weighing the pretensions of a number of specifics, that have 
from time to time been highly recommended ; but which never have come into 
general use, as they would have done, no doubt, if they had been entitled to such 
a denomination. 

In the first place we must satisfy ourselves as to the kind of case we have to deal 
with ; whether it be mixed of unmixed. We must watch our patient: and keep 
him on low diet, and take blood either in small quantities from the arm, or by 
leeches or cupping from the chest, whenever inflammatory symptoms arise; 
whether they are discovered by observation of the general or of the physical signs. 
The bleedings must of course be small — and palliative only of the symptoms. 

Emetics, frequently repeated, have been recommended in the early stage of 
phthisis : partly on account of their reputed efficacy ; partly on theoretical grounds ; 
it being supposed that the tubercular matter may be thus removed from the mucous 
surfaces as fast as it is deposited. Of the value of this emetic plan, I am unable 
to speak from any experience of my own. 

Counter-irritation is often of undoubted service : mustard-poultices to the chest 
when it is painful ; or a blister or succession of blisters, or pustulation by tartar- 
emetic ointment, to encounter local symptoms. The effect of counter-irritation 
upon the progress of the tubercular disorder is apparent sometimes by accident. 
Dr. Abercrombie has related an example in which cerebral disease operated in 
this way ; the previous symptoms of phthisis disappearing. In some cases mania 
seems to have a similar consequence, obscuring the manifestations, and probably 
retarding the course, of consumption. It has been often remarked — you will find 
this stated by Sir B. Brodie — that after amputation of a scrofulous leg, phthisical 
symptoms, very little noticed before, have rapidly increased. And there is another 
fact, in relation to phthisis, analogous to these, which it is fit you should know 



PHTHISIS. 



661 



and attend to, viz., that the progress of consumption is often suspended by preg- 
nancy : — and when a mother is suckling her child, if the suckling be not too long 
continued, so as to exhaust the mother. I suppose there is no doubt that women 
disposed to phthisis have been kept alive by successive pregnancies and sucklings. 
It is a very rare thing for a pregnant woman to die of phthisis. I have known 
only one instance of it. One of my patients in the hospital, a French woman, 
died of that disease; and we found suppurating tubercles in her lungs; and a 
foetus of about five months in her womb. 

Riding on horseback has been strongly advised in the earlier periods of the 
disease. Its main advantage seems to arise from its allowing the enjoyment of 
fresh air, and of exercise, without putting the patient out of breath : and these 
advantages are great. It is affirmed that many phthisical patients remain free 
from cough, and those affected with haemoptysis cease to spit blood, so long as 
they continue to take exercise on horseback. Gestation in a carriage, or in a 
boat, has the same good effects, but in a less degree. We are not able, however, 
to look upon equitation as so certain a cure in consumption as Sydenham did; 
who says that riding on horseback is as much a specific in phthisis, as the Peru- 
vian bark is for an ague. 

Iodine and its compounds, and especially the iodide of potassium, have been 
much praised of late years, for their reputed efficacy in phthisis. Given in small 
doses, I believe that they often have a beneficial influence upon the general health. 
I wish I could tell you that I had ever known them operate. a cure of the mani- 
fested disease. 

Often — too often — all that we can attempt to do is to relieve the most urgent or 
distressing symptoms: and to make easier the patient's decline. One symptom 
which is both distressing and weakening is the nocturnal perspiration. The 
common remedy for this is the dilute sulphuric acid : and a very good remedy it 
is, but it is not equally adapted to all cases. If the bowels are costive — or if the 
bowels have not, as they often have, a tendency to be relaxed — then the sulphuric 
acid may be freely given : and it will often have very good results. It may be 
exhibited three or four times a day, in doses of from twelve to twenty minims. 
But when this fails, or when the bowels are irritable and will not bear it, we must 
have recourse to other means. One of these is sponging the surface of the body, 
at bed-time, or before the patient settles himself for the night, with tepid vinegar 
and water: using twice as much water as vinegar. And if the bowels are at the 
same time purged, I find the compound kino powder of the Pharmacopoeia an 
admirable medicine. It certainly has much power over the perspiration ; and it 
has these further advantages, that (containing opium) it tends to control the diar- 
rhoea, and to calm the cough. 

Steel is another substance which exercises a marked influence sometimes over 
the hectic fever. It was its efficacy in this way that gave celebrity to the famous 
antihectic mixture of Dr. Griffith, the Mistura Ferri Compositu of the Pharma- 
copoeia. Certain it is, that when steel is borne in the advanced stage of consump- 
tion, it often does a world of temporary good ; — but in many cases it is not borne 
well. It increases the cough, occasions headache, and distresses instead of re- 
lieving the patient. Nor is it always easy to say beforehand, whether it is likely 
to suit the case or not. I apprehend it will at length be found most applicable to 
the unmixed forms — the uninflammatory forms, that is — of phthisis. I have fre- 
quently, however, succeeded in checking the wasting sweats by the tincfura 
ferri muriatis, given in doses of twenty minims thrice a day, after other expe- 
dients had failed me. 

When the cough is very troublesome, and especially when it breaks the patient's 
rest at night, we must endeavour to quiet it ; and there is no drug, I fear, that we 
can depend upon for that purpose, hut opium. The old paregoric has been, and 
is, a favourite form for giving opium to, appease cough ; and old-fashioned apothe- 
caries will tell you that the alteration which was made by leaving the aniseed out 
of this compound tincture of camphor, in the last Pharmacopoeia but one, impaired 



662 



MELANOSIS. 



its efficacy. Whether it was so or not I cannot tell; but Dr. Prout is of opinion 
that aniseed has considerable power in allaying the irritation on which the cough 
depends. He infuses three drachms, or half an ounce, of the bruised seeds in 
half a pint of distilled water at a temperature not exceeding 120° ; and lets it stand 
till it is cold. On his strong recommendation I have tried this, as a vehicle for 
paregoric, when the same dose in other vehicles had failed ; and I must say that 
it has frequently been followed by a marked abatement of the frequency and vio- 
lence of the cough. The aniseed is restored in the paregoric of the last Pharma- 
copoeia, that of 1836. Hydrocyanic acid has sometimes a very soothing effect 
upon this harassing symptom. However, at last, opium will be found our sheet- 
anchor, not merely" for the cough, but for the diarrhoea which is so seldom absent 
in the later periods of phthisis. The diarrhoea depends, as I have told you, upon 
an ulcerated state of the bowels. In those cases in which it could scarcely be 
kept in check at all, I have always found very extensive ulceration in the large 
intestines : but the diseased condition is often seated higher up, in the ileum or 
jejunum. Catechu is of great service in these cases, combined with laudanum 
and with the officinal chalk mixture: — or a few grains of the confect-io opii may 
be given in peppermint water, after every loose evacuation : or in obstinate cases, 
a pill composed of a quarter of a grain of the sulphate of copper, and the same 
quantity of opium, will often answer well, though it sometimes gripes. I mention 
ihese several expedients, for you will often require them all. The injection of a 
small quantity of starch, as much as the rectum will receive and retain, with ten 
or twenty drops of laudanum, generally affords the patient most sensible comfort; 
and suspends the further action of the bowels for a considerable time. 

These, I think, are the principal means by which we may endeavour to smooth 
the pillow of the patient dying of consumption. Sometimes very little pain or 
distress is felt at all, from first to last; the intellect remains free, and the patients 
are proverbially sanguine about the issue of their disorder. In other cases, do 
what we will, the patient suffers greatly. One harassing incidental combination 
of symptoms is nausea and vomiting. I should have stated before, that when, in 
phthisis, these symptoms last long, and are accompanied by pain and tenderness 
of the epigastrium, they denote, almost always, a thinned and softened condition 
of the mucous membrane of the stomach. They may be alleviated by a few 
leeches — -by a blister — -by the effervescing draught: or the prussic acid may be 
used; that is a medicine which certainly tranquilizes an irritable stomach: and it 
now and then seems to allay an urgent cough. Sometimes, again, the bones of 
ihe miserable patient are laid bare, in consequence of pressure upon parts in which 
the circulation is already very feeble. We cover these vvith soap-plaster; take 
off the pressure by arranging cushions ; or, what is much the best of all, we put 
the patient upon the water-bed, invented by Dr. Arnott. 



LECTURE LVIII. 

Melanosis of the Lung ; true, and spurious. Accidental intrusion of solid sub- 
stances into the air-passages. 

I yesterday adverted to certain callings which are unhealthy for various rea- 
sons, and among the rest for this ; — -that the work-people engaged in them breathe 
habitually an atmosphere loaded with particles of matter which clog or irritate the 
pulmonary tissues. There is one morbid condition, so produced, which hitherto, 
or till lately, has scarcely been mentioned by writers on disease, but which de- 
serves a moment's attention ; for although it is very uncommon in many parts of 
this country, it is by no means rare in some others. The texture of the lungs is 
spoiled by matters carried in with the air, in the acts of breathing. This morbid 



MELANOSIS. 



663 



state has been called spurious melanosis. The lungs are found after death to be 
throughout of a black colour, more or less uniform. Sometimes the pulmonary 
substance is dry and friable, as well as black ; sometimes moist, cedetnatous, infil- 
trated with an inky fluid ; not unfrequently broken down into irregular cavities of 
various sizes ; and these cavities are often full of the same black liquor. 

You are not to confound these appearances, when you happen to meet with 
them — (and as you will probably scatter yourselves, some here and some there, 
over various parts of the kingdom, some of you are very likely to meet with them) 
you must avoid, I say, mistaking these black appearances and products, for true 
melanosis. The disease so denominated is a singular one. It was first fully 
described and named by Laennec in 1806. It consists in a morbid product, pre- 
senting a black or deep brown colour of various degrees of intensity, moist gene- 
rally, unorganized, and differing in the form it assumes, and in its consistence, 
according to circumstances. I shall take this opportunity, for I am not likely to 
have a better, to tell you the little that has been ascertained in regard to this kind 
of disease ; and having done so, I shall revert to a short account of spurious 
melanosis. 

These black deposits take place most frequently of all in the areolar tissue, and 
in the adipous tissue: and they occur in greater abundance, and in larger masses, 
according as these reticular tissues are more plentiful, and more lax. They are 
met with also in the compound organs of the body ; especially in the liver. Less 
frequently in the lungs. Sometimes in the eye. Occasionally in the brain. The 
serous membranes are obnoxious to the same kind of disease ; the mucous very 
little so. The black or dark-coloured matter may also exist, in a liquid condition, 
in the natural cavities of the body. And lastly, the melanotic material is some- 
times mixed up with scirrhous and brain-like malignant tumours. 

With respect to the shapes in which it appears — it is sometimes dotted, the sur- 
faces affected by it looking as if they had been thickly sprinkled over with coal- 
dust or soot. But more commonly melanosis assumes the form of solid tumours, 
of variable magnitude. These tumours are largest, where reticular tissue is most 
loose and abundant. They may be no bigger than a pin's head, or they may be 
as large as a man's head. Masses of this kind have been found in the horse, 
weighing as much as six-and-thirty pounds. In the human subject they may 
attain the size of an orange. These large tumours ( like large pulmonary tuber- 
cles)are usually formed by the union and agglomeration of several smaller ones,- 
and hence they have generally a lobulated surface : while the shape of the separate 
smaller tumours is mostly spherical. Sometimes the areolar tissue lying around 
the melanotic masses is condensed into a kind of cyst : more generally the black 
matter is in naked contact with the tissue, whatever that may be, in which it is 
lodged. 

From the serous surfaces, especially from the pleura and peritoneum, knobs of 
a dark colour are seen in some instances to project ; in others, the round tumours, 
as big as peas, or cherries, hang from these surfaces by a sort of peduncle. The 
omentum is a common habitat of melanotic tumours. 

Occasionally, I say, the black matter is found spread in a continuous layer 
upon the serous membranes ; or is collected in a liquid state in their cavities. But 
this, compared with the occurrence of solid tumours, is rare. 

When this remarkable disease is met with in one tissue or organ of the body, 
it is met with in others. It is never confined to one part, but pervades several: 
resembling in this respect both the scrofulous matter which constitutes tubercle; 
and the matter of cancer. Miiller indeed considers melanosis to be a species or 
variety of carcinoma. 

Scattered notices of these singular and striking changes in the animal frame 
occur in the works of Morgagni and of Haller ; but since the period when Laennec 
first drew the special attention of the profession to the subject, the black matter 
has been carefully analyzed by several expert chemists. Without going into any 
tiresome detail, which you could scarcely remember, as to its exact composition, 



664 



SPURIOUS MELANOSIS. 



it is interesting to know that it is very like that of the blood : and no doubt the 
material is somehow deposited from the blood. Very little, however, has been 
ascertained about its primary origin and cause. Some have supposed that the 
melanotic matter is analogous to the natural pigments which are found in the 
animal economy ; all of which are known to be rich in carbon. It is a curious 
fact that the disease has been more often observed in white or gray horses than in 
others. (I should tell you that the complaint is not at all uncommon in various, 
quadrupeds: examples of it have been noted in the horse, ox, dog, cat, rabbit, rat, 
and mouse.) It has been conjectured that, in white animals, the colouring matter 
of the surface, and of the hair, has been diverted, by some morbid process, from 
its proper locality. But the very same disorder occurs als-o, though not so often, 
in dark, or bay, horses and cows : and certain pathologists imagine that in these 
eases there has been an undue accumulation, in the blood, of the carbon which is 
destined to colour different parts. In the one case, you see, they hold that the 
pigment is misplaced ; in the other that it is excessive. What value these specu- 
lations as to the nature and origin of the disease may possess, time alone can 
determine. 

When the tumours are divided, and moist, or when they are rendered moist by 
admixture with water, they freely impart the colouring matter; staining white 
paper, and blackening ^one's fingers, just as Indian ink might do. The disease 
most frequently happens, when it happens at all, in the decliife of life. 

The changes to which the melanotic tumours are liable, are very much like the 
changes which tubercular matter is apt to undergo. In certain situations where 
the secreted black material is subject to pressure, and is poured out in a soft con- 
sistence, the watery parts are sometimes absorbed, and the mass becomes hard 
and firm. On the other hand, the pressure occasioned by the tumour sometimes 
provokes inflammation in the tissues surrounding it; and then it is liable to be 
broken down, exactly in the same way as that in which tubercles soften prior to 
their expulsion from the lungs. 

The injurious effects of these collections of black matter arise from the pres- 
sure they occasion ; and they may evidently thus cause pain, irritation, ulceration; 
and according to their situation, number, and extent, they may materially interfere 
with important functions. And in this manner they do, in fact, at length destroy 
life. 

There are no symptoms that I know of, distinctive of this disease, except the 
appearance of the black masses upon the surface of the body. Nor can I pretend 
to point out to you any cure for it, when it is ascertained to exist. 

Yet it is right that you should be aware of what pathologists have learned 
respecting this curious morbid state; although that be little, and not very satisfac- 
tory. And I have introduced this brief consideration of melanosis here, some- 
what irregularly, perhaps, to enable you to distinguish from it that pulmonary dis- 
ease to which I referred in the outset of the lecture, and to which I shall now 
return. This, I say, has been called spurious melanosis: and it has doubtless 
been mistaken for the specific disease of which I have just given you a sketch; 
for real melanosis. 

It is. however, a very different affection. 

Laennec had conjectured that certain kinds of black discoloration of the lungs 
were of extraneous origin; were owing to the introduction of black matters from 
without in the process of respiration; and Mr. Pearson, in this country, had 
thrown out the same idea. But this was first ascertained to be actually the case 
in Edinburgh. Dr. J. C. Gregory had a patient who died in the infirmary of that 
city, and whose lungs exhibited the following appearances : — They both presented 
one uniform black carbonaceous colour, which pervaded every part of their sub- 
stance. The right lung was broken down, in its upper and middle lobes, into 
irregular cavities; and the walls of these cavities were black; and they contained 
a considerable quantity of a black liquid like ink. Portions of the pulmonary sub- 
stance were dense, hepatized, and friable. The rest of this lung was cedematous ; 



SPURIOUS MELANOSIS. 



665 



and when the serum which then rendered it thus (Edematous was pressed out, it 
also, the serum I mean, was quite black. The left lung was infiltered, in the same 
manner, with black serum. No tubercles could be detected. The bronchial glands 
were not enlarged, but they were stained of the same sable hue as the substance 
of the lungs. No other organ of the body presented any trace of this black dis- 
coloration. 

Dr. Christison, who is known to be a very exact and able chemist, undertook 
an analysis of the black matter contained in the serum expressed from these lungs. 
I shall not follow out the details of his researches (you may read them at length 
in the 109th number of the Edinburgh Medical and Surgical Journal), but con- 
tent myself with stating their result. And I may state it in Dr. Christison's own 
words. "In the product of this experiment (he says) it is scarcely possible not 
to recognize the ordinary products of the distillation of coal. A gas of the same 
quality was procured, and likewise a naphthous fluid holding in solution a crys- 
talline principle, analogous to, if not identified with, naphthaline." 

Now the man, whose lungs presented the appearanres I have described, had, 
for the last ten or twelve years of his life, been employed in the coal-mines at 
Dalkeith. He had been exposed, therefore, to the habitual inhalation of coal- 
dust into his lungs in breathing: and taking this circumstance in conjunction 
with the result of the analysis of the black matter contained in the lungs, and 
nowhere else throughout the body, we cannot doubt that the carbonaceous sub- 
stance so abundant in these organs was introduced from without. In truth we 
have now a large amount of evidence in proof that it must have been so. In the 
twenty-first volume of the Medico- Chirurgical Transactions, Dr. William Thom- 
son has recorded the results of extensive inquiry into the subject. Thus he gives 
ten examples of black sputa going along with pulmonary symptoms during life, 
and of black infiltration of the lungs discovered after death? and of the ten persons 
who were the subjects of these observations, nine had been engaged in working 
coal-mines, and the tenth was a moulder at the Carron iron- works. He gives 
also six cases of black infiltration of the lungs, all occurring in persons exposed 
to the inhalation of carbonaceous matters (one of them was an engineer, and the 
others were all colliers); but in these six cases there had been no black expecto- 
ration noticed during life. 

That such carbonaceous particles, floating in the atmosphere, may be, and 
must be, and actually are, drawn into the lungs during inspiration, no one who 
has been long in this smoky town can doubt. Many persons remark that they 
-expectorate during winter, and while in London, a little mass or two of dark gray, 
dirty mucus, every morning; but when in the country, in the summer, the mucus 
so spat up is transparent and clean. So I have noticed, and pointed out to some 
• of you, that the crackoirs of the patients in the hospital often bear witness that 
there has been during the previous twelve hours, one of our dense and dirty fogs, 
which come with an easterly wind, and bring with them a vast quantity of blacks, 
and soot, and smoke. Immediately after the prevalence of one of these filthy 
blankets of vapour, we find the contents of each of the little vessels given to the 
patients whose expectoration is kept for inspection, to be deeply tinged with 
black. And I had, in the year 1832, a patient whose sputa were remarkably 
loaded with dark matter. He came into the hospital complaining of cough, and 
shortness of breath, and a sensation at the lower part of the right side of the chest, 
as if it were [Merced by needles; and he was spitting a considerable quantity of 
thick mucus, which was almost black. This colour never entirely left the expec- 
toration while he remained in the hospital ; but it very greatly diminished in pro- 
portion as his ailments were relieved. Now this man was a stoker at one of the 
gas-works. And he attributed his illness, which had come on gradually, to the 
great alternations of heat and cold to which his occupation exposed him : and the 
blackness of the sputa he ascribed to the 'continual inhalation of coal-dust. And 
no doubt he was right. 

It may seem strange, if the inhalation of atmospheric air loaded with minute 



666 



INTRUSION OF SOLIDS 



particles of coal or other carbonaceous matter be sufficient to produce this remark- 
able condition of the lungs, and the characteristic black spit, that the change, and 
its nature and cause, should not have been earlier made out ; considering the vast 
number of men who are employed in our mines and collieries. It appears, how- 
ever, that a great repugnance has existed, and probably still exists, among the 
labourers in the coal-mines, to allowing their dead to be opened and examined. 
And it appears also that the peculiar state of the lungs which I have been speak- 
ing of is produced in a comparatively small number of those who are so employed. 
The precise cause, why some are thus affected, and some are not, is yet to be 
discovered. Dr. Thomson has circulated among medical men residing in the 
coal-districts, a list of queries (which he gives in his paper), respecting various 
points of interest in relation to this pulmonary condition: and we may expect to 
obtain, by degrees, more exact information about it. I recommend it as an inte- 
resting subject of inquiry to such among you as may have opportunities of prose- 
cuting it. It has been conjectured that the specific change takes place, in a marked 
degree, only in lungs that were previously unsound. It is a question whether 
the cavities met with in the pulmonary substance, in the fatal cases, were the 
result of the spurious melanosis; or of the explosion of tubercular matter which 
had co-existed with the melanotic state. It is a curious circumstance that the 
black-spit, as it is called in those districts, sometimes does not make its appear- 
ance until some time has elapsed after the labour in the coal-mines was given up. 
Certainly this is a complaint that offers several interesting points of research, and 
requires further investigation. 

You will remark that the spurious melanosis is distinguished from the true, by 
its occurrence in those persons only who are somehow exposed for a certain 
length of time to breathe an atmosphere which is largely encumbered with car- 
bonaceous particles; whereas true melanosis may occur in any locality. The 
spurious discoloration never affects any other organs than the lungs and bron- 
chial glands ; the true black deposit of melanosis is never confined to a single 
organ or tissue. Moreover, the one disorder is absolutely beyond remedy; the 
other, as soon as its presence is rendered probable, by the black expectoration, 
and the pulmonary distress, may be mitigated, checked, perhaps gradually cured, 
by removing the patient from the operation of the exciting cause, and pursuing 
such other measures as the symptoms may seem to require. The distinction is 
not a matter therefore of mere curiosity : it bears upon the treatment to be followed, 
which is our proper business. It is connected also with medical police or hygi- 
ene, which we should all of us cultivate as extensively as we may : as a science 
intimately related to our strictly professional pursuits, and to the welfare of the 
community. 

Other forms of disease, unquestionably cancerous, occasionally infest the lungs. 
Their chief symptoms, when the malady does not reach the surface of the body, 
result from the pressure which the carcinomatous masses exercise on the parts in 
their neighbourhood. I shall postpone a more particular consideration of these 
effects of intra-thoracic pressure, until I come to aneurismal tumours, which have 
a similar mechanical influence. 

There is yet another affection of the breath-machine, to which I must briefly 
direct your attention : a casualty that is apt to befall the air-tubes. I said nothing 
of this, indeed, last year; but having sinee witnessed an example of the accident 
to which I allude — the entrance, namely, of some solid substance into the wind- 
pipe — I have thus been reminded of my former omission, and taught at the same 
time the necessity that every medical man should have well considered such cases. 
I was taken to Kentish Town, in the autumn (1837), by a professional friend, to 
see a child, into whose trachea a small nail, what is commonly called a tack, was 
thought to have passed. When I saw the boy, he seemed to have nothing the 
matter with him : but he had been subject, ever since the accident, to paroxysms 



INTO THE AIR -PASSAGES. 



667 



of most violent choking cough; alarming the parents and his attendants for his 
life. There was good reason for concluding that the -nail, which was missing, 
and which he said he had swallowed, had really got into the windpipe, and was 
still there, or in the lungs; and the question was much discussed, what ought to 
be done in such a case? The result was, that nothing was done : but that, after 
the lapse of several weeks the nail was at length coughed up. 

Now there are some interesting points arising out of this sort of mischance. 
The instance I have just referred to will probably be published; and therefore I 
dwell upon it the less. Dr. Stokes has devoted a short chapter to the considera- 
tion of foreign bodies in the air-passages: and examples of that accident are more 
common than you might suppose. 

It is, at first sight, a surprising circumstance, that a solid body of any con- 
siderable magnitude (a molar tooth for instance), should be able to pass at all 
through the narrow chink of the glottis. But, supposing the chink to be plugged 
by the sudden entrance of a passing substance, just at the commencement of a 
forcible endeavour to inspire, when, of course, the opening is at the widest, that 
substance must necessarily sustain, as the chest expands, a strong degree of pres- 
sure from the external atmosphere : strong enough, often, to force it through. If 
you cork a bottle that contains air only, and sink it sufficiently deep in the sea, 
the pressure of the water will push the cork into the bottle. The condition of 
the lungs, in the case supposed, and the condition of the bottle, are analogous. 
A vacuum beyond the plug is attempted by the act of inspiring, and obviated by 
the displacement/.^ the plug, inwards. There are no such powerful forces called 
into action to drive the intruding substance out again. 

The matters which have been actually thus caught in the rima glottidis, and 
forced through, are, as you might almost expect, oddly various in kind. Morsels 
of food : the stones of fruit ; of these there are many instances : teeth ; three such 
are referred to by Dr. Stokes : portions of bone : pebbles : a piece of money : a 
nut: a nut-shell: a button: a musket ball: a large shot : a fragment of nutmeg: 
iron nails: kidney beans : ears of grass or corn ; of these, four examples at least 
have been noticed : one is mentioned by Dr. Stokes, two are recorded in the 
Gazette Medicate, and I show you a monument of the fourth, in this interesting 
preparation, for the history of which I am indebted to Mr. Mayo. The young 
son of an English nobleman was riding in a carriage, in or near Paris, and had 
an ear of rye in his mouth. The carriage made a sudden jolt, and the ear of corn 
disappeared. Little was thought about this at the time: but soon afterwards 
symptoms of pulmonary irritation set in, attended with hectic fever, and with the 
most foetid expectoration. The boy gradually sunk. The ear of rye lay, as you 
may perceive, in an abscess which was common to the right lung and to the liver, 
through the diaphragm. 

If any of you have tried the boyish trick of slipping beneath your wristband an 
ear of bearded corn, you will have no difficulty in understanding how and why, 
with every movement of the parts in contact with it, the ear will travel onwards; 
and how improbable it is that such a substance should eveF be expelled from the 
lungs by coughing. Yet, in one of the cases, recorded in the Gazette Medicale, by 
a physician whose sister was the subject of the accident, an ear of barley was so 
rejected, seven years after its entrance. During that long period she had suffered 
repeated attacks of copious haemoptysis. Her recovery was perfect. 

The very enumeration which I have just made may convince you that the acci- 
dent is not a very unfrequent one ; and it is more than probable that fatal cases 
happen, the nature of which escapes detection. 

The results of the accident are various also. 

In the first place, it sometimes causes speedy death by apnoea. 

2dly. It may be followed by inflammation of the lung, and perhaps abscess ; and 
so destroy life. 

3dly. Death may ensue, after symptoms resembling those of chronic phthisis. 
4thly. The "foreign body," as we oddly enough call it, may be expelled 



668 



INTRUSION OF SOLIDS 



through the glottis, after a variable period of time. Sometimes, yet not always, 
its expulsion is the condition and the harbinger of the patient's recovery ; but he 
is never safe while it remains. 

Death may take place in a few seconds when the substance sticks in the glot- 
tis. Death has occurred within three days, when the substance had passed the 
glottis; and in eleven days when it had reached the lung. The intruding piece 
of matter has escaped, through the natural passages, after remaining imprisoned 
for seventeen years. s In that case, the patient died, hectical and emaciated, a 
year and half afterwards. 

It may be worth our while to consider these particulars somewhat more closely ; 
and to inquire what, in different cases, becomes of the foreign body which thus, 
to use a common phrase, "goes the wrong way; " and what the symptoms are 
to which it gives rise. 

First, then, I say, it may get wedged in the slit of the glottis, and produce im- 
mediate suffocation. I mentioned, before, the frequency of this kind of death by 
misadventure. If you are summoned to any one whom you find comatose, or 
apparently just dead, and you learn that he had been suddenly attacked with 
choking during a meal, lose no time in examining his pharynx and gullet. You 
may chance to save a life so. The accident often happens to persons who are 
drunk. No doubt it happens oftener than we are aware of. The attack is very 
likely to be mistaken for an apoplectic seizure. 

In these cases of sudden choking, the morsel of food is not always caught in 
the rima glottidis. If it be large enough to stick fast in the pharynx, it may pro- 
voke, through a reflex action, an abiding spasm of the littte laryngeal muscles, 
and so produce death by apncea. The remedy for such an emergency, as Dr. 
Marshall Hall truly observes, must be immediate : and this is what he tells us 
should be done. 

" Pressure being made on the abdomen, to prevent the descent of the dia- 
phragm, a foTcible blow should be made by the flat hand on the thorax. The effect 
of this is to induce an effort similar to that of expiration ; the larynx being closed, 
oesophageal vomiting takes place, and the morsel is dislodged." 

" If this plan fail, not an instant being lost, the pressure should be kept up on 
the abdomen, the finger should be introduced into the throat, and the same smart 
and forcible blow made on the thorax as before. By the irritation of the fauces 
the cardia is opened, and by the blow on the thorax (firm pressure being made on 
the abdomen) an effort similar to that of expiration, with a closed larynx, is made, 
and a direct vomiting ensues, and the morsel of food is carried away." 

2dly. The substance, if small, may, after it has passed the chink, remain in 
the larynx: entangled in its ventricles, or between the chordae vocales. In that 
case it usually occasions very severe laryngeal symptoms — spasmodic gasping 
cough, choking sensations, croupy respiration, and pain in the larynx — symptoms 
which harass the patients without intermission, until death ensues, or until the 
substance is driven upwards into the pharynx, or passes downwards into the 
windpipe. There is, however, one instance on record, in which a piece of gold 
was lodged for years in the ventricles of the larynx, without these distressing con- 
sequences. 

3dly. Having passed the upper part of the larynx, it may stop, and become 
fixed beneath the cricoid cartilage, or in the trachea. In these situations, unless 
it quite blocks up the passage, its presence may be productive of but little distress. 
A wheezing or croupy sound during one or both of the movements of respiration, 
and some degree of pain and tenderness of the part where the substance was 
lodged, have constituted all the evidence of its position in the air passages, in 
more than one instance. A very singular and whimsical case of this kind, rela- 
ted by Professor Macnamara, is referred to by Dr. Stokes. A boy had made a 
whistle, by perforating a plum-stone, and extracting the kernel. This, during a 
strong inspiration, passed from between his lips, through the glottis, and became 
fixed transversely in the larynx. So little inconvenience did it create, that the 



/ 



INTO THE AIR-PASSAGES. 669 

boy, finding that he still whistled as he breathed, went about for some hours, 
pleased to display this new accomplishment. For three days he continued to oc- 
cupy himself in his childish amusements, suffering now and then a seizure of 
suffocating cough. He was then taken to the Meath Hospital. He had no pain 
in deglutition; but he said when the cough was severe, it caused pain in his 
throat. He had also uneasiness in the epigastrium, a bloated countenance, and a 
frequent pulse. The chest sounded well on percussion, and the vesicular mur- 
mur was natural. The fits of coughing were followed by white frothy expecto- 
ration. Laryngotomy was performed; but during the struggle and the convul- 
sive cough which took place when the opening was made, the stone (so the 
patient declared) was coughed up, and swallowed. The symptoms were relieved ; 
and the whistling ceased. But it was found that, as the wound healed, the dis- 
tress and the whistling sound returned; which showed that the stone lay above 
the opening; and that the disappearance of the, symptoms had been owing, not to 
its dislodgment, but to the admission of air below the point where it was fixed. 
Soon after this, however, it changed its place, passed down into the right bron- 
chus, and then up again towards the larynx. By a second operation it was ex- 
tracted ; and the lad recovered without any bad symptom. 

4thly. The substance may get beyond the trachea, into one of the bronchi, and 
stay there. And it is a very curious fact, and one which has evident importance 
in respect to. diagnosis, that it is almost always the right bronchus -which the 
substance enters. Dr. Stokes has explained why it is so. The septum that 
divides the extremity of the trachea into two branches is not placed in the middle 
of the channel, but decidedly towards the left; so that any solid body falling down 
through the windpipe, is naturally directed into the right bronchus. Perhaps this 
tendency is aided by the more vertical direction, and by the somewhat greater 
capacity of that tube, compared with its fellow. Now you will readily apprehend 
what sort of symptoms would be likely to result from the impaction of a solid 
body in either of the primary bronchi. It would be very apt to excite inflamma- 
tion of the corresponding lung, which inflammation would reveal itself by its pro- 
per signs ; but it would produce peculiar auscultatory phenomena, prior to and 
independent of such inflammation. It would prevent, partially or altogether, the 
entrance of air into the lung of that side. Hence, when we have other reasons 
for thinking that a solid body has passed the glottis, if we find the vesicular mur- 
mur suspended or enfeebled in one lung, while percussion gives out its usual 
clear sound, we may conclude that the intruder is lodged in the bronchus belong- 
ing to that lung. 

Dr. Stokes believes, and his opinion is fortified by his own experience on the 
subject, that smooth bodies (beans or shots, for example), are more calculated 
than such as are rugged and uneven to cause urgent distress when impacted in 
one of the bronchi; inasmuch as they more completely plug and obstruct the 
tube, thereby depriving the patient at once of the use of half his lungs. An 
irregular substance, which can neither seal the passage up, nor be closely grasped 
by its spasmodic contraction, will probably occasion less dyspnoea, and at the 
same time will be less likely to be dislodged by the effort of expiration. Under 
these circumstances we look for more chronic symptoms. 

5thly, and lastly. The intruding substance may not be fixed anywhere, but 
may shift its place from time to lime ; and this, in fact, is what most frequently 
happens : and when it does happen, it gives rise to a very striking and distinctive 
series of symptoms. Paroxysms of suffocating cough and extreme distress, when 
the substance is driven up into or near the larynx ; with intervals of comparative 
quiet, and sometimes indeed of apparent health, when it subsides into the trachea 
or bronchi. But during these intervals, the signs that sometimes mark its situa- 
tion in those tubes may perhaps be discoverable. 

There are, then, a set of general symptoms, which lead us to believe, or»to 
suspect, that some solid body has entered the air-passages: and there" are other 
sets of particular symptoms, which inform us, with more or less certainty, where- 



670 



DISEASES OF THE HEART. 



abouts it is fixed, or that it is not fixed at all. A person, previously in good health, 
is seized with violent cough and choking dyspnoea, suddenly, during a meal, or 
while he had in his mouth some loose substance, which he fancies he has swal- 
lowed. This is a sufficient clue to the probable nature of the case : and we next 
inquire for a sense of soreness in the windpipe, and wheezing respiration ; for 
signs of bronchitis or of pneumonia, especially in the right lung; for signs of 
obstruction of the bronchus on one side, and especially on the right side, or for 
alternations of suffocating cough, with intervals of outward calm. In the last case, 
we may expect to find the bronchus unstopped during the periods of laryngeal 
irritation ; and vice versa. 

When we know that a solid body has been entrapped in the air-tubes, our 
business is plain ; there is no room, in my opinion, for hesitation ; we must let 
the substance out through an artificial wicket. There is danger, so long as it 
remains in these vital passages, of speedy suffocation; of fatal damage to the 
larynx, or to the lungs; of cerebral mischief during the violent paroxysms of 
coughing. Convulsions and apoplexy have, under such circumstances, actually 
occurred. Against these perils there is no security, except in the early perform- 
ance of tracheotomy. If the included substance be loose and smooth it will pre- 
sently be shot forth at the new orifice ; if it be fixed, or angular, it may generally 
be extricated by a skilful and delicate hand. 



Even while this sheet has been passing under the press, (May, 1843,) another 
instance has occurred of the same accident v and excited a degree of anxious interest 
in the public mind, scarcely less than is accorded to a royal illness. It befel a 
gentleman whose name was previously famous. Mr. Brunei, in amusing the 
children of a friend with some tricks of legerdemain, put a half-sovereign into 
his mouth ; and the coin slipped, as from its size and shape it might easily do, 
through the chink of the glottis. It seems to have occasioned no very urgent 
distress. The patient was made- aware, by some internal sensation, that it lay 
towards the right side. After more than three weeks had passed, the trachea was 
opened : but the piece of money did not come forth. Probably its weight pre- 
vented its being driven up and down in the windpipe; and its form, when it lay 
edgeways, did not oppose much impediment to the breath. The same weight, 
however, brought it back to the larynx whenever Mr. Brunei placed himself with 
his head downwards. In some of these experiments, coming crossways I sup- 
pose, it produced most violent cough, and feelings of impending suffocation : but 
in a final and happier trial, at the end of six weeks, it dropped out again, through 
the natural passage — just as a coin may sometimes, by good luck, be shaken out 
of a box through a slit in its lid. 



LECTURE LIX. 

Diseases of the Heart : usually partial. Changes in its Muscular Texture. 
Mechanism of those Changes. Natural Dimensions of the Heart. Natural 
Sounds. Modifications of these by Disease. Review of the Physical and 
General Signs that accompany Cardiac Disease. 

You will perhaps accuse me, gentlemen, of a disposition to magnify the im- 
portance of every new class of diseases at which we arrive, in our survey of the 
morbid conditions of the various parts of the body in succession. There are few 
complaints, in truth, which are not important; either from the discomfort to 
which they give rise, or from their tendency to abbreviate the span of human 
existence. Yet of the strictly vital organs the derangements are necessarily the 



DISEASES OF THE HEART. 



most perilous ; and therefore, to ns, the most interesting. Two props of the 
tripod of life we have passed in review, and seen how they may be weakened, 
and how they may fail altogether. The office of the heart is not less essential 
to life and health, than that of the brain, or of the lungs. The well-being of 
every portion of the frame depends upon its being duly supplied with arterial 
blood, and duly relieved of that which has become venous: and this supply and 
relief require that the central organ of the circulation should be sound in its struc- 
ture, and perfect in its working. But it is frequently otherwise. I can remember, 
indeed, the time when disease of the heart was thought to be a very rare thing; 
but it is now well-known to be one of the commonest of disorders, and it connects 
itself with a variety of other affections, with which it was formerly supposed to 
have no relation. 

Like other organs that are complex of structure and formed of different tissues, 
the heart is subject to partial disease. Its lining membrane alone may, in the 
first instance, become the seat of inflammation, with its various effects; or its 
investing membrane only may undergo morbid alterations ; or the muscular sub- 
stance that constitutes the organ itself may be gradually changed in its qualities, 
in its bulk, or in its proportions. 

But the morbid conditions of the investing and lining membranes do not always, 
or immediately, compromise the life of the patient. They are fatal at length, in 
ninety-nine cases out of a hundred, through the alterations to which they lead in 
the muscle wherewith they are connected. It may be practically useful therefore 
to consider, first, these ultimate morbid states which are incompatible with the 
continuance of life; and then to trace them back to the next link in the chain of 
their causes, which will be found, in -a very great number of instances, to consist 
in some antecedent morbid state of the exterior or of the interior membrane. 

The heart, you know, is a living forcing pump; a hollow muscular engine, 
with its chambers and their outlets, its contractile walls and their strength and 
thickness, so admirably adjusted, that the healthy balance of the circulation is 
continually maintained, under many varying outward influences and inward 
emotions which tend to destroy it. In treating of disease of the heart we have 
to consider, therefore, the modes in which its mechanism may be spoiled or 
deranged : and the effects of such derangements. 

Not only the component tissues, but different portions also of the organ maybe 
separately diseased. It seldom happens, indeed, that the whole heart is affected; 
although that is probably the vulgar belief. The left side is much more obnoxious 
to morbid changes than the right: and when both sides are implicated, the altera- 
tion is almost always more decided and conspicuous in the left than in the right 
chambers. 

In the rapid sketch which I attempted of general pathology, in the outset of the 
course, I pointed out the various kinds of alteration to which the tissues and 
organs of the body, and therefore the heart among the rest, are subject. One or 
more of the chambers of the heart, you will remember, may become larger or 
smaller than is natural ; or have their walls increased or diminished in thickness, 
and consequently in power; or one or more of its outlets and orifices of commu- 
nication may be widened or contracted : and the purposes and function of the 
organ will be more or less impaired by these changes. 

In order, then, to have a clear conception of cardiac disease, it is necessary to 
analyze it, and to investigate the derangements of the several parts of the heart. 
And I begin with hypertrophy; augmentation of bulk in its muscular substance. 
And I must first of all define one or two phrases which are current among patho- 
logists in respect to this condition. 

The muscular tissue of one, or more, of the chambers of the heart may become 
thicker and stronger than natural, while the capacity of that chamber, or of those 
chambers, remains unaltered. The hypertrophy in that case is said to he simple. 

But, while the muscular parietes are thickened, the corresponding chamber may 



672 



DISEASES OF THE HEART. 



become unnaturally large. This constitutes the active aneurism of the heart of 
Corvisart, the eccentric hypertrophy of more modern writers. 

On the other hand, it has been supposed that the capacity of a cavity of the 
heart may diminish in size as its walls increase in thickness: that the hypertrophy 
may take placed the expense (as it were) of the chamber. This has been called 
concentric hypertrophy. 

Now of these three reputed forms of hypertrophy, considered in their relation 
to disease, two only, the simple and the eccentric, have any real existence. The 
third, or concentric form, never occurs, I believe, except as a congenital malform- 
ation., And of the two genuine species of hypertrophy, the eccentric, which is 
plainly a compound affection, consisting of hyvertrophy with dilatation, is much 
the most common. The reason of this is to be found in the physical cause of the 
morbid condition, in most instances. The physical cause, in nineteen cases out 
of twenty, is some obstacle, mechanical or virtual, to the perfect accomplishment 
of the function of the chamber; some obstruction opposed to the free and thorough 
exit of the blood from it ; or something which hinders the easy play of the organ : 
hence, in the first place, a gradual yielding, or tendency to yield, in the sides of 
the affected chamber, from the continual and unwonted pressure of the accumulated 
blood against them, and in the second place, a striving action of the muscle to 
overcome the hindrance, or to counterbalance the obstacie ; and consequently, 
according to the law formerly announced, an augmentation in the bulk of the 
muscle whereof the function is thus increased. If the hypertrophy, which is the 
result of a truly conservative process, keeps pace exactly with the amount of the 
obstacle and exactly balances it, no dilatation happens, or next to none. But this 
is comparatively seldom the case. According to the principles of mechanics, a 
little distension of the spheroidal cavity must require an increase of force to propel 
from it a given quantity of blood, in the same time, through a given discharging 
orifice. So that incipient dilatation becomes (in addition to the supposed obstacle) 
an efficient cause of hypertrophy: and the two, the dilatation and the hypertrophy, 
commonly make progress together. 

Cruveilhier appears to have been the first to reject concentric hypertrophy from 
the catalogue of cardiac diseases. The smallness of its cavity, with a proportional 
increased thickness of its walls, was regarded by him as a transient condition of 
the ventricle, depending upon the mode of death. -He found these phenomena 
very strongly marked in the hearts of all those whose bodies he had examined 
after decapitation by the guillotine ; " Les parois ventriculaires se touchaient dans 
tous leurs points." It is therefore his opinion that the hearts which had been 
thought by others, to present examples of concentric hypertrophy, were in reality 
" hearts more or less hypertrophied, which death had surprised in all their energy 
of contractility." 

This question has since been considered by Dr. Budd, in a communication to 
the Medical and Chirurgical Society, which you may read in the twenty-first 
volume of its Transactions. He has lately favoured me with a statement of his 
matured views upon the subject. 

The semblance of concentric hypertrophy is most common in the left ventricle ; 
and depends upon the ventricle being nearly empty at the time of death, and upon 
the corpse being examined while the heart is contracted by the rigor mortis. The 
fallacious appearance is accordingly noticed in cases where, from the manner of 
death, the left ventricle, or the entire heart, contains but little blood, and where, 
from the muscular power not having been previously exhausted, the rigor mortis 
is of long duration. 

"In all these concentrically hypertrophied hearts (writes Dr. Budd) the ven- 
tricle may be readily dilated by means of the fingers, and always dilates of itself 
when the rigor mortis goes off." 

** In the published cases of concentric hypertrophy, in which there was no dis- 
ease of the valves (I have given eight such cases in my paper, and could now add 
a long list to them) there were no signs, or only very slight signs, of disease of 



HYPERTROPHY. 



673 



the heart, during the life-time of the patient. This circumstance is sufficient 
proof that the cavities of the heart in these cases could not have been during life 
permanently in the contracted state in which they were found after death. A left 
ventricle that could scarcely contain an almond (a common form of expression in 
the description of these cases) would surely have caused a great impediment to 
the circulation." 

Moreover, concentric hypertrophy could answer no mechanical purpose; nor 
could its formation be accounted for on mechanical principles. But "concentric 
hypertrophy of a ventricle, in a high degree, with obstruction at its discharging 
orifice, and an extraordinary channel for the passage of the blood, occasionally 
exists as a congenital malformation ; and in most cases, the right is the ventricle 
so affected." 

To resume. Recollect that there may be two distinct kinds of physical cause 
of excessive action of the heart, and therefore of hypertrophy. In the one kind, 
there is some mechanical obstruction to the exit of the blood from one or more of 
the cavities ; a constricted state of the orifices, is the most common condition. 
In the other kind, without any such mechanical bar or dam to the fluid, there is 
something to hinder the free and sufficient play of the organ ; an adhering peri- 
cardium it may be, or mal-position of the heart. If the heart be pushed, for 
instance, out of its proper place and posture by effusion into the pleura, or by dis- 
tortion of the chest, it will not work with the same ease as when all is perfect and 
symmetrical; and the unusual labour imposed upon it fully to execute its office, 
will lead to hypertrophy. The causes of hypertrophy may therefore be situated 
within the heart itself, or without and beyond it; but in all those cases in which 
the effect of the hindrance or obstacle is to detain the blood in one or more cham- 
bers, the hypertrophy will be likely to be accompanied by dilatation: and, gene- 
rally speaking, the hypertrophy and dilatation result from disease in some part 
which lies beyond the affected chamber, in the order of the circulation. Thus 
either a narrowing, or a dilatation of the aorta at its commencement, will tend to 
cause hypertrophy and dilatation of the left ventricle. 

That contraction of the aorta, or of the aortic orifice, may have this conse- 
quence, you will have no difficulty in perceiving. The blood cannot so readily 
pass through the narrowed channel; hence it will tend to accumulate in undue 
quantity in the ventricle, therefore to stretch and dilate it; and the increased mus- 
cular efforts necessary to drive the delayed blood onwards, tend also to thicken 
the muscle itself. But it may not be so obvious that dilatation of the mouth of 
the aorta — a wider channel of egress — would also virtually prove an obstacle to 
the emptying of the ventricle. Yet it certainly would, in two ways.. In tlie first 
place, dilatation of the entrance of the aorta implies a diminution in the elasticity 
of that vessel; and the blood after it has left the heart is urged onwards by the 
healthy elasticity. But again, dilatation of the mouth of the aorta commonly 
implies an imperfect closure of that vessel by the sigmoid valves ; so that during 
the diastole, a part of the blood is apt to regurgitate from the aorta, and to keep 
the ventricle morbidly full. You see, therefore, that a deviation from the healthy 
state of the aorta and of the valvular apparatus which lies at its mouth, may ob- 
struct the course of the blood, and lead to hypertrophy and dilatation, whether 
the deviation be in the one way or in the other : whether, I mean, the natural size 
of the vessel be increased or diminished. Again, disease of the mitral valve, 
obstructing the flow of the blood at that point, will lead to an accumulation in the 
left auricle, in the pulmonary veins, and in the lungs themselves. The auricular 
action is always less regular and energetic than the ventricular, so that we less 
frequently meet with hypertrophy of the auricles; but very often with dilatation. 
And if we go to the other side of the heart, we find hypertrophy with dilatation, 
and more especially dilatation of the right ventricle, when, from some reason or 
other, the blood passes with difficulty towards or through the lungs: either from 
disease of the pulmonary artery, or from disease in the substance of the lungs — 
emphysema, for instance : and if the difficulty be great, the accumulation and dis- 
48 

/ 



674 



DISEASES OF THE HEART. 



tension will affect successively the right auricle, and the venae cavae ; and then we 
have, in most cases, general dropsy. So that, I repeat, disease in the heart tends 
to propagate itself in a direction contrary to that of the circulation. Furthermore, 
if the muscular tissue of the heart be pale, flabby, soft, and weak — as it frequently 
is in feeble, ill-nourished, cachectic persons — it will the more readily yield to the 
centrifugal pressure of the blood it embraces. In this way we may have dilatation 
without any hypertrophy. I am anxious that you should in the outset comprehend 
the mechanism by which the natural dimensions, and relative proportions of dif- 
ferent parts of the heart, may be altered in disease. 

One reason why disease of the heart used formerly to be overlooked, was 
that these natural dimensions and relative proportions were not ascertained or 
much attended to. It is not easy to form any very precise estimate of the size of 
a healthy heart. It is commonly held that if the heart be about the same size 
with the closed fist of the subject, its general dimensions may be considered as 
being natural. Bouillaud, who has taken much pains with this matter, weighing 
and measuring a great number of different hearts, states that the mean weight of 
that organ, with the origins of its large vessels, and empty of blood, in adults from 
twenty-five to sixty years old, is from eight to nine ounces ; that in subjects from 
sixteen to twenty-five years old it may be one or two ounces less ; and that, in 
very large and robust persons, it may rise to ten or eleven ounces. Also, what 
we should expect, that the weight is less in women than in men. 

So much for the general bulk of the heart. And we must have some standard 
whereby to estimate its relative proportions. Every one knows that the walls of 
the left ventricle are thicker than those of the right. Bouillaud found that the 
mean thickness of the walls of the left ventricle at its base was seven lines, while 
that of the right ventricle was two and a half lines. And taking the thickness 
generally, he says, that the thickness of the parietes of the right ventricle, has not 
a greater ratio to that of the parietes of the left, than two to five, or even than one 
to three. 

So again of the auricles ; he lays it down that the mean thickness of the walls 
of the left auricle, is to the mean thickness of those of the right, as three to two. 

He holds also that the mean capacity of the right ventricle exceeds, by a little, 
that of the left: and that the right auricle is larger than the left. You must always 
make allowance in actual cases, for the possible distension of these cavities with 
blood, beyond the size to which they would have contracted if they had contained 
no blood. 

I may add, that the same author declares the rule I just now mentioned, which 
had been p/oposed before his researches were instituted — the rule, viz., which 
makes the bulk of the healthy heart equal to the fist of the subject — to be tolerably 
correct. By keeping in mind these general facts, you will be better able to appre- 
ciate the appearances presented by the heart when it is taken from the body to be 
examined : but you will recollect that they relate to averages only. 

Now having pointed out the modes in which the natural proportions of the 
heart and of its several parts may be morbidly altered; and given you a rough 
standard which may enable you to estimate these proportions in the state of health, 
and the deviations from them in the state of disease : I will go on to consider the 
symptoms, by which the altered conditions are accustomed to declare themselves. 
And it is with respect to the heart, as with respect to the lungs, there are general 
symptoms or signs, and there are physical symptoms or signs : and the informa- 
tion derived from these sources respectively is of variable utility. Neither of them 
can be safely neglected; and it is often found that the indications derived from one 
of these sets of symptoms are confirmed or corrected by those collected from the 
other. I believe it will be best to pursue the same course in both cases, and to 
speak, in the first place, of the signs that are brought within our notice by the 
sense of hearing. 

But, in order that we may comprehend the morbid sounds of the heart, we must 
first make ourselves acquainted with those that belong to its healthy condition. 



NATURAL SOUNDS. 



675 



The heart may be heard by the ear laid flat against the precordial region, or 
through a stethoscope, to beat over a certain space. That space, in ordinary cir- 
cumstances, corresponds to the inferior half of the sternum,' and to the cartilages 
of the ribs, from the fourth to the seventh, on the left side. The apex of the 
organ may often be seen to pulsate between the cartilages of the fifth and sixth 
left ribs; about two inches below the nipple, and one inch from it towards the 
sternum. 

This is the space over which, in the sound state of the heart and lungs, the 
pulsations of the former are plainly audible. But there are several diseased con- 
ditions both of the heart itself, and of the parts around it, which interfere with this 
rule. 

In the first place, if the heart be larger than natural, it will be heard to beat 
over a proportionally larger space. In this way it may come to be heard all over 
the chest in front ; and behind on the left side of the spine ; and even, in extreme 
cases, on the right side of the spine. 

Again, the extent of space over which the heart may be heard to beat will be 
increased in proportion to the thinness of its walls; and diminished, caeteris pari- 
bus, according to the thickness of its walls. So that when the he^art is nearly its 
proper size, if its walls be thin, it will be heard beyond its natural limits ; and if 
its walls be morbidly thick, i. e., if it be affected with considerable hypertrophy, 
it will not be heard beyond, nor even to the extent of its natural limits. I will 
endeavour, presently, to explain the reason of these differences. 

Again, and this it is of great importance to remember, the heart may be heard 
far beyond its natural limits, even when it is perfectly healthy, in consequence of 
the lung between the ear and the heart having become solid, and therefore a better 
conductor of sound: and the solidification may have resulted from hepatization, 
or from the presence of a number of crude tubercles. The sound of the heart's 
action will also be conveyed to a distance by the liquid effusion in pleurisy. If 
we are not aware of these circumstances, we are continually liable to fall into 
mistakes. 

The heart is likewise heard more distinctly, and over a space which is com- 
paratively larger, in children than in adult persons; and I need scarcely say that 
it may be heard over a wider extent of the chest whenever its action is augmented 
by exercise, by emotion of mind, or by febrile excitement. 

The impulse of the heart is another point which yon must attend to. In 
healthy persons who are thin, you may generally feel the stroke which the heart 
gives to the ribs, by placing your hand on the precordial region. In persons 
who are fat, you often cannot feel the heart at all in this manner. For obvious 
reasons, it is felt more distinctly, over a larger space, and higher up, while the 
person is stooping forwards, or makes a forced expiration ; less distinctly, over a 
smaller space, and lower down, when he makes a deep inspiration, or is lying on 
his back. In proportion as the heart is enlarged by disease, it can be felt more 
extensively: and when there is hypertrophy, the force with which it strikes the 
parietes of the chest is sometimes extraordinary, and very instructive. You will 
see the ear and head of the listener distinctly lifted at every pulsation; sometimes 
the whole of the patienfs body, nay his very bed, is shaken by the strong shock 
of the heart during its systole. There is no sign of hypertrophy so sure as that 
afforded by the heart's impulse. You feel, not a smart, quick, and sudden knock, 
but a steady, heaving, irrepressible swell, which is perfectly characteristic. You 
may always infer increased thickness of the walls of the organ, when you meet 
with this regular heaving motion ; and the extent to which the whole heart is 
enlarged in such cases may be conjectured by the extent of space over which the 
heaving impulse is perceptible. 

The sounds which we hear are two. One of them coincides, in point of time, 
with the impulse ; and barely precedes the beat of the radial artery. It happens, 
therefore, when the ventricles contract ; during the systole. It is called, accord- 
ingly, the systolic sound, or the first sound of the heart. The other of the two 



676 



DISEASES OF THE HEART. 



sounds coincides with the diastole, and is spoken of as the second or the diastolic 
sound., It takes place at the instant when the heart reverts to that place and con- 
dition in which it had been prior to the systolic movement. These two sounds 
occur in quick and regular succession, and then follows an interval of silence, 
after which the two sounds are repeated; and so on. 

The two sounds are not, however, exactly alike. They differ somewhat, both 
in quality and in duration. The first is a dull, prolonged noise; the second a 
shorter and smarter sound, having more of a clacking or flapping character. At- 
tempts have been made to assign the respective duration of each sound, and of the 
period of repose. I confess that I have never succeeded in measuring them satis- 
factorily in my mind. Probably Dr. C. J. B. Williams' estimate is as near the 
mark as any. He divides the whole period, from the beginning of one pulsation 
to the beginning of the next, into five equal parts : and allots two of these to the 
first sound, one to the second, and the remaining two to the interval of silence. 
This order of succession is called the rhythm of the heart : and it may be per- 
verted. 

Respecting the physical causes of these natural sounds there have been much 
recent discussion and research. Our time, however, will permit me to do little 
more than tell you what I believe to be the facts of the matter. And I take, first, 
the diastolic sound, as being the simpler of the two. It used to be ascribed to the 
contraction of the auricles : but that was quite a mistake. The contraction of the 
auricles, such as it is, happens immediately before each systole of the ventricles ; 
whereas the sound in question occurs immediately after it, and is succeeded by 
the period of silence. This we know from the visible movements of the organ 
when exposed in a living animal. In truth, the auricular contractions are very 
feeble, and not attended with any appreciable noise. 1 have no doubt that the 
second sound is produced mainly, if not altogether, by the sudden shutting of the 
floodgates placed at the mouths of the two great outlets of the heart. The recoil- 
ing blood forces back the semilunar valves of the aorta and of the pulmonary 
artery, as one unfurls an umbrella; and with an audible check as they tighten. 
There is no other tenable mode of accounting for the sound. Experimenters have 
contrived, by hooks and wires, to prevent these valves from unfolding; and then 
the flapping sound has been converted into a hiss. Disease of the same valves 
demonstrates the same things ; as we shall presently see. .Nevertheless, it is 
both possible and probable that the relapse of the whole organ to its former place 
may contribute an ingredient towards this second sound. 

The first, or systolic sound, is more complex. Partly it is owing, as I be- 
lieve, to a similar cause with that which occasions the diastolic sound, viz., the 
abrupt closure of the orifices of communication between the auricles and ventri- 
cles, by the reflux of the blood against the ventricular surfaces of the tricuspid 
and mitral valves ; partly, sometimes, to the blow of the heart's apex against the 
ribs ; chiefly, however, it consists of the sound that results from the muscular con- 
traction of the ventricles. The systolic sound commences with the tightening of 
the walls of the ventricles, including the valves; and it is prolonged by the mus- 
cular noise. You are aware, I dare say, that the vigorous contraction of a large 
muscle is accompanied by audible sound. If, during the stillness of night, when 
lying in bed, with your cheek and ear upon the pillow, you set your teeth firmly, 
vou will hear a continuous dull rumbling, like the noise of carriage wheels in the 
street, and evidently caused by the action of the masseter and the temporal mus- 
cles. Dr. Williams states that, with the help of a flexible stethoscope, one may 
hear the voluntary jerking contraction of his own abdominal muscles ; the sound 
being as loud as that of the heart's systole and very like it in character. That 
the systolic sound is essentially due to muscular contraction is proved by the fact, 
that when a heart is taken from the living thorax and placed upon a table, its con- 
tractions (which persist for awhile) are still attended with a noise similar to the 
natural first sound, though weaker. Here there is neither collision of the blood, 



NATURAL SOUNDS. 



677 



nor valvular reaction, nor impulse against the ribs, to render the experiment am- 
biguous. 

If you acknowledge and comprehend this source of sound, you will understand 
without difficulty why the heart, cseteris paribus, is heard more clearly and ex- 
tensively when its walls are thin, less widely and loudly when they are thick. 
" The transition (says Dr. Williams) of a thick muscle from slack to tight can 
never be so complete and sudden as that of a thin one. Where there are many- 
fibres they choke and muffle each other's vibrations; hence the sound is dull and 
prolonged, rather than loud and clear. If we observe the different sounds pro- 
duced on tightening thin silk and thick baize or cloth, we find that the thinness 
of the silk gives a unity and briefness to the impulse which it receives, and the 
sound is short and loud ; whilst in the baize the impulse is divided and prolonged 
in the complexity of the fibres, and the sound is dull and less brief: so, under 
similar circumstances, a thin ventricle will give a louder, sharper sound than a 
thick one." 

The natural sounds which I have been describing are liable to be changed, or 
modified, by disease. Some of the modifications, indeed, I have advened to as I 
went along. But others, of a more striking and extraordinary character, are yet 
to be explained. Either sound, or both, may be accompanied by a noise, which, 
in its commonest type, very closely resembles that produced by the blowing of a 
pair of bellows. Four persons out of five, I should think, if they were asked 
what this sound resembled, when they heard it accompanying each systolic 
movement of the heart, would say that it was exactly like the repeated blowing 
of bellows in an adjoining room. It is called, accordingly, by the French, the 
"bruit de soufflet;" and, in homely English, a bellows sound. This is the 
generic sound. It may be divided into species ; but it is scarcely worth while so 
to divide it. We are only likely to confuse our notions by over-refinement. So 
I will only add, that, when this bellows sound is very harsh or rough, persons 
will tell you that it is more like the noise of a rasp, or a file, or a saw : but all lhe 
while it is some kind of bellows sound. These sounds are often denominated 
murmurs also. 

Now what is the cause of this singular deviation from the natural noises made 
by the successive contractions and relaxations of this hollow muscle, the heart? 
The whole matter may, I believe, be briefly thus expressed. The blowing sound 
may be occasioned by any change which alters the due proportion between the 
chambers of the heart, and their orifices of communication with each other, and 
with the blood-vessels that respectively enter or leave them ; it may also be occa- 
sioned by a preternatural velocity in the passage of the blood through a healthy 
and well adjusted heart. Dr. Elliotson, I think it is, who has offered this oppo- 
site illustration of the phenomenon. If the arches of a bridge have a certain rela- 
tion to the quantity of water in the river, and to the force of the current, the water 
passes through them quietly, and without any noise. Diminish the size of the 
arches, and the water begins to go through them with an audible rushing or roar- 
ing sound. The very same thing will happen if the arches remain unchanged in 
size, but the quantity of water in the river, and therefore its velocity and force, 
be augmented by heavy rains. So it is in the heart. If one of its orifices — say 
the aortic orifice — be narrowed, by disease of the valves, or in any other way, the 
blood will not, as before, glide through it smoothly and without noise, but will 
yield that sound which we call a bellows sound. So also, if the orifice retain its 
natural dimensions, but the capacity of the cavity from which the blood is driven 
be augmented. Nay, the same blowing sound may be produced though the 
cavities and orifices are all healthy, and duly proportioned to each other, if the 
velocity of the circulating blood be increased beyond a certain measure. If you 
bear this explanation in mind, it will be found applicable, I think, to almost every 
case in which there is a blowing sound accompanying the systole of the organ. 
If, at the same time, the valves over which the blood must pass be rigid, or rough, 
or even loose and vibrating, those circumstances may modify the blowing sound, 



678 



DISEASES OF THE HEART. 



and render it louder, or hoarser than it would otherwise be, and justify the appel- 
lations of bruit de scie, and bruit de rape, with which you will find the French 
books, and many of our English also, full. 

But this explanation applies to a systolic blowing sound only. What are we 
to say when there is a similar sound attending the diastolic movement of the 
heart? Why a diastolic bellows sound will mostly, if not always, be found to 
accompany and denote some organic disease affecting the valves of the heart. 
Thus, if the mitral valve be converted, as it often is, from a loose flapping valve 
into a bony and rigid unvarying chink, the blood which passes through it from 
the auricle to the ventricle, during the diastole, may (though it seldom does) cause 
a rushing or blowing sound. On the other hand, the reflux of blood through the 
unshut mitral orifice, during the ventricular contraction, may also be attended with 
an audible noise ; and thus we have another and not unfrequent source of a sys- 
tolic murmur. Again, if the aortic valves are imperfect, as they often are, and do 
not effectually close that vessel, blood will regurgitate through them during the 
diastole, and produce a bellows sound. That this is the true explanation of the 
diastolic murmurs, I am convinced, both by the observation of disease, and by 
the results of experiments on animals. In some of Dr. Hope's experiments, 
which he was good enough to allow me to witness, the short clack of the diastole 
was at first distinctly audible ; then hooks were introduced, so as to prevent the 
perfect closure of the sigmoid valves during the diastole, and then the short smart 
clack was converted into a prolonged bellows murmur; and, upon letting them 
go again, the short smart clack recurred. The presence of a diastolic bellows 
sound has repeatedly enabled me to foretell some disease of the sigmoid valves, 
interfering with their proper function — that of forbidding the re-entry of the blood 
into the ventricle from the aorta; and what I have thus predicted during life, has 
been verified by observation after death. 

Such are the principal sounds, natural and morbid, which are audible to the 
naked ear, applied to the precordial region, or which may be heard through the 
stethoscope. But we derive assistance, in respect to cardiac disease, from per- 
cussion also. It enables us to measure, in some cases, the bulk of the heart ; in 
others, to ascertain that the pericardium is distended by fluid. In the perfectly 
healthy state of the viscera of the thorax, the heart is somewhat overlapped by 
the thin edge of the lungs; and the sound elicited by percussion over a part of 
the precordial region is intermediate between the hollow sound rendered by lung, 
and the flat sound yielded by the solid heart. In the centre of the prascordial 
region, where the heart is not covered by lung, the sound is decidedly dull. 
When, however, the heart is enlarged by disease, a larger part of its surface is 
exposed, and a larger portion of the prsecordial region yields a dull sound on per- 
cussion. And when the pericardium is full of liquid, which distends and expands 
it, you will sometimes find that not less than a third part of the anterior and lateral 
portion of the left side is quite dull : and it is interesting often to measure, by 
percussion, the diminution or extension of the limits of the dullness, as the amount 
of fluid effused decreases or augments. 

What I stated before, concerning the effect of different positions of the body 
upon the space over which the healthy beating of the heart may be heard, felt, 
and sometimes seen, applies, mutatis mutandis, to the natural dullness which it 
causes when the prascordial region is percussed. This dullness comprehends a 
space of between one and two square inches, reckoning from the spot where the 
impulse is felt, toward the left edge of the sternum. The dullness should diminish 
or disappear, in the supine position, and when a full breath is drawn ; and increase 
in degree and extent upon a forced expiration, and when the posture is prone. 

There is another physical sign which is much dwelt upon by Laennec, and 
which is sometimes very striking. In certain conditions of disease, the hand 
placed over the situation of the heart perceives a peculiar thrill or vibration 
accompanying its movements. The sensation conveyed to the hand is really very 
much like what Laennec compares it to, viz., that tremor which you feel, when 



PALPITATION. 



679 



coaxing the back of a cat while it is purring with pleasure. Accordingly he calls 
this sensaiion, " fremissement cataire," the purring thrill. You feel this vibration 
often when there is present also a loud and strong bellows sound ; and Dr. Davis 
is of opinion, that the bruit de soufflet, and the fremissement cataire, constitute, 
in fact, but one phenomenon, which is rendered evident to the touch by the vibra- 
tions communicated to the hand ; and to the ear by the vibrations communicated 
to it through the solid walls of the chest. I know, however, that the fremissement 
cataire does accompany other sounds, as well as the bellows sounds: sounds of 
which I have not yet had any occasion to speak, but which I shall make you 
acquainted with when we come to the subject of pericarditis. And I pass from 
this general account of the sounds belonging to the action of the heart, in health 
and in disease, to consider the other symptoms by which we judge that such dis- 
ease is present. 

Among the general symptoms, then, of cardiac disease, some are direct — as 
pain; palpitation or excessive action of the heart perceptible by the patient; irre- 
gular or intermittent action, which the patient may or may not be conscious of: 
and some are indirect, declaring themselves through the medium of other parts 
and organs — such are dyspnoea; cough; dropsical accumulations; hemorrhages; 
various affections of the nervous system, especially an increased and morbid 
sensibility, what is usually called nervousness : and some others, which I will 
cursorily notice as we proceed. 

I shall take this opportunity of considering, once for all, some of these symp- 
toms ; whether they really proceed from organic disease of the heart or not : for 
the determination of the question, whether they do or do not indicate such disease, 
is often of great moment, and is not always easy. 

We are not, in general, sensible of the beating of our hearts: but when the 
pulsations become inordinately forcible, they make themselves felt, and the sen- 
sation is, in many cases, a most troublesome and distressing one. Palpitation 
implies increased force, or increased frequency — or an increase both in force and 
in frequency — of the contractions of the heart. Every one has experienced 
palpitation in his own person who has run himself out of breath. The pulsations 
are sometimes tumultuous also, and irregular, as well as unduly frequent and 
forcible ; but this is by no means always or necessarily the case. There may be 
great palpitation with perfect regularity of the heart's action. The increased 
beating not only can be felt internally by the patient, but it may often be heard 
both by himself and by others. However, we do meet with persons whose hearts 
throb with excessive violence, without their being at all aware of it. Such cases 
are always, I believe, cases of disease ; whereas the palpitations that annoy and 
harass the patient are very often connected with functional disorder only. 

Irregular action of the heart consists in some derangement or discord of its 
rhythmical movements, and is discovered by the condition of the arterial pulse 
—by unnatural fluctuations in the strength, or in the number, of its beatings, or in 
both. Sometimes a few rapid and feeble pulsations occur at uncertain intervals, 
and are followed by others that are fuller and slower. Sometimes one or more 
beats are left out, and the next beat, as if to make up for this pause, is unusually 
strong. The pulse is then said to intermit. The intermissions may be unper- 
ceived by the patient himself; but in general they are attended with a singularly 
disagreeable fluttering, or trembling sensation in the breast. The pulse may 
intermit though the heart does not: the ventricle may now and then contract so 
faintly as not to propel a wave of blood so far along the artery. Intermission 
implies irregularity ; but the action may be irregular and disorderly without inter- 
mitting. 

Now, any of these deviations from the natural rhythm and action of the heart 
alarm people very much, and impress them with a belief that they have some fixed 
disease of that organ ; and you will continually be appealed to for your opinion on 
this point. I suppose there are few medical students who have not, at some time 
or another, admitted into their minds the apprehension that they had disease of the 



680 



DISEASES OF THE HEART. 



heart; an apprehension engendered by its occasional palpitation or irregularity. 
For though there may be palpitation without irregularity, yet it is practically con- 
venient to consider the two together. 

These deviations certainly belong both to organic disease and to mere functional 
disorder of the heart ; but I repeal, that in a great number, nay, in a great majority, 
of the cases in which they so distress and alarm the patient as to lead him or her 
to complain of them, they are unconnected with any change of structure; and this 
it is of much importance that you should be aware of. 

Palpitation of the heart, and intermission or irregularity of the pulse, are often 
dependent upon some disordered condition of the stomach, and will cease at once 
when that disorder is rectified. It is curious that this may happen although the 
gastric affection does not manifest itself by any other symptom: and it is curious, 
too, how slight a cause may suffice tp produce the irregular action. A friend of 
mine, a barrister, used to be very anxious about himself, because a fluttering sen- 
sation frequently occurred at his heart; an intermission of one or two beats, and 
then a violent throb when the organ again resumed its play. This is a sensation 
very familiar to myself, and probably most persons have occasionally experienced 
it. However, it happened so often to the gentleman I speak of, that it made him 
very unhappy. He persuaded himself that he had disease of the heart, and that 
he should some day suddenly drop down dead. But there was no other symptom 
of cardiac disease direct or indirect, general or physical. He was accordingly 
told that the intermission depended upon some fault in his digestive organs; and 
he was advised to leave off different articles of food and drink in succession, in 
order to discover whether any one thing in particular offended the stomach, and 
gave rise to the symptom. He began by abstaining from tea, which he had been 
in the habit of drinking in considerable quantity ; and thereupon the fluttering of 
the heart ceased. After a while he took to tea again, and then the fluttering 
returned. He repeated the experiment many times, and always with the same 
result, till at length his mind was satisfied ; and by renouncing tea altogether lie 
got rid of his palpitation and of his apprehensions. 1 mention this instance, 
because it came within my own cognizance ; but it is only a sample of many such, 
and tea is frequently found to be the disturbing substance. 

I must caution you, however, against the mistake, which is often made, of 
inferring that the heart is free from organic change because its irregular move- 
ments are accompanied by dyspeptic symptoms. Structural disease of that organ 
is very apt to derange the digestive functions. You will commonly find that 
patients who labour under such disease are exceedingly liable to flatulence of the 
stomach ; and free eructation of the gas which plagued them mitigates wonderfully 
the cardiac distress. It does so, no doubt, by relieving the diaphragm from that 
upward pressure which embarrassed the motions of the heart. 

We judge that palpitations and irregularities are merely symptomatic conse- 
quences of gastric disorder when they occur occasionally only ; when the rhythm 
of the heart is perfect during the intervals ; and when we fail to discover any other 
physical or general signs that its texture has undergone alteration. 

Besides these overstrong or irregular movements, which are symptomatic of 
disorder of the stomach, and are remedied by correcting that disorder, there are 
palpitations of a purely nervous kind. I mean, that they depend upon a peculiar 
and highly sensitive condition of the nervous system ; which condition is itself 
dependent, in general, upon a particular state of the vascular system. Persons of 
a k4 movable" constitution, whether male or female, are subject to these palpita- 
tions : but especially young women ; and, of these, such as are pale, exsanguine, 
hysterical, in whom the menstrual functions are deficient, or excessive, or some- 
how unnatural. Anaemia, if not a constant, is certainly a frequent and most 
remarkable feature of this nervous state. The blood is aqueous; poor in fibrin, 
and in red particles. The age, and frequently the sex, of the patient form leading 
points in the diagnosis. Nervous palpitations are apt to come on when the 
patient is quite at rest: palpitations that result from organic disease are, on the 



VENOUS MURMURS. 



681 



contrary, always mitigated by repose. The occurrence of palpitations in the night, 
however, is but an equivocal circumstance, for nervous persons who dream, awake 
often with palpitation; and the recumbent posture generally excites or aggravates 
the palpitations that are organic. Neither, in forming our diagnosis, can we trust 
entirely to the presence or absence of physical signs. The heaving impulse of 
hypertrophy is indeed wanting; but, as 1 told you formerly, the short abrupt 
knock of chlorotic palpitation is often attended with a bellows sound. The weak 
and flabby muscle dilates (I fancy), and the natural proportion between the cham- 
ber and its outlet is for a time destroyed. The sound may partly depend upon 
the thinness of the blood in such patients ; and this reminds me of another diag- 
nostic clue which you should be acquainted with. In nervous, susceptible persons, 
especially if they exhibit the pallor of anaemia, very curious noises are often audi- 
ble, by means of the stethoscope, in the neck. Continuous rushing or roaring- 
sounds, very like those which are to be heard in shells, and whieh poets feign, 
and the vulgar believe, to be the noise of the distant sea. 

Shake one, and it awakens; then apply 
Its polished lips to your attentive ear, 
And it remembers iis august abodes, 
And murmurs as the ocean murmured there. 

Sometimes the sound is more like the hum of a gnat, or the sighing of the wind 
through a crevice. Dr. Hope very truly states that it may be imitated, by a pro- 
longed whispering pronunciation of the syllable luho. Bouillaud, from its resem- 
blance to the whizzing of a well-known toy, calls it the " bruit de diable." He 
supposed this singular sound to reside in the arteries of the neck : but it is quite 
distinct from the true arterial bellows murmur, and it has been clearly shown (first 
by Dr. Ogier Ward, of Birmingham), that it is produced by the descent of the 
attenuated blood through the great cervical veins. The sound, though continuous, 
has often a marked and regular increase, or swell, which keeps time with the 
heart's systole, and is believed to depend upon the pulsating pressure of the con- 
tiguous artery. It is best heard on the right side of the neck, just above the 
clavicle, and just behjnd the posterior edge of the sterno-mastoid muscle. You 
must take care not to produce these sounds, as you easily may, by pressure with 
the stethoscope. So, also, you may suspend them at your pleasure, by pressing, 
above the stethoscope, upon the track of the veins, so as to stop the current of 
blood through them, without arresting the pulsation of the arteries. This proves 
that the murmurs are venous. I have no leisure to go more into particulars con- 
cerning these sounds; but when you meet with them, concurring with cardiac 
palpitations, in a young, nervous, anaemic subject, the palpitations, ninety-nine 
times in a hundred, will turn out to be simply functional — independent of any 
organic disease. No doubt there may be co-existing change of structure ; but that 
is a rare exception, and when it does occur the signs proper to structural disease 
will be present, and will betray it. 

Now these palpitations, and these musical or rushing sounds in the jugular 
veins, are to be cured by remedying the state of the blood. And the remedies 
are preparations of steel, aloetic purgatives, animal food, the cold shower-bath, 
and exercise, short of producing great fatigue, in pure air. 

I have further to remark, with respect to intermissions of the heart's action, and 
therefore of the pulse at the wrist, that they are frequently connected, both in 
health and in disease, with feebleness, and also with unusual slowness, of pulsa- 
tion. So that a slovy pulse which is likewise feeble is often converted into an 
intermitting pulse by depletion ; by blood-letting, for example, or by an active 
purgative; and the intermittence may be removed again by a stimulant. I men- 
tion this now, because there is another and very different state of disease, in 
which the pulse is apt to intermit. I mean when there is plethora capitis, and 
cerebral mischief is presenter impending. But then the pulse will be full and 
strong, and labouring. In these cases a stimulant treatment would of course be 



682 DISEASES OF THE HEART, 

injurious ; while blood-letting, which would cause the other form of intermission, 
is the remedy of this. 

Some assistance in determining between organic disease and mere functional 
disorder of the heart may perhaps be derived from observing the position of the 
patient. It is stated that when there is mere nervous palpitation, the patient lies 
as well, and perhaps better, on the left side than otherwise : whereas, when the 
heart is actually diseased, the decubitus on the right side is more comfortable than 
that on the left. If there be any tenderness of the heart, or of its enveloping 
membrane, the posture on the right side is supposed to be the easiest, because 
the heart is further removed from the ribs, and impinges upon them during the 
systole with less force. However, no great stress can be laid upon this symptom. 

Of the remaining general symptoms of heart-disease there is not much to be 
said. Dyspnoea and cough are indirect symptoms declared through the lungs, 
between which and the heart there is a close and obvious reciprocal influence. 
But dyspnoea and cough are direct symptoms of pulmonary disease; and even of 
pulmonary disease they scarcely help the precise diagnosis. That disease of the 
heart may materially alter the quantity of blood that is sent to, or transmitted from 
the lungs, is too plain to require any formal proof; and where the quantity of 
blood in the lungs is affected, the quantity of air necessary to ventilate that blood 
must vary : in other words, dyspnoea must ensue. Haemoptysis is also an equivo- 
cal symptom. 

One very common effect of cardiac disease is an impeded and sluggish trans- 
mission of venous blood from the abdominal viscera. Hence congestions of 
various parts, and especially of the liver, which enlarges and grows tender; and 
the biliary secretion and functions are deranged. These symptoms are a fruitful 
source of mistake, leading the unwary practitioner into the belief that the whole 
of his patient's malady is hepatic ; whom he comforts accordingly with the as- 
surance, that " it is all liver." 

The circulation through the brain is also apt to be much disturbed in heart dis- 
eases: and to this circumstance we must attribute the headaches and giddiness 
that often accompany them ; the dread and causeless apprehension which such 
patients frequently exhibit ; the cowardice and irritability which disease of the 
heart engenders in men who previously were intrepid, and of strong and firm 
nerves; also that propensity to dreaming, and especially to distressful and fright- 
ening dreams, so commonly observable in them; and the sudden starting from 
sleep in horror and alarm. The relations that exist between apoplexy and 
organic disease of the heart, were fully discussed in a former lecture. 

One of the most common indirect symptoms of cardiac disease is dropsy ; yet, 
sometimes, the disease of the heart may continue long, and even prove fatal, 
without giving rise to any dropsy. It will produce that symptom, or not, accord- 
ing as it leads to venous congestion or not. Hence dropsy is more particularly 
connected with dilatation and attenuation of the right cavities of the heart. But 
these are points to which I must revert. 

Having thus run over, gentlemen, the morbid changes to which the heart, as a 
muscular organ, is liable: the alterations of thickness in its walls, and of capacity 
in its chambers, and the derangements of the natural relations between the several 
chambers and their orifices ; having considered, also, in a brief and cursory man- 
ner, the sounds which the heart gives out in its different movements during health, 
and the modifications to which these sounds are subject in disease ; and having, 
moreover, passed in review the general symptoms which frequently display 
themselves in connection with cardiac disease, we shall be the better prepared, I 
hope, to investigate, when we next meet ?l some of the specific diseases of that 
important organ. 



DISEASES OF THE HEART. 



683 



LECTURE LX. 

Diseases affecting the muscular texture of the heart; and their treatment. 
Changes to which the valves of the heart are subject. Effects, and diagnosis 
of those changes. Angina pectoris. 

I know not how I can so well put you in possession of what I know, or think, 
concerning particular structural diseases of the heart, as by taking them in succes- 
sion, and offering a sort of running commentary upon them. The mechanism of 
those structural changes, and the altered sounds, and the other physical signs, 
arising out of them, I endeavoured to explain in the last lecture. Bear in mind 
that in this place I can do no more than draw broad outlines. 

Simple hypertrophy of the left ventricle. This sometimes occurs when we 
can discover no mechanical obstacle to the passage of the blood out of the ventri- 
cle, which might account for it : none, I mean, by the closest scrutiny made e\ r en 
after death. Is it then possible that this change may be brought about by physical 
causes which are not permanent, and have no place within the body: such as 
undue action of the organ for a length of time, in consequence of habitual bodily 
exertion? A runner, for example, we may conceive to keep his heart beating 
with a degree of force and frequency beyond what is natural, for the greater part 
of the day ; and that for many days, or weeks together. Again, can simple 
hypertrophy grow out of that excessive action of the heart which may be kept up, 
day after day, for a long period by protracted mental emotion ! It is difficult to 
answer these questions. But I presume that causes of this kind — that any cause, 
in short, which implied long-continued increase in the function of the organ, — 
would suffice to generate hypertrophy. What is certain, however, is that such 
causes seldom do act with sufficient intensity and constancy to produce these 
effects : and simple hypertrophy of the left ventricle, with no physical obstruction 
to the flow of 'blood through the heart, and no impediment to the free play of the 
organ, is rare. 

We ascertain its existence when it does exist, first, by the account which the 
patient gives of himself. He has a sensation of beating of his heart, which he 
ought not to have ; he feels it, and hears it beating as he lies awake in bed ; or 
even at other times when he is at rest. The pulsations are regular. Hyper- 
trophy has no tendency in itself to cause the pulse to intermit or to become irre- 
gular. There is no marked dyspnoea : the circulation of the blood through the 
lungs is not much affected by this alteration of the left ventricle; they are in 
fact protected by the mitral valve: there is seldom any dropsy: but the arterial 
circulation being forced, there is a tendency to active congestion in, the capillary 
vessels. As there is no mechanical obstacle to bridle the excessive power of the 
muscle, the pulse is full and strong; the face is florid; the patient is liable to 
headache, to bleeding from the nose, to active hemorrhage, and to local inflam- 
mation. If you listen to the heart in such a case, you find that the systolic sound 
is less loud and clear than natural. It is not heard beyond the precordial region, 
nor even perhaps over its whole extent: but there is no bellows sound. And if 
you place your hand upon the left breast, you feel that steady, swelling, incon- 
trollable impulsion, which I spoke of in the last lecture as the surest sign that I 
am acquainted with, of hypertrophy. Sometimes the precordial region is mani- 
festly bulging and prominent. 

If I were to preach for an hour concerning the treatment of such cases, I could 
say no more than this : that they require perfect quiet of mind and body ; unde- 
viating abstinence; in short, the strict observance of the antiphlogistic regimen as 
formerly described ; and some of the antiphlogistic remedies j particularly moderate 



684 



DISEASES OF THE HEART. 



topical bleedings, often repeated ; with a close attention to the functions of the 
digestive organs. These are the cases in which, if any, we may expect to cure 
hypertrophy. 

If simple hypertrophy of the left ventricle be rare, hypertrophy of the same 
chamber from a mechanical obstacle, or from some hindrance to the easy working 
of the hydraulic machine, is exceedingly common. What difference, then, let us 
inquire, is made in the symptoms, in the treatment, and in the prospect of re- 
covery, by the presence of a physical impediment, out of which the hypertrophy 
has grown ? 

The mechanical impediment will frequently signify its existence, by causing 
some unnatural sound: a systolic bellows sound most commonly, which is audible 
over the sternum, along the course of the aorta. And the mechanical impediment 
will tend to cause faltering of the pulse ; but generally the hypertrophy corrects 
that tendency. So, on the other hand, the mechanical obstacle corrects the ten- 
dency of the hypertrophy to cause active capillary congestion: and when the 
obstacle is considerable, it will prevent the pulse from being so full and strong as 
in the former case. If to the physical signs of hypertrophy of the left ventricle 
there be added a systolic bellows sound, and a disproportionate smallness and 
feebleness of the pulse at the wrist, we may safely conclude that there is some 
impediment to the escape of the blood from the left ventricle into the aorta; and 
that this impediment has given occasion to the hypertrophy. 

Now, in this case, the hypertrophy is really an endeavour towards health. 
The increased power of the ventricle compensates for the bar which is opposed 
to the current of the blood. The blood would not be able to go on without the 
hypertrophy. There would ensue a tendency to stagnation in the circulation, a 
faltering pulse, imperfect arterialization of the blood, blue cheeks and lips, dyspnoea, 
dropsy ; but the augmentation of bulk and force in the impelling muscle obviates this ; 
obviates it at least for a while : puts off the evil day to a distance. Since this is the case, 
and since we have no means of removing the mechanical impediment, we should 
be mad to desire the cure of the hypertrophy, which is to a certain degree a remedy 
for the impediment; nor indeed could we. cure it if we would. But we have to 
endeavour to keep it within due bounds. If the beating be troublesome to the 
patient, we may alleviate that symptom, and check what there may be nnneces- 
sarily active in the contractions of the morbid chamber, by abstracting blood from 
the praecordia by leeches ; and by soliciting the action of the kidneys, by means 
of cooling- diuretics, among which small doses of digitalis may find an appropriate 
place. The labouring action of the heart is sometimes calmed by the application 
of a belladonna plaster. In this variety, also, of the disease, it is of primary 
importance that no undue efforts of the body be made, and that the patient be 
protected, as much as possible, against all causes of mental emotion ; that scru- 
pulous temperance be enforced; and that all the functions of the body be carefully 
watched and regulated. 

These are not cases in which we can look for recovery : but they are crses 
which bad management and imprudent habits may hurry on to a fatal termination ;. 
and which judicious treatment and a well-regulated course of living may render 
tolerable, and carry forwards for a considerable period. 

Under the same condition of mechanical impediment, we ofrener have eccentric 
hypertrophy of the left ventricle; hypertrophy, i. e., with dilatation. Of course 
the bulk of the whole organ is augmented by both of those conditions ; and some- 
times it becomes enormous, as big as that of a bullock. The symptoms will differ 
somewhat, according as the hypertrophy, or the dilatation preponderates, and 
therefore it will be as well to state here what are the symptoms of simply dilated 
ventricles. They are a diminished impulse of the heart's action ; and therewith 
a clearer sound than is natural. The first sound approximates to that of the 
heart's diastole ; to the clacking second sound, and it is heard extensively. There 
is more or less tendency to fluttering palpitations and irregularities of the pulse, 
which is usually weak and small; to faintness and debility, and to coldness of the 



DISEASES OF THE HEART. 



685 



extremities: and when the right ventricle is dilated, there are some other symp- 
toms which I shall notice presently. 

Now, I say, there will be a mixture or modification of the symptoms, when 
the left ventricle is both dilated and hypertrophic. The dilatation will aid the 
mechanical impediment in giving a tendency to irregularity and intermission of 
the pulse ; and the hypertrophy will tend to rectify that disposition. And we 
must trim our management of such cases accordingly. If the pulse flutters, we 
cautiously administer tonics, or stimulants: if it is steady, and the signs that be- 
long to simple hypertrophy predominate, and are excessive and troublesome, we 
must starve the patient, take blood from his side, purge him, and give him diure- 
tics ; but at all times keep him as tranquil as we can. 

Simple hypertrophy of the right ventricle is not a common disease. When it 
occurs, it results from some actual or virtual impediment to the passage of the 
blood from the ventricle into the lungs. The most extreme instance of it that I 
ever saw, was in the heart of a medical friend's son, who died at the age of seven- 
teen; having been for many years affected with the morbus cseruleus as it has 
been called, i. e., an habitual blue state of the cheeks, lips, and tongue, finger- 
nails, and the skin generally; attended with shortness of breath, and augmented 
by every kind of exertion. It is seldom that persons thus affected live so long 
as this poor boy did. The heart, as is usual under such circumsiances, was mal- 
formed. The septum between the ventricles was imperfect at its upper part; and 
the aorta belonged as much to the one ventricle as to the other. The pulmonary . 
artery would not admit a goose-quill ; the walls of the right ventricle were as thick 
as those of the left. , 

Authors tell us that hypertrophy of the right ventricle of the heart is a cause of 
pulmonary apoplexy. I explained to you in a former lecture why I cannot believe 
in this doctrine. In the first place I say that the increased thickness and strength 
of the walls of that chamber supply a measure of the difficulty, and not of the 
freedom and force, with which the blood is conveyed to the lungs. In the second 
place pulmonary apoplexy does hot result from rupture of vessels by the vis d 
tergo, nor in general from rupture of vessels at all ; and therefore is a quite dif- 
ferent lesion from cerebral apoplexy. It is simply an accident of pulmonary 
hemorrhage. And lastly, I never met with pulmonary apoplexy coincident with 
mere hypertrophy of the right ventricle. The right ventricle lies on this side the 
lungs, in the order of the circulation ; and accordingly, following the rule I mentioned 
in the last lecture, its morbid states are for the most part effects, and not causes of 
pulmonary disease. 

The commonest affection of the right ventricle is dilatation without any increase 
of thickness, but with attenuation even, of its muscular parietes. This is in 
general the consequence of long standing pulmonary disease ; which has pre- 
vented the easy passage of the blood out of the right ventricle. It is often, or 
ultimately attended with dilatation of the right auricle, and of the jugular veins, 
which stand out in relief from the sides of the neck, and exhibit an undulating sort of 
pulsation, produced by the regurgitation- of a part of the btood, whenever the 
ventricle contracts. I have taken from the neck of a person dead of such disease, 
veins into which I could pass my forefinger. With all this there is a fluttering 
action of the heart, an irregular pulse, great distress and shortness of breathing, a * 
dusky skin, and blueness of the countenance, which is bloated and anxious: and 
a tendency to delirium and drowsiness ; while, sooner or later, the whole areolar 
tissue of the body becomes charged with accumulated serum. Some degree of 
this may now and then be noticed towards the fatal close of phthisis. Much 
oftener it accompanies the latter periods of extensive pulmonary emphysema. 
The same condition of the right chambers, producing the same afflictive conse- 
quences, is the very frequent sequel of organic changes that orignated in the left 
side of the heart. 

Disease, such as I am now describing, in its advanced stages especially, is diffi- 
cult to treat. If you stimulate, you run the risk of increasing the patient's distress ; 



686 



DISEASES OF THE HEART. 



if yon deplete, you incur the hazard of producing fatal syncope, of bringing the 
heart to a pause from which it is never able to recover. Here, again, you must 
try to keep the kidneys active; you must enjoin that, as far as may be possible, 
all causes of agitation or hurry, everything which has previously been found pre- 
judicial to the patient, may be sedulously warded ofT. I have found more benefit 
in these cases from steel cautiously employed, than from any other drug. With- 
out forcing the heart's action, it appears to have the effect of increasing the tone of 
its muscle; which it thus enables, for a time, to compete more successfully with 
the load it has to carry, and the impediment which it cannot overcome. We can 
do no more in such cases than palliate. 

Sometimes the parietes of one or of the other ventricle become so thin — either 
in consequence of dilatation with tenuity, or through ulceration of the muscular 
tissue — as to bulge out into a pouch, or even to crack ; in which case the patient 
almost always dies suddenly, the motion of the organ being stopped and strangled 
by the effusion of blood into the pericardium ; so that to die of a broken heart, is 
not a mere metaphor. A clergyman from the country, whom I previously knew, 
called at my house in the autumn, and waited some time in my absence ; but went 
away at last without seeing me : and after consulting Dr. James Johnson, set out 
for his home, ten miles on the other side of Colchester. He had been unwell for 
some time; had suffered occasional attacks of dyspnoea ; and was unusually ner- 
vous and irritable. He must have been conscious of some severe distress, for he 
was extremely anxious to get home, and bribed the post-boys to drive fast. As 
soon as he reached his own house, he took some supper, and went to bed, appa- 
rently comfortable. Half an hour afterwards one of his servants went to him, 
and found him asleep. At the expiration of another half-hour, he was again 
visited, and was then a corpse. Among other changes, the pericardium was full 
of blood, which had escaped from the heart through a rent in the left ventricle, 
large enough to admit one's finger. That part of the ventricle which surrounded 
the laceration, was unnaturally thin, to the extent of a crown-piece. There are 
several specimens of rupture of the left ventricle in the Museum at St. Bartholo- 
mew's Hospital. George II. died of rupture of the heart. It is curious enough 
that a Duchess of Brunswick, of the same family with George II., died of the 
same disease. In her case an ulcer penetrated the parietes of the right ventricle, 
which in other respects was healthy. In most instances, the rupture has taken 
place in the left ventricle. The same chamber is liable also to aneurisms: that 
is, to partial distension of its walls into lateral cells or pouches. This form of 
disease has not been met with in the right ventricle. 

Hypertrophy — or dilatation — or dilatation and hypertrophy — may affect, in 
their various degrees and combinations, one chamber only of the heart ; or several 
at the same time ; or all of them together. It would be vain to attempt to repre- 
sent, in verbal description, these complicated changes. Enough, I trust, has been 
said, to enable you to unravel them when they come before you ; and to ascertain, 
with sufficient exactness, the general indications which they severally furnish, 
and the plan of treatment which they require. 

You will often find the muscular substance of the heart pale, soft, and flabby; 
easily broken down, or penetrated by pressure. This may occur with general 
debility and looseness of tissue; it sometimes accompanies a plentiful deposit of 
fat about the organ: and it is supposed to be sometimes also a consequence of 
inflammation affecting the muscle. Walls thus soft are likely to yield under 
pressure; but I know of no particular symptom by which we can detect such a 
state of softening. 

The morbid conditions of which I have been speaking, involving the muscular 
substance of the heart, spring very frequently indeed from pre-existing morbid 
conditions of the membrane lining the heart, or of the membrane investing the 
heart. It is necessary therefore, in the next place, to inquire into the nature and 
history of these morbid changes : and I will first request your attention to the 
diseases of the lining membrane. The investing membrane is familiar to you as 



DISEASES OF THE HEART. 



687 



the pericardium. Of late years, since the diseased slates of the internal mem- 
brane have been more studied and understood than they formerly were, it has 
been called the endocardium : a convenient enough name, which may occasion- 
ally spare us circumlocution. Now, certain parts of the endocardium are much 
more obnoxious to disease than others : those parts which enter into the fabric 
of the valves and orifices of the organ. The membrane is here in close contact 
with a dense fibrous tissue ; and participates in the changes to which that tissue 
is subject. And it is an important fact, that the valves and orifices of the left side 
of the heart are much more frequently affected with disease than those of the right 
side. I have adverted to this fact before. What is the prevailing cause of it I 
cannot tell ; but it seems to be a portion of a more general fact ; namely, that the 
arteries are more liable to chronic morbid changes than the veins. Some explain 
the difference by alleging that the left side of the heart has the heavier task to 
accomplish. But nature seldom executes her purposes so clumsily, as not to 
adjust the strength of her machinery to the labour it is destined to perform. 
Others remark that fibrous tissue is more abundant, and therefore the changes 
proper to that tissue are more numerous and extensive, on the left side. And this 
may be the true explanation. Others, again, have conjectured that the arterial 
blood is more irritating than the venous. But there is no evidence of this : and it 
is better to content ourselves with noticing the fact, without attempting to account 
for it by mere gratuitous hypothesis. 

You are not, however, to suppose that the right side is exempt from valvular 
disease. When there is much change on the left, we often find a less degree of 
the same kind of change upon the right. The valves of the pulmonary artery 
are, perhaps, the least frequently of all the valves found otherwise than healthy. 

Many of the alterations that take place in the internal lining of the heart result, 
apparently, from inflammation, which causes a deposit of lymph upon or beneath 
the serous membrane. The valves are apt to lose their thinness, and transparency, 
and pliancy. They become thick, stiff, puckered, curled up, or glued to each 
other, or to the opposite walls of the channel. On the other hand, quite inde- 
pendently of inflammation, they may become morbidly thin, riddled with holes, 
and even rent asunder. What are called vegetations or excrescences may also 
project from them, very much resembling warts. Or they may be converted 
wholly or partly into bone. 

Alterations of some kind or another are very frequent in the semilunar valves 
of the aorta. When they are of such a nature as to diminish the orifice during 
the systole, they commonly occasion a systolic bellows sound. When the dis- 
eased valves offer no obstruction to the exit of blood from the ventricle, but do 
not close again immediately afterwards, so as effectually to prevent the reflux of 
that fluid from the aorta, they commonly give rise to a diastolic bellows sound. 
When both these defects of function occur, there is often a double bellows sound ; a 
sawing alternate noise ; one murmur during the systole, another, distinguishable in 
tone and quality, as well as in time, during the diastole. These sounds are con- 
veyed along the tube in which they are formed, and are therefore most audible in 
the track of the aorta, as it leaves the heart. If the sound be diastolic, it will take 
the place of the smart clack of the second sound of the heart, or perhaps succeed 
it. Sometimes the new sound is very loud and curious. I had a patient in the 
hospital last year, in whom this diastolic sound was, in character and intensity, 
like the cooing of a pigeon. The patient could plainly hear it ; nay, it could be 
heard by a person standing near him, but not touching his body, even with a 
stethoscope. In that instance we found one of the aortic valves irregularly thick- 
ened, with its free edge loose and flapping, and unable to fulfil its function of 
closing the aperture. During the diastole it was retroverted, and vibrated in the 
regurgitating stream of blood; and thus, no doubt, the musical note, heard alter- 
nately with the first sound, was produced. In March, 1837, I heard in a man 
(Henry Milton) who was under Dr. Latham's care in St. Bartholomew's Hospital, 
and who had had acute rheumatism, a very shrill diastolic sound, like the repeated 



688 



MSEASES OF THE HEART. 



whining of an imprisoned puppy-dog wishing to be released. This remarkable 
sound was audible, by means of the stethoscope, even in the radial artery. The 
patient died at last in St. George's Hospital, and his ca?e is mentioned in Dr. 
Hope's book on the heart. One of the aortic valves was torn downwards to some 
distance from its edge, and formed a flap, which was perforated by a round hole. 

I need not again paint out to you the manner in which such disease of these 
semilunar valves tends to produce hypertrophy and dilatation of the left ventricle. 

The mitral valve is often thickened; and it is particularly subject, more so even 
than the aortic valves, to ossification. And the effects of the ossification are to 
prevent its closing the auricular orifice during the systole; and to prevent its lying 
flat against the walls of the ventricle, and allowing a free passage of the blood out 
of the left auricle, during the diastole. The orifice is often converted into an un- 
varying oval slit, with puckered edges, and resembling a button-hole; or the valve 
projects, like a thimble of bone, into the left ventricle. And it is remarkable how 
small the chink, which is thus permanent, may be, and yet life go on. The heart 
having been taken out of the body, and the auricle filled with water, I have seen 
the water pass into the ventricle, by its gravity, stillatim ; drop by drop. 

Let me just remind you, that the direct and necessary consequence of constric- 
tion of the mitral orifice, is an accumulation of blood behind it; i. e., in the left 
auricle, in the pulmonary veins, in the lungs. Hence so much mechanical con- 
gestion, that the blood bursts at length through the bronchial membrane; hemor- 
rhage, slow or copious, ensues from the air-passages; and pulmonary apoplexy 
is formed. 

In extreme cases, where the mischief is chiefly confined to that valve, the blood 
necessarily reaches the ventricle in a penurious manner; that chamber contracts 
unsteadily and irregularly ; and its cavity sometimes diminishes. This I think I 
have seen. But far more commonly there is disease of the aortic valves also ; 
and the condition of the left ventricle is that of hypertrophy with dilatation. 

When there is a permanent chink in place of the limber valve, there may be a 
double bruit. The first heard during the systole, and produced by the regurgita- 
tion of blood from the ventricle into the auricle, through the rigid slit. This is 
common. The second accompanying the diastole, and resulting from the me- 
chanical impediment to the free passage of the blood from the auricle into the ven- 
tricle. This is uncommon. The constriction must be great for the diastolic 
murmur to occur at all : and when it does occur, it is faint; from the comparative 
feebleness (I presume) of the auricular contractions. 

The form and the consistence of the altered valves being the same, no difference 
whatever in the sounds, or in the general symptoms, will arise from the particular 
nature of the changes. It will, I mean, make no difference whether the obstacle 
to the flowing blood, or the imperfect closure of the orifice, depends upon mere 
thickening of the valve by cartilaginous deposition, or upon ossification, or upon 
wart-like vegetations. These last may be found upon any of the valves, but, like 
other morbid states, they are less frequent on the right than on the left side of the 
heart; and they are most common of all on the aortic valves. Ossification — the 
deposition of the phosphate of lime — is almost confined, I believe, to the left side. 
I never saw the tricuspid valve, or the semilunar valves of the pulmonary artery, 
converted into bone. 

The warts, or wart-like excrescences, which are so often found upon the valves 
of the heart, are very curious things. Sometimes they are separate, like rows of 
beads. Sometimes several appear to spring from a common base, which spreads 
out so as to exhibit a cauliflower appearance. And occasionally they hang in long 
strings from the valve into the adjoining chamber of the heart, In a patient of 
Dr. Hawkins", I saw a cylindrical excrescence of this kind which measured ai: 
inch in length. The valves presented slit-like perforations ; and from the edge of 
one of these slits in the mitral valve, this long vegetation dangled into the ventricle. 
The whole of the valves of the aorta were covered, on their ventricular surface, 
with similar but shorter excrescences. 



VALVULAR CHANGES. 



689 



They vary much, these vegetations, in consistence. Sometimes they are soft, 
easily crushed, and capable of being readily detached from the smooth surface of 
the valve. Others are more firm, and yet separable from the valve without injury 
to it. Others, again, are so adherent, so rooted into the valves, that they can be 
removed only by tearing or cutting them off. They are found sometimes on the 
free edge of the valves ; sometimes on their surface, or even on the inner mem- 
brane of one of the chambers, especially of the left auricle. 

Much difference of opinion has prevailed respecting the nature and origin, of 
these singular appearances. It was a common notion among the French, at one 
time, that they were really, what they so much resemble, venereal warts. What 
seems to be certain is, that they are somehow connected with inflammation of 
the internal lining of the heart; and of that which covers the valves in particular. 
But, then, are they lymph poured out from the inflamed membrane? or are they 
fibrin deposited from the blood upon an inflamed membrane? It is probable that 
the last is, sometimes, at least, the true explanation of their origin. You know, 
that when the membrane lining a vein becomes inflamed, the blood in contact with 
it has a strong tendency to coagulate upon it, and to adhere to it. The fleshy 
excrescences found on the valves are often attached to the edges of slits in the 
valve: the broken surface having probably been the especial seat of inflammation. 
When the formation of vegetations is recent, they are very soft and frangible. 
But the most interesting fact that I am acquainted with, in evidence of ihe mode 
in which these little projections arise, is one that accidentally came to light in one 
of Dr. Hope's experiments upon an ass, at which I was present. The aortic 
valves had been held back by a wire passed into the vessel, with the view of 
ascertaining the physical cause of the second sound. The animal was previously 
rendered insensible by a narcotic poison; and the circulation was kept up — lan- 
guidly, however, towards the last — -by artificial respiration. Upon the final 
cessation of the heart's motions, the organ was removed from the body and exa- 
mined: and the valve that had been mechanically irritated by the wire, was found 
studded with these little wart-like appearances, which were so soft as to admit of 
being readily brushed off- from the subjacent membrane. Here the deposit took 
place after the death of the animal, and while some of the functions of organic life 
alone were kept up by the artificial breathing. 

There are still some curious circumstances to be mentioned, connected, in some 
instances, with the formation of these warty vegetations. I shall not, however, 
enter upon them in the present lecture: but when I speak, at our next meeting, of 
rheumatic inflammation of the heart and its membranes. 

Any or all of the lesions that I have been describing may and must lead, at 
length, according to their places and magnitude, to some of those changes in the 
actual and relative dimensions of the heart that were considered in the last lecture. 
They obstruct the stream of blood when moving in its natural course, and when 
its passage ought to be free ; or they allow of its refluent course, when it ought 
to be effectually opposed : and the necessary results, in either case, are dilatation 
of one or more of the chambers of the heart, with thickening, or with attenuation, 
as the case may be, of its walls. I have already spoken of the symptoms, phy- 
sical and general, to which these secondary changes give rise ; and of the treatment 
which they admit and require. 

There being valvular disease, and that valvular disease giving rise to a bellows- 
sound, can we distinguish the particular valve affected ? Generally,, we can. Our 
skill in diagnosis outruns here, as indeed it too often does, our skill to cure. A 
few simple rules and considerations enable us, in most cases, to satisfy our natural 
curiosity to penetrate the ex-act conditions even of changes that are incapable of 
repair. These rules relate chiefly to the time when the murmur is heard ; to the 
direction in which it is most audible ; and to the state of the arterial pulse. 

When a bellows-sound accompanies the systole, it must be caused by a current 
passing out of a ventricle. But serious disease of the valves, sufficient to occa- 
sion a murmur, on the right side of the heart, is very rare, In nineteen cases out 
44 ' 



690 DISEASES OF THE HEART. 

of twenty, valvular murmurs belong to the left side; so that practically the dis- 
tinction lies, almost always, between two orifices, the mitral and the aortic, the 
inlet and the outlet of the left ventricle. The natural inlet has become an outlet 
also: or the natural outlet is obstructed. Now if the sound be heard at the base 
of the heart, and along the track of the thoracic aorta, up towards the right clavi- 
cle, and even in the carotids ; and if it be less audible towards the apex, and if 
the pulse be steady and regular, the mischief is seated in the semilunar valves of 
the aorta : there is some obstacle which produces a ripple in the onward stream 
of the blood. 

On the other hand, if the pulse be irregular, and if the sound be heard better 
towards the apex of the organ, on the left, it is owing to regurgitation through a 
diseased mitral valve. Such regurgitation is often attended with a purring thrill. 

When, what scarcely ever happens, the sound does result from injury of the 
semilunar valves of the pulmonary artery, it is heard plainest in the track of that 
vessel, up towards the left clavicle. So also a murmur produced by change in 
the tricuspid valve would be loudest towards the apex, .on the right. The arterial 
pulse for obvious reasons is but little influenced by disease affecting the orifices 
of the right heart. 

Again, if the morbid sound be diastolic, it accompanies the entrance of blood 
into a ventricle ; and for similar reasons as before, the fault is most probably in 
the left ventricle. It may be owing to the direct, but impeded, passage of the 
blood from the left auricle through a narrowed mitral orifice: yet this very sel- 
dom occasions any audible noise. Or the diastolic murmur may proceed from regur- 
gitation through the defective aortic valves: the natural outlet having become an 
inlet also : and this is exceedingly common. We attend, as before, to the situation 
and the track in which the sound is the loudest. We listen also for the smart clack 
of the natural second sound ; and if it is not to be heard, or is very indistinct, we 
have, in that circumstance, corroborative evidence of an imperfect aortic flood-gate. 
Moreover, we are again assisted by the pulse. The pulse of aortic regurgi- 
tation is very striking and peculiar: sudden, like the blow of a hammer, without 
any prolonged swell of the artery. It always reminds me of the well known 
chemical toy, formed by including a small quantity of liquid in a glass tube, ex- 
hausted of air, and hermetically sealed. On reversing the tube, the liquid falls 
from one end of it to the other with a hard short knock, as if it were a mass of 
lead. The sensation given to the finger by the pulse, when there is much regur- 
gitation through the aortic valves, is very similar to this. It is as if successive 
balls of blood were suddenly shot along under the finger. Dr. Hope calls this 
pulse a jerking pulse ; the pulse of unfilled arteries. And this abrupt pulse makes 
itself visible in the arteries : the wave of blood lifts, and moves, and sometimes 
contorts the vessel. When this kind of pulse occurs with a diastolic bellows 
sound heard in the track of the aorta, and the short clack of the second sound is 
absent or diminished, you may be quite sure that the aortic orifice is patulous 
during the diastole. The reflux of the blood, when the patency is great, is strong 
enough sometimes to produce a palpable shock or jog, called the diastolic impulse. 
And this refilling of the ventricle from the artery may even provoke it to a super- 
numerary contraction. 

In a patient by whom I was lately consulted, the hard, sudden, hammering 
pulse led me to conclude that the blood regurgitated from his aorta ; and accord- 
ingly, upon applying my ear to his chest, I discovered a loud murmur, coinci- 
dent with the diastole, and most distinct in the direction of the right clavicle. The 
shock of this man's artery was plainly to be felt, through his clothes, by one's 
hand laid lightly upon the bend of his arm. His wife told me that, for five years 
past, this jarring blow had made it uncomfortable for her to take his arm when 
they were walking together. The same kind of jerking impulse was strikingly 
perceptible in the femoral arteries, and in the carotids. 

Of regurgitant sounds belonging to the right side of the heart I can tell you 
nothing. I never heard one, that I know of, from the pulmonic valves. Through 



DISEASES OF THE HEART, 



691 



the tricuspid orifice the blood is believed to be often refluent; causing-, as I stateti 
before, tumescence and pulsation of the jugular veins* The structure of the 
valve permits this ebbing movement of the blood under circumstances which might 
otherwise be perilous. The tricuspid has accordingly been called the safety vavle 
of the heart. But the reflux seldom, if ever, announces itself by a bellows-sound. 

We cannot always thus rigidly connect morbid changes with definite signs 
Disorders arise of which the symptoms are more cognizable and constant than 
the seat. We assign a name to the peculiar assemblage of symptoms, and make 
it thenceforth a distinct object of our study ; tracing the symptoms as well as we 
can up to their organic causes and conditions. Now the complaint called angina 
pectoris is one of this kind. It is, moreover, a very curious and interesting dis- 
order; and I shall devote the remainder of the present hour to its consideration. 

This disease was first accurately described, in this country at least, by the cele- 
brated Dr. Heberden, the author of the Commentaries. It had been adverted to 
by many writers before, but obscurely ; and Dr. Heberden's observations were 
quite original. The description that he has given of the complaint, in the second 
volume of the Transactions of the College of Physicians, is very accurate and 
striking. He calls it a disorder of the breast; and observes that "the seat of it, 
and the sense of strangling and anxiety with which it is attended, may make it 
not improperly be called angina pectoris." 

** Those who are afflicted with it are seized whilst they are walking, and more 
particularly when they walk soon after eating, with a painful and most disagreea- 
ble sensation in the breast, which seems as if it would take their life away, if it 
were to increase or to continue. The moment they stand still, all this uneasiness 
vanishes. In all other respects the patients are, at the beginning of this disorder, 
perfectly well ; and in particular have no shortness of breath, from which it is 
totally different." Such is the brief description of the malady, given by Dr. 
Heberden. You will observe, that the distress occurs in paroxysms; and the 
patient at first, has intervals of apparent health : and even when the disease is 
more advanced, he has periods of comparative ease between fits of suffering. 
The paroxysms are especially liable to come on when the patient is walking, and, 
above all, when he is ascending, — going up a hill. He is then seized, all at once, 
with a painful sensation, which seems to be, in many cases, indescribable, but 
which is always referred to the heart, or its neighbourhood. Sometimes the sen- 
sation is spoken of as being a spasm, as giving the patient a notion of constriction; 
but it also carries with it the impression, that any continuance of the exertion, the 
stirring another step, would be fatal. Yet the patient is not out of breath. It is 
not dvspnoaa that oppresses him ; for he can, and generally does, breathe freely 
and eas-ily. He lays hold of any neighbouring object for support. His face is 
pale and haggard ; and you would suppose, from his appearance, that he was 
actually at the point of death. But in the early stages of the disease, tHe pang 
soon subsides, the distress is over, and the patient is entirely himself again. 
However, after the lapse of some time, generally of some months, the anguish 
does not so instantaneously cease upon standing still; nor does it always require 
some bodily exertion to bring it on. It will occur when the patient is quiet, even 
in bed. He feels as if the action of the heart was arrested: and he is obliged to 
rise up, every night perhaps, for many weeks together. In exquisite cases it 
will be brought on by causes of any kind that slightly accelerate the circulation : 
coughing, straining at stool, mental emotion. 

The pain, which is at first referred to the region of the heart, frequently extends, 
accompanied by a sort of numbness, from that part to the left shoulder, and down 
the left arm ; stopping short, in a curious manner, and from some inexplicable 
cause, either just about the insertion of the deltoid muscle, or at the elbow, or at 
the wrist. Sometimes, however, it runs down to the very extremities of the 
fingers; particularly of the last two fingers, following mainly the course of the 
ulnar nerve. And occasionally similar pains affect the right side and arm. There 



692 



DISEASES OF THE HEART. 



is (I say) no dyspnoea in the genuine form of the disease ; although you will find 
it stated by some modern writers, of good repute, that the paroxysm is accom- 
panied with difficulty of breathing. In the instances that I have seen,- and they 
have been few, the patient was able slowly and fully to inspire and expire, even 
when the fit was on him. The truth I believe to be, that other affections, more 
akin to asthma, have been confounded with angina pectoris ; and this confusion 
has led to the belief, that it is not altogether so dangerous a complaint as used to 
be thought: but in its genuine shape it is undoubtedly a very fatal disorder. Dr. 
Forbes, by a diligent search among authors, has collected some statistical facts 
respecting it, which are worth remembering. Thus, out of eighty-eight cases, 
eight only, or one in eleven, occurred in females. The ages in eighty-four of 
these eighty-eight cases are recorded ; and of the eighty-four, seventy-two were 
above fifty years ; and twelve, or one-seventh of the whole, under fifty years. It 
is a disease, therefore, for the most part, of advanced life : and this alone would 
afford a strong presumption of its dependence upon some organic change. Again, 
the event of the disease was recorded in respect to sixty-four of the patients. Of 
these forty-nine died, almost all of them suddenly ; while fifteen recovered, or 
were relieved. And among the forty-nine fatal cases, there were only two of 
women. 

That the seat of the disorder is the heart, and that it consists in some structural 
change, can scarcely be doubted. Yet some pathologists are disposed to consider 
it a merely neuralgic affection, "commencing, for the most part, in the pneumo- 
gastric nerve, and spreading in different directions, as other nerves become in- 
volved." But this doctrine is scarcely consistent, in my judgment, with the facts 
— first, that the paroxysm is excited by such causes as are " especially calculated 
to disturb the natural action of the heart, bodily exertion, and mental emotion ;" 
and, secondly, that the disease is so very frequently and so suddenlyjfafa/. This is 
slot at all the character of mere neuralgic diseases in general. And when we add 
to these facts the further fact, viz., that, in a vast majority of instances, organic 
disease of the heart, or of the great blood-vessels, has been discovered after death, 
I think we shall be obliged to admit, that the symptoms are often (for I will not 
say always) dependent upon cardiac disease. One theory explains the "breast- 
pang," by supposing that the blood, whenever its movement is accelerated by 
exercise or otherwise, arrives in the heart faster than it can be transmitted onwards ; 
and accumulating in its cavities, painfully distends them. It is not improbable 
that the paroxysm may be sometimes so produced. The great Dr. Jenner took 
a most ingenious view ofuhe matter, which was made public and further enforced 
by Dr. Parry. He had found, in examining the bodies of some who had died of 
well marked angina pectoris, that the coronary arteries of the heart were ossified ; 
converted into bony canals, and constricted in their calibre. He thence concluded 
that the paroxysms result from the circumstance, that when some increase of the 
muscular contraction of the heart happens to be called for, the increased supply of 
blood, rendered necessary by the additional exertion, is not capable of being fur- 
nished by the diseased nutrient arteries of the organ ; that the heart comes to a 
stand, because its muscular tissue is not duly injected with arterial blood: and the 
phenomena of the paroxysm agree remarkably well with that theory. He calls 
the disease accordingly "syncope anginosa." And this simple and beautiful theory 
was for some time admitted as the true one. However, later investigations have 
abundantly shown that angina pectoris may occur in a decided form, without 
there being any ossification or other disease of the arteries ; and, on the other 
liand, that the coronary arteries may be ossified, and yet no angina pectoris be 
the result. 

I may here again avail myself of the researches of Dr. Forbes, and give you a 
numerical account of the organic changes in the heart that have been found associ- 
ated with this disease. The total number of instances collected by him, in which 
the body was examined after death, was forty-five. Of this number there was 
disease found in the liver only, in two instances : organic disease of the heart, or 



DISEASES OF THE HEART. 



693 



great vessels, in forty-three. Dr. Forbes, indeed, makes the last number thirty- 
nine, instead of forty-three, excluding four cases in which nothing morbid was 
found in or about the heart, except an excessive coating of fat. This Dr. Foth- 
ergill considered the essence of the disease : and certainly a heart cannot be said 
to be in a healthy condition which is thus loaded with adipous matter. The fat 
is generally deposited at the expense of the muscular substance, which is apt in 
such cases to be thin, pale, and soft; atrophied, in short. Taking, however, the 
table as it is given by Dr. Forbes, the thirty-nine cases, in which there was no 
disease except in the heart and great vessels, were thus distributed : — In ten of 
the cases there was organic disease in the heart alone : in three, organic disease of 
the aorta alone. In one instance only was the disease confined to the coronary 
arteries ; but there was ossification, or cartilaginous thickening of the coronary 
arteries, combined with other disease, in sixteen instances. Again, there was 
ossification, or other disease of the valves of the heart, in sixteen cases also. 
There was disease of the aorta (ossification, or dilatation, or both), in twenty-four 
cases ; and in twelve cases there was preternatual softness of the heart. 

My friend, Dr. Latham, lately gave me this sketch of a case of angina pectoris, 
which had fallen under his own observation. It is remarkable for the shortness of 
its course. A gentleman, about fifty years old, was recovering from the influenza, 
of which nothing remained but a slight cough, that troubled him at night. It was 
to relieve this that Dr. Latham was consulted. The gentleman looked perfectly 
well. After Dr. Latham had prescribed for this little ailment, the patient begged 
to see him the next day to talk over with him (he said) a very strange affection he 
had. Accordingly he then described a paroxysm of angina pectoris in terms that 
could not be mistaken; dwelling especially upon the precordial pain, the sensation 
down the left arm, the sense of approaching dissolution, and then the perfect re- 
covery. This gentleman had, during the previous summer, performed a walking 
tour through Switzerland, and returned home in excellent health. The first 
notice of his angina was not more than a month ago, when he was walking up 
Hainpstead Hill. It was then that he had his first paroxysm. In the short period 
which had elapsed, the attacks had rapidly increased in severity and frequency: 
occurring now every two or three days, or every day, or several times a day, with 
or without an exciting cause. Dr. Latham made a careful examination of the 
chest, and found the respiration perfect, the heart free from all unnatural murmurs, 
and its beats rhythmical. The only thing that particularly attracted his notice was 
the exceeding feebleness of its impulse. In the afternoon of the next day Dr. 
Latham visted him again, when he described a paroxysm he had suffered in the 
course of the morning, of much greater severity than any that he had hitherto 
experienced. Dr. Latham saw enough to convince him that his patient's existence 
was very precarious : and as he had previously been a stranger to him, he inquired 
about his friends, and took down the address of a brother, intending to call and 
apprize him of what he feared. On reaching his own home, two hours afterwards, 
a messenger met him, announcing that his patient had fallen into another paroxysm, 
soon after he left the house, and was dead. The body was carefully examined by a 
thorough anatomist, Mr. Stanley. There was no disease of the aorta, or of the 
heart generally ; but the coronary arteries resembled tubes of coral, being completely 
ossified as far as they could be traced. 

The patient may even expire in the first or second paroxysm. This happened, 
I believe, in the case of the late lamented Master of Rugby school. 

You will perceive,' from what has been said, that the prognosis of this singular 
and formidable affection is extremely unfavourable. The cases are very rare in 
which no disease of the heart has been detected : and the organic changes that 
have been found are remediless, and for the most part, progressive : and, in point 
of fact, the greater number of those who have laboured under the disease have 
died suddenly. 

It follows, also, as another corollary from the facts now brought before you, that 
there are very few cases in which we can dare to contemplate a cure. Our mea- 



694 



PERICARDITIS. 



sures must be preventive when the paroxyms are absent: and our object will be 
to shorten the fit when it is present and protracted. 

Now the preventive measures are simple and obvious. The patient must be 
cautioned to avoid the exciting causes of the paroxysm ; walking up hill ; or against 
the wind, which has also been known to produce it. Whatever is likely to hurry 
the circulation, and therefore, among the rest, all mental emotion and anxiety, 
should be guarded against as much as possible. John Hunter died of angina 
pectoris : and the fatal seizure was brought on by a fit of anger. Care should be 
taken also to obtain and preserve a healthy stale of the digestive organs. It is 
observable of this, as I mentioned before it is observable of other cardiac diseases, 
that they are often attended and aggravated by flatulence of the stomach and bowels. 
Persons labouring under a paroxysm of angina often experience great and sudden 
relief upon getting rid of a quantity of gas, by which the stomach had been distended. 
The flatulence acts, no doubt, by pressing the diaphragm upwards, and so dimin- 
ishing the dimensions of the thorax, and impeding the play of the heart. It is 
upon the same principle that we'must explain the fact, that the paroxysms are 
particularly apt to come on if the patient walks soon after a meal: also that they 
occur in the night, when he is in a horizontal position, and are relieved by his 
getting out of bed; that is, by his assuming the vertical posture, and taking off 
the pressure of the abdominal viscera from the diaphragm. 

In the paroxysm itself, bleeding has been fairly tried; but, as I think might have 
been foreseen, it has seldom been attended with any benefit, and sometimes it appears 
to have done harm. The affection has a nearer relation to syncope, and often to 
syncope by asthenia, than to any thing else. That is the way in which the patients 
die; and consequently, cordials, stimulants, and antispasmodics, are found to be 
of service. Dr. Elliotson thinks prussic acid is the best thing you can administer. 
Dr. Davies has more faith in belladonna plasters than in most other things. Dr. 
Copland advises stimulant liniments externally ; and warm carminative or aperient 
medicines, as the circumstances may require, internally. The general condition 
of the sufferer will suggest, I believe, the proper treatment. Not that it will 
suggest any particular drug, but it will teach you the main principle on which you 
are to proceed. If auscultation reveal any of those morbid states of the heart 
which were noticed in the beginning of the lecture, the means which I pointed 
out as suitable for remedying them may be put fn force. 



LECTURE LXI. 

Pericarditis ; its frequent connection ivith Acute Articular Rheumatism. Rheu- 
matic Carditis. Anatomical characters of acute Inflammation of the Peri- 
cardium; of the Endocardium. General symptoms. Auscultatory signs. 
Relations of Carditis with Rheumatic Fever. 

I yesterday considered, cursorily indeed, but as fully as the limits of these 
lectures will permit, the effects of hypertrophy, and of dilatation with and without 
hypertrophy, of the several chambers of the heart: and the means we possess of 
obviating or alleviating those effects. I passed in review also the chronic changes 
to which the endocardium, especially in those parts where it covers the valves, 
and the tendinous rings that give support to the valves, is liable ; and most of the 
circumstances which give origin to such changes: and I spoke of that singular and 
perilous affection to which the name of angina pectoris has been applied. I pro- 
ceed this afternoon to the diseased conditions of the pericardium. This membrane 
is often the seatof acute inflammation; and the consequence of such inflammation 
is sometimes, though rarely, the speedy extinction of life. But in nineteen cases 
out of twenty, the disorder proves fatal at a remote period ; destroying the subject 



PERICARDITIS. 



695 



of it more slowly, indeed, but almost as surely. Pericarditis is therefore, and has 
always been regarded as, a very interesting disease; and the more so, that it is 
in many instances a very insidious disease also. 

Acute^ pericarditis is liable to arise, like all other internal inflammations, after 
exposure to cold ; or when no exciting cause is to be discovered. But for one 
such case of what may be called spontaneous acute inflammation of that membrane, 
you will meet with a dozen, or more, in which it occurs in connection with a dis- 
ease that we have not yet had before us — acute rheumatism ; a febrile disorder, 
characterized by inflammation of a specific character, affecting the structures that 
lie around thejoints, or enter into their composition — the fibrous tissues. I shall 
therefore consider acute pericarditis with reference to its occurrence in rheumatic 
fever ; for in so doing, I shall embrace all the practical points which belong to it 
under any form. But I must tell you that when pericarditis happens, in the 
course of an attack of rheumatism, so also, to the best of my belief, in almost 
every instance, does enc/ocarditis. For this reason I shall include, in the account 
I am desirous to give you of rheumatic carditis, both these inflammations : in- 
flammation of the investing membrane, and inflammation of the lining membrane 
of the heart. I mentioned in the last lecture, that, in respect to the latter, to 
endocarditis, there were some peculiarities noticeable which I should reserve for 
the present occasion. 

The pericardium is one of the serous membranes; so also may the endocardium 
be considered. But the pericardium is also a shut sac; and the primary effects 
of inflammation upon it are the same, mutatis mutandis, as upon the shut sac so 
near it, the pleura. The second series of effects is however much more formida- 
ble. Adhesion of the pleura does not necessarily abbreviate the natural term of 
the patient's life; adhesion of the pericardium almost always does: and effusion 
into the cavity that contains the lung is far less serious than effusion into the bag 
that surrounds the heart. In the one set of organs the mischief may be great, 
but it is final ; in the other, it leads, with unfailing certainty, sooner or later, to 
worse changes, which at length prove incompatible with the further continuance 
of life. 

You will understand, then, without the necessity of my going again into much 
detail, that the pericardium, under acute inflammation, may undergo the same 
changes, which, on a former occasion, we saw that the pleura might undergo. 
Coagulable lymph may be poured forth from the entire membrane, and abolish 
the cavity by glueing the whole of the pericardium to the heart: or serous fluid 
may be effused, distending the bag of the pericardium, and keeping its smooth 
surfaces more or less asunder: or both serum and lymph may be effused together; 
or fibrin, in some shape or another, may be deposited, for aught I know, from the 
homogeneous fluid which is thrown out by the inflamed membrane in the first 
instance; and the result of this mixed effusion may here, also, as in the case of 
the pleura, be the partial adhesion of the membrane to the heart. 

But in the majority of instances the inflammation spreads over the whole mem- 
brane, as it is apt to do in serous membranes generally; and one of these two 
things happens: either there is a large quantity of liquid effusion, which is not 
reabsorbed ; and then generally the patient dies in a few days : or there is not 
much liquid effusion, or the liquid part is absorbed, and the pericardium becomes 
permanently agglutinated to the heart, and apparent recovery takes place. 

In the cases that have proved fatal at an early period, when the inflamed mem- 
brane has been unadherent, it has been found to contain serous fluid; sometimes 
clear, oftener turbid, frequently tinged with blood: and it has been seen to be 
covered with a coating of the fibrinous or albuminous part of the blood ; what we 
call plastic or coagulable lymph. The deposited lymph assumes a variety of forms 
in different cases; but in every case that I have seen, the prevailing character of 
the unattached surface has been that of roughness ; and this is a circumstance of 
some importance, as we shall presently see. The lymph is not arranged in 
smooth layers ; but it is rugged, villous, or cellular. According to the fancy of 



696 



RHEUMATIC CARDITIS. 



different observers, it has been thought to resemble lacework, or a sponge, or a 
honeycomb, or some kinds of coral, or the interior of a calf's stomach. Some- 
times it bristles with a multitude of small, short, pointed papillae: less frequently 
it is softer and shaggy ; always it is rough and uneven. Dr. Hope, following 
Laennee, states that the surface looks sometimes like that which would be pro- 
duced by suddenly separating Uilo flat pieces of wood, between which a thin 
layer of butter has been compressed. To my own eye, the appearance presented 
by the membrane, in its recent condition, has been more like the rough side of 
the pieces of tripe which you see in butchers' shops than any thing else. 

When, on the other hand, the patient dies, as he sometimes will do, soon after 
the whole of the membrane has become adherent, you will find the medium of 
adhesion to consist of lymph, in which a number of bloody points or streaks are 
visible : but still the connecting substance is soft, and the agglutinated membranes 
can readily be torn apart. 

Such is the state of things on the outside of the heart in such cases. But 
" what do we find within? Why, here also, in all cases probably, certainly in by 
far the majority of cases, we discover evident traces of active inflammation; and 
we discover them chiefly on the valvular apparatus. There does not appear to 
be such a tendency in endocarditis to diffuse itself over the whole membrane. 
Occasionally that naturally transparent portion of it which covers the muscular 
fibres is rendered whitish and opaque ; and occasionally some of the deposits 
that are common on the valves, encroach also somewhat beyond them, and even 
stud, here and there, the interior of one or more of the chambers of the heart, 
and especially of the left auricle. But the valves or the fibrous rings from which 
they spring, are the parts first and chiefly implicated, especially the aortic valves, 
and the mitral valve: not uncommonly the tricuspid valve also; and. sometimes 
even the semilunar valves of the pulmonary artery. Inflammation thus affecting 
both the external and internal membranes of the heart, in acute rheumatism, I 
would call rheumatic carditis. 

The inflamed valves undergo two kinds of change, distinct from each other. 
They become thicker than natural ; they lose their transparency and pliancy, and 
are puckered. These changes depend upon the deposit of lymph beneath the 
membrane ; between the membrane and the fibrous substance it covers. Some- 
times they are folded down, and glued, as it were, to the opposite surface. This 
must be by coagulable lymph deposited on the outer side of the membrane. But 
more frequently than all, they present more or fewer of those wart-like excres- 
cences, or fleshy granulations, which I spoke of in the last lecture, and which are 
of course above the membrane. Sometimes these vegetations are scattered irre- 
gularly over the convex surface of the valve, or in its immediate neighbourhood; 
but much oftener they have a more definite and curious distribution ; an arrange- 
ment which I have never seen noticed by any author, but which it has been my 
lot so many times to observe, that it has led me to remark an anatomical peculi- 
arity with which it is connected ; and this piece of minuter anatomy I have looked 
for in vain in books, and have in vain sought information about it from all my 
anatomical acquaintances. They none of them have seemed to be aware of it, 
though they acknowledged that the fact was so when I pointed it out to them. 
Recently, indeed, I have been told that the peculiarity of structure to which I 
allude is somewhere adverted to by Morgagni. 

It becomes necessary, therefore, that I should describe this discovery of mine 
(if it deserves so grand a name) to you, as I have, for several years past, been in 
the habit of showing it to the pupils of the hospital in the dead-house. It derives 
its chief interest from the light it throws upon the morbid appearances to be spoken 
of presently. You will find, then, if you examine closely the semilunar valves 
of the aorta, or of the pulmonary artery, that in each valve there may be distin- 
guished two parts ; one thicker, the other thinner. The thicker part lies next the 
base of the valve, the thinner next its edge. And the valve does not become thin 
by degrees, but the difference is marked by a manifest line of separation between 



HHEUMATIC CARDITIS. 



697 



the thicker and thinner portions ; and this is not a straight, nor even one sweep- 
ing curved line, but it is a double curve. It consists of two semicircular lines, 
running each from the centre of the edge of the valve, from the sesamoid body 
there situated, to either extremity of the edge, where the edge joins the side of 
the aorta. So that there are two segments, of a crescentic shape, thinner and 
less opaque than the remaining part of the valve, and lying near its free margin. 
This peculiarity of structure is uniformly present. It is less distinctly visible in 
the valves of the pulmonary artery than in those of the aorta ; and it is much less 
apparent in some individuals than in others ; but it is always to be seen when it 
is looked for. 

The anatomical account of this arrangement is not far to seek. The cardiac 
valves consist of a loose duplicature of the delicate endocardium, between the 
folds of which is received a thin prolongation of fibrous tissue, from the tendinous 
rings surrounding or constituting the several orifices that are furnished with a 
valvular apparatus. In the semilunar valves this fibrous substance does not inter- 
pose itself between the entire space of the folded membrane. It reaches the free 
edge of each valve at three points only ; namely, at the centre, where it forms the 
corpus aurantii, and at the two extremities. Between these points it stops short, 
and has a definite limit and outline ; a scolloped edge : and so leaves two crescent- 
ic portions of the valve formed merely by the doubled endocardium. The cre- 
scentic margins are thin and transparent: the remaining shield-shaped portion of 
the valve is more or less thick, firm, and opaque. 

And the physiological reason of this arrangement is also apparent enough ; 
though I failed to perceive it until it was pointed out to me by Mr. Thurnam. 
Each valve, when opened out, is convex towards the ventricle. The three valves 
do not merely meet by their edges. Their common purpose would be but inse- 
curely provided for if such were the case. They meet and bend up, and come 
broadly into contact with each other. Each valve during the diastole has its right 
and left crescentic portion applied respectively to the corresponding portion of its 
right and left fellow valves. The thin segments are pressed mutually together, 
and lie dos-d-dos, as dancers say; while their edges look in the direction of the 
vessel. All this you may convince yourselves of by injecting the aorta of an ox 
with wax, and picking out the wax when it is cold. 

Now the curious fact which first led me to remark this natural structure is, that 
the minuter vegetations, which form upon the aortic valves, in acute rheumatic 
carditis, most commonly arrange themselves in a row, like a string of beads, along 
the line of union between the scolloped edge of the thicker scutiform portion of 
the valve, and the inner convex margin of the two thinner crescentic portions. 
Sometimes they follow that double festoon very exactly and completely: some- 
times the continuity of the line is broken, and the excrescences straggle from it 
a little ; but still the general tendency to adhere to it is evident. No one that I 
know of has publicly noticed this fact; yet that it is a fact, a good many persons, 
who have been for some time about the Middlesex Hospital, are perfectly aware. 
The truth is, that death seldom happens early in these cases ; and perhaps the 
valves have not always been carefully examined when opportunity did offer. My 
friend, Dr. Latham, had been watching for such a case in vain for some years. 
Recently, however, two of his hospital patients died in the first attack of rheu- 
matic carditis ; and he tells me that, looking with great interest for the morbid 
appearances within the heart, he found them such as I have been stating. I have 
chanced to see six or eight such early fatal cases. 

The arrangement just described is the most common one, so far as the aortic 
valves are concerned : but sometimes even there, and generally upon the mitral 
and the tricuspid valves, the little wart like excrescences have a different position; 
jagging the free edge of the valve with numerous fine serrae, like the teeth of a 
small saw ; or being disposed, just within its border, in one continuous line. 

After what has been said, you will readily detect the physical cause of this 
curious distribution of the wart-like excrescences. The membrane suffers acute 



698 



PERICARDITIS. 



inflammation. Soft lymph exudes from, or is deposited upon it: and as fast as 
it is formed it is pressed aside, by the repeated concourse of the opposed surfaces, 
from the crescentic portions of each valve; and heaped up along the boundary 
lines of contact: just as a thin layer of butter on a board would be displaced, and 
heaped up in a little curvilinear ridge, by the pressure of one's thumb. The 
double festoon, and the little marginal teeth, are obviously both formed in this 
way. 

If my verbal description has been insufficient to make all this clear to your 
apprehension, the drawings before you speak, I hope, in plainer language. 

These, then, are the appearances commonly seen within and without the heart, 
when the patient does not long survive the first attack of rheumatic carditis. 
When death takes place at a later period, you find more than this. You find the 
consequences which flow from these primary lesions, operating as mechanical 
causes of further change : hypertrophy and dilatation in their various degrees and 
combinations. 

You will please to bear the primary changes in mind : for they satisfactorily 
account for the physical signs of pericarditis and of endocarditis which are dis- 
played in these cases, and which I shall describe and explain after I have shortly 
inquired into the general symptoms. 

The symptoms, then, of pericarditis, as set down by authors, and such as I 
have myself frequently noticed, are the following. There is often, very early in 
the disease, a singularity of manner, and peculiar expression of countenance, 
difficult to describe, yet strikingly manifest to the observer; a strangeness of 
deportment mixed somehow with an aspect of distress. To this are frequently 
added, palpitation ; a sense of oppression at the epigastrium ; a catch in the breath- 
ing; a dry cough; inability or unwillingness on the part of the patient to lie on 
his left side; pain in the situation of the heart, increased by a full inspiration, by 
pressure upon or between the correspoding ribs, and more particularly increased 
by pressure upwards against the diaphragm by means of the fingers thrust beneath 
the cartilages of the false ribs ; stiffness and pain in and about the left shoulder, 
and extending thence down the left arm, and stopping short perhaps at the elbow 
or wrist. This last circumstance, however, the pain shooting down the arm, is 
more common in chronic affections of the heart. And I have yet another symp- 
tom to mention, and a very important one ; and that is delirium, sometimes quiet, 
but often wild and furious delirium, not dependent upon any disease of the ence- 
phalon. 

Of course there are also the febrile symptoms which accompany the acute 
rheumatism ; or if the pericarditis occur independently of acute rheumatism, there 
will be fever symptomatic of the local inflammation. 

Now each of these symptoms I have repeatedly observed ; but they seldom all 
concur in the same case. If they did, there would not be much difficulty in the 
diagnosis : nor would the cardiac disease be so often overlooked as it is. The 
diagnosis of pericarditis has been confessedly uncertain and obscure. Not unfre- 
quently, nearly all the symptoms I have been enumerating are wanting; or so 
indistinctly marked as to attract no attention. It is therefore an important matter 
to ascertain what help we may derive, in these equivocal cases, from auscultation. 

In truth, the help we sometimes get is peculiarly valuable and satisfactory. 
There are certain morbid sounds to be heard when the heart is beginning to 
labour under rheumatic carditis. 

The morbid sounds which may reach the ear applied in such cases to the sur- 
face of the chest are two : very distinct the one from the other, and very distin- 
guishable: depending upon different causes, and denoting diversities of operation 
and of site in the morbid processes going on within. But they are not both 
heard in all cases. 

One of these sounds I have been accustomed to call a to and fro sound. It 
conveys to the ear the notion of the rubbing of two rough surfaces, backwards 
and forwards upon each other. It seems near to the ear ; and therefore near to 



PERICARDITIS. 



699 



the surface of the patient's body. Like all the other morbid sounds heard within, 
the^ chest, it is capable of much variety in tone and degree. Sometimes it very 
closely resembles the noise made by a saw in cutting through a board. Some- 
times it is more like that occasioned by the aetion of a file, or of a rasp, or of a 
nutmeg grater. But its essential character is that of alternate rubbing ; it is a to 
and fro sound. This very peculiar sound I had noticed and described, and 
explained, before I was aware that it had attracted the attention of any other per- 
sons. Others, however, had remarked it, and had correctly interpreted its mean- 
ing. I claim no credit therefore for the discovery of what I think a very important 
symptom : but I claim for the symptom itself that additional weight which accrues 
to it, from its having been originally perceived by different observers, indepen- 
dently of each other. The physician who, in this country, without my being 
aware of it, had noted and published some cases in which this phenomenon 
occurred, is Dr. Wm. Stokes, of Dublin. There is a good deal said about it by 
Bouillaud also; and he too appears to have discovered the sound, without any 
previous knowledge of its having been noticed by others. I have heard the to and 

fro sound now in upwards of a score of cases. In a few of these it never ceased 
except with life. The patients died during the primary attack, and the to and 

fro sound remained as long as the heart continued to beat. In all the other cases ? 
the to and fro sound was audible for a few days only, and then ceased entirely 
and for ever: the patients recovering more or less completely. 

The other of the two morbid sounds, is the ordinary bellows-sound, with which 
you are already familiar. In the cases in question it is a single sound ; a deep- 
seated rush, or whiz, accompanying the systole of the heart. It usually continues 
loner ; often for life. 

These two sounds, the superficial to and fro sound and the deep-seated bellows- 
sound, may sometimes be heard, by a careful listener, to exist together. Some- 
times the bellows-sound begins to be distinguished when the rubbing sound ceases ; 
appears to supervene upon it, or to take its place; perhaps it then first becomes 
audible, simply because it was previously drowned in the louder superficial sound. 
Sometimes there is no to and fro sound, but only the deep blowing noise; or 
(what in many cases is extremely probable, nay, what I may venture to say is 
certain) the to and fro sound has come and gone unnoticed — unlistened to. 

Now of these sounds, which I repeat are perfectly distinct, and capable of being 
easily discriminated the one from the other, the first mentioned, viz., the to and 
fro sound, is always indicative of inflammation of the external membrane; the 
other, the bellows-sound, is always, as I believe, in these cases, indicative of 
inflammation of the internal membrane of the heart. You will bear in remem- 
brance, that I am speaking of these sounds as they somewhat suddenly occur 
for the first time, and especially as they occur in rheumatic carditis at its first 
accession. 

Those of you who have seen the thorax opened in an animal whose heart still 
continued to palpitate, may have observed, as I have done, that the pericardium 
lies closely in contact with the heart, but that a considerable extent of slipping 
motion between them goes on at every successive act of systole and diastole. 
They glide over each other evenly and without noise; but this is only while the 
surfaces are smooth and healthy. When they are already made rough by inflam- 
mation and the deposition of lymph, which lymph always, as I have shown you, 
is rough in such cases, then the attrition will be no longer noiseless : it will give 
rise, in the alternate movements of the organ, to the harsh and superficial ^ and 
fro sound. But why does that sound, when once it has occurred, at length cease; 
and why, having once ceased, does it never by any accident, when the inflam- 
mation has been universal, recur? Clearly because the pericardium has become 
adherent to the heart: after which there can be no motion of the one membrane 
over the other, and therefore no sound indicative of such motion. 

That thjs is the true explanation of the occurrence, and of the permanent ces- 
sation, of the to and fro sound, I am now (March, 1837) convinced. It was & 



700 



PERICARDITIS. 



matter of inference with me for some time. A few of the patients died during 
the primary attack. By much the majority recovered. I do not mean got per- 
fectly well as they had been before ; but they regained a great share of their usual 
health, perhaps thought themselves well, and left the hospital where they had 
been under treatment. Now of those who died, the pericardia were non-adherent. 
The opposite surfaces of the membranes were rough, and like tripe : and the to 
and fro sound never ceased in these persons. Such cases are always soon fatal. 
But, in the others, did adhesion take place ? I make no doubt of it. Within the 
last twelve months I have had demonstrative proof of it in two instances. One of 
these occurred in a hospital patient, whose case has been published in the Medical 
Gazette.* He was a painter, nineteen years old ; and he became my patient last 
May, with acute rheumatism and carditis. From the 26th of May to the 13th of 
June, a to and fro sound was distinctly audible, as well as a bellows-sound which 
had preceded it. After that date, the bellows sound continued, but the rubbing 
sound was no longer to be heard. The patient improved; and was about to be 
discharged from the hospital : when, on the 29th of June, sixteen days after the 
sound of friction had finally ceased, he suddenly dropped down dead in the garden 
of the hospital. 

Here I had concluded that the pericardium was adherent; though I had not 
expected to have so soon the opportunity of verifying my opinion. And accord- 
ingly, except over a small portion of the posterior part of the right ventricle, the 
union was complete at all points. The agglutination was evidently the work of 
recent disease. The medium of adhesion was of considerable thickness ; and 
consisted of coagulable lymph and coagulated half-organized blood. The peri- 
cardium was stripped off, as I have seen a poulterer skin a rabbit, and with about 
the same ease. This was a very interesting case to me, for it was the first in 
which I had had the privilege of examining the heart after having witnessed the 
peculiar succession of phenomena that I have been describing. 

But since that time, I have met with another such a case in private practice. 
The particulars of it are sufficiently important to warrant my relating them.t 

In the month of October, 1836, I was taken by Dr. Sweatman to see a patient 
of his; whom I found sittting up in bed, pale, with sharp features, breathing 
shortly and laboriously. His legs were anasarcous, and his belly was tense and 
fluctuating. 

I learned that he had been for years given up to intemperance in drinking, and 
to indolent and low habits. He told me, that the wind troubled him, shooting up 
through the whole of the left side of his chest. On further inquiry I found that 
he meant that he had much pain there. There was loud wheezing over the upper 
lobes of both lungs: both sides of the thorax were dull on percussion at their 
lower part; and on the right side no breathing whatever was audible below. 
These latter symptoms were indicative of dropsical effusion into the pleura also. 
The jugular veins were swollen and tortuous on both sides of the neck. On 
applying my ear to the prascordial region I at once heard a very loud and distinct 
to and fro sound. This was equally manifest when he held his breath. Dr. 
Sweatman, who was not so much accustomed as I have been to listen to the 
sounds of the heart in disease, recognized instantly the peculiar character of this 
sound. I ventured to express my certain conviction, that the patient was labour- 
ing under recent and acute pericarditis. I added, that he had also hydrothorax; 
and that, whatever chronic changes might have taken place in his heart previously 
to his present illness, dilatation of the right cavities constituted at least one of 
them. 

He had been attacked by his present urgent symptoms three days before I saw 
him, viz., on the 8th of October. On that day, in all probability, the inflamma- 
tion of the pericardium commenced. 

This was his history. In the spring of the year, having, from indolence, kept 



* Vol, xviii, p. 701, 



t Medical Gazette, vol, xxi. p. 544> 



PERICARDITIS. 



701 



the house for months before, he crossed from the Isle of Man to Liverpool, and 
was sick, and suffered a good deal during the passage. After landing he had a 
mile or more to walk. His companions outstripped him, but were called back, 
to him, and found him very pale, breathing with difficulty, and unable for a time 
to proceed. He attributed all his subsequent complaints to that exertion : and he 
had been ailing, though not confined to his room, till the 8th of October. I did 
not venture, in his condition, to open a vein : but leeches were applied to the 
praecordia, and he took diuretics. 

I did not see him again till the 15th of October, four days after my first visit. 
The rubbing sound was still there, though less loud, less harsh, and less exten- 
sive. The leeches had given him much relief. His pulse was very small. A. 
blister was now applied. On the 20th I saw him for the third and last time alive. 
The rubbing sound was quite gone. This Dr. Sweatman also satisfied himself 
of. There was a-dull systolic bellows-sound in its place. The pulse was scarcely 
perceptible: but he continued apparently improving, making a vast quantity of 
urine, while the dropsical swellings fast diminished, till the 31st; when, after 
talking a short time oddly, and in a peculiarly loud voice, he sat up to take some 
medicine; and having done so, reclined his head against the nurse, and expired. 
Mr. Shaw assisted in the subsequent examination of the body. I omit giving an 
account of the condition of the lungs and pleura, which was what we had antici- 
pated ; and confine myself to the state of the heart. That organ was large. The 
pericardium was adherent universally by means of lymph, mottled with blood: 
and it was easily separated, so that the adhesion must have been recent; as was 
proved indeed by the symptoms. The right cavities of the heart were very large; 
and the aorta was diseased. 

The existence of the to and fro sound in these cases no one can doubt who has 
once listened for it when present: and the facts respecting it, which have been 
established beyond the reach of controversy, are these: — 1st. That when it occurs 
de novo, it always surely denotes acute inflammation of the pericardium. I say 
de novo, because (as I stated in the last lecture) a bellows -sound may accompany 
each movement oi the heart* in consequence of internal disease of some standing; 
and this double, sawing, bellows-sound might possibly be confounded with the 
alternating noises produced by the attrition of the opposite surfaces of the inflamed 
pericardium. 2dly.' The to and fro, or rubbing sound, is never of long duration, 
but soon terminates in one of two ways. Either the patient dies in a short time, 
the sound continuing to the last; and then the pericardium is found coated with 
rough lymph, but throughout the far greater part of its extent, or altogether, imad- 
herent: or the sound ceases, never to return, while the condition of the patient 
improves ; or he even seems to himself and to others, to recover his perfect health, 
In these cases, the sound ceases from a physical impossibility of its continuance, 
viz., from adhesion of the pericardium over the whole, or the greater part, of the 
surface of the heart. And in this category of apparent but unreal recoveries, I 
cannot doubt that many of Bouillaud's cases of "pericarditis terminating in 
health" ought to be included. 

It follows as a necessary consequence from these facts that acute pericarditis, 
so far advanced as to occasion the pathognomonic rubbing sound, does not admit 
of a perfect cure : and that its best event is the adhesion of the membrane, and 
the obliteration of its cavity. 

And even then, I say, the change is not final. Mere adhesion of the pericar- 
dium does so embarrass the movements of the heart as to produce at length, 
sometimes rapidly, sometimes slowly, hypertrophy, or other alterations which 
have already been considered. It is held, too, and I believe justly, though I am 
not so sure of this, as of some of the other points I have been dwelling upon, that 
the inflammation which begins' in the membrane, sometimes dips into the muscu- 
lar substance of the heart, weakens its elasticity and cohesion, and so leads ulti- 
mately to dilatation of its cavities. 

I need not occupy much of your time in speaking of the other morbid sound 



\ 



RHEUMATIC CARDITIS. 



that is audible in these cases, the bellows-sound : which sometimes may be heard 
before the to and fro sound commences ; which I have heard through the to and 
fro sound ; and which often remains after the superficial rubbing sound has ceased. 
This depends, no doubt, upon those alterations in the valves of the heart which 
take place from inflammation, at the same time with the alterations of the pericar- 
dium. And when it is met with in such cases, it may be set down as very strong 
evidence of the existence of endocarditis. 

I am anxious that you should take an interest in the disease which I have been 
speaking of at so much length this evening, and that you should keep it in mind 
in your future practice: for I am sure that it is a fertile, but often unsuspected 
source of chronic disease of the muscular substance of the heart, and of its conse- 
quences; asthma, dropsy, sudden death. The number of patients that come into 
the hospitals of London affected with acute rheumatism is annually very large : 
and I am sure that I do not exaggerate when I say that nearly one half of them 
have the heart or its membranes implicated. The cardiac affection may easily be 
overlooked both by the patient and the physician. The recovery may appear to 
be perfect. But after some time, palpitation begins to be occasionally felt; and, 
by degrees, other symptoms, marking disease of the heart, declare themselves: 
but their origin is unsuspected or forgotten. You will be surprised, if you search 
back into the past history of all the patients who apply to you having disease of the 
heart, especially among the lower classes of society, — you will be surprised to 
find how many of them will tell you that at some time or other of their lives they 
have been laid up with rheumatic fever. 

It is no part of my purpose to treat at present of that specific disease of the 
joints to which we give the name of acute rheumatism : but I may as well com- 
plete what I have to say of carditis as it occurs in connection with that disease; 
and then I shall not need to repeat myself when I come to rheumatism itself. 

In the first place, then, I would say a word more respecting the nervous dis- 
turbance which is apt to supervene in such cases, and to mask the real disease, 
and to mislead the unwary practitioner. Patients labouring under rheumatic car- 
ditis very frequently become affected with delirium,, or violent mania, or stupor 
and coma, or convulsions, or all of these in succession: and you might suppose 
that they were labouring under inflammation of the brain, or of its membranes. 
Such cases are in fact spoken of as cases of metastasis to the brain. It may some- 
times be so, nay, I know that it sometimes is so; but not often. Again and again, 
when death has occurred, and the delirium had been extreme, no traces of disease 
have been discoverable within the skull, while marks of violent and intense in- 
flammation were visible in the pericardium. I presume that the acute cardiac 
affection interferes somehow with that regulated supply of blood to the head, 
which is necessary for the due performance of the cerebral functions. But what- 
ever the explanation, recollect the fact; and whenever, in acute rheumatism, you 
find your patient flighty and wandering, or more distinctly delirious, examine 
carefully the condition of his heart. 

As this is really a point of great importance, and as you will not find much 
information respecting it in books, I shall take leave to quote, here, some part of 
a clinical lecture delivered by^nyself at the Middlesex Hospital, in the year 1835, 
and printed in the 16th volume of the Medical Gazette. My subsequent experi- 
ence has been quite in conformity with what I then stated. 

" The functions of the brain not unfrequently become disordered in rheumatic 
fever: and disordered in such a manner and degree as would lead, and has led, 
many to believe in the presence of active inflammation of that organ, or of its 
enveloping tissues. Yet this affection of ihe brain is not, I believe, inflammation, 
but some secondary affection of the circulation therein; resulting from disturbance 
at the central organ of the circulation, capable of producing a corresponding 
derangement in the cerebral functions. I can best explain what I mean by reciting 
a few examples. 

" The first case of this kind that I ever saw or heard of, occurred in St. Bar- 



HEAD SYMPTOMS. 



703 



tholomew's Hospital, many years ago. I took notes of it at the time, and will 
read you the substance of them. Charlotte Rankin, aged 17, was admitted there 
on the 12th August, 1824, under the care of Dr. Roberts, with acute rheumatism 
of the joints. Her illness had come on suddenly a week before, after unusual 
exposure to cold and wet. The pain and swelling had shifted much from joint to 
joint. She had been bled, on account of pain in her left side, two days before 
admission. On the 14th, she complained of much difficulty of breathing, and of 
pain when even slight pressure was made upon the chest. These symptoms 
were entirely removed by a blister. On the 16th, she was observed to be odd in 
her manner — peevish, querulous, restless, without sleep, and desirous of getting 
out of bed. Her pulse was then 100. On the 20th the pulse had risen to 120 ; 
it was quite regular. She said she felt no pain, except the soreness occasioned 
by the blister. She slept very little. On the 2lst, the pulse was 128. Some 
jactitation of the left arm was now observed, which, she said, had never happened 
before. No sleep. On the 22d, about nine in the evening, she became furiously 
maniacal, and it was necessary to confine her by a strait-waistcoat. She con- 
tinued in that state for upwards of four hours, and then died.. 

44 Twelve hours afterwards the body was examined. The brain was found 
quite healthy : its vessels seemed, indeed, somewhat fuller of blood than is usual, 
but there was no effusion, nor any other vestige of inflammation. 

44 The pericardium was glued to the heart in several places, by recent adhe- 
sions; and it was universally coated, where not adherent, by a layer of rough, 
reticulated lymph, remarkably harsh to the touch. 

44 Now here the most prominent symptoms were such as we are accustomed to 
refer, with tolerable confidence, to inflammation of the membranes of the brain; 
whereas, in fact the inflammation was strictly confined to the heart. If no exa- 
mination of the body had been made, the case might have been quoted, with much 
show of reason, as a well-marked example of metastasis to the brain. It ivas so 
considered, before the brain was inspected. 

44 There had, indeed, been symptoms which indicated, and that not obscurely, 
the cardiac disease. At that time, however, I did not know how frequently car- 
ditis is combined with acute rheumatism. Auscultation had not yet come much 
into fashion in this country ; at any rate, I knew little or nothing of its use ; and 
I had supposed (and it had been supposed by others who witnessed the case) that 
the chest symptoms resulted from rheumatism of the intercostal muscles. 

44 Another instance, in which the course of the symptoms was somewhat dif- 
ferent, yet equally calculated to mislead, you have lately seen in this hospital. 

44 William Wilkins, a post boy, 28 years old, was admitted on the 25th of last 
November. 

44 He complained of pain in most of the large joints, shifting from one joint to 
another. There was no visible redness or swelling, but he had much fever. The 
pain was greatest at night. He had profuse perspirations, during which the pain 
was not mitigated. 

44 He had been ill eight weeks ; and at first his joints (according to the state- 
ments of his friends) were both swelled and red. He appeared to be recovering 
at one time, but relapsed. For three or four days previously to his admission 
he had coughed a little, and spoken of pain at the pit of his stomach. He lay 
more comfortably on the right than on the left side, but this was habitually the 
case. He had never had acute rheumatism before. 

44 He rambled a good deal during the night of the 26th, and on the 27th, he 
began to refuse to take his medicine, appeared confused and stupid, and answered 
questions tardily and imperfectly. He was bathed in perspiration, which had the 
strong acid smell so common in cases of acute rheumatism. 

44 During the next ten days he remained in a singular state of quiet delirium, 
rejecting medicine and food, saying he had had enough ; getting out of bed, espe- 
cially in the night, and declaring that he was going home. When questions were 
put to him, his lips moved, and his limbs began to stir and fidget, as though he 



704 



RHEUMATIC CARDITIS. 



were about to answer ; yet he said nothing. He understood what was said to 
him, and put out his tongue when desired so to do ; imperfectly, however, and 
with slowness and apparent difficulty. His bowels were costive, and he passed 
his stools, when purgatives acted, in the bed. His pulse was small and frequent; 
and when his wrist was taken hold of that the artery might be felt, he always 
resisted, and forcibly contracted his arm. 

" Then for three or four days he appeared to improve ; his countenance became 
more clear and lively ; but he still showed the same restlessness, and maintained 
the same dogged silence when spoken to, and obstinately refused to swallow 
medicine. He was somewhat cunning, too, for he would take pills into his 
mouth, and then, when he thought he was not observed, chew and spit them out 
again. 

" His pulse became at last very frequent, and his strength diminished rapidly. 
He died on the 18th December, and the body was examined on the following 
day. 

" The cerebral veins were gorged with dark blood, and there was a consider- 
able quantity of serous fluid beneath the arachnoid and in the lateral ventricles. 

"The pericardium was free from disease; but upon the mitral valve, near its 
edge, there was a perfect row of small, slender, bead-like warts. 

" A few weeks ago I was consulted in a case of a similar nature, which occur- 
red in the practice of a gentleman who was formerly a pupil here, and who was 
fully aware both of the frequent occurrence of carditis in acute rheumatism, and 
of the anomalous symptoms with which it is sometimes attended. The patient 
was a young man, 24 years of age. 

" On the 22d of December he was seized with pain and swelling of several of 
the larger joints, and with fever. The attack was ascribed to exposure to cold 
the day before ; he had previously enjoyed perfect health. The inflammation 
shifted rapidly from one joint to another. He was confined to bed for six days i 
then, feeling better, he got up, changed his room, and presently underwent a re- 
lapse. Mr. El win tells me that, after that time, he was never comfortable about 
this patient; his countenance was pale, and his aspect unpromising; his pulse 
frequent ; and more than once he complained of slight pain in the epigastrium, 
increased by a full inspiration. This was removed by a mustard- poultice. No 
morbid sound was detected upon a careful examination of the precordial region 
by the ear. He remained low-spirited, but slowly mending, till the 3d of Janu- 
ary, when in the evening, without any notice or obvious cause, he began to be 
restless and delirious. 

" On visiting him the next morning, Mr. Elwin found him with an anxious 
countenance; a frequent and irregular pulse, which occasionally intermitted ; his 
mind wandering; the action of his heart strong, and attended towards the sternum 
with a loud bellows-sound. The next day his breathing was difficult, and 
* catching;' the pulse 120, hard and wiry. At that time I had the opportunity 
of seeing him. He was lying in a sort of stupor, yet not unconscious, for he put 
out his tongue at my request, and answered pertinently one or two questions, 
after they had been frequently repeated. He had the air of a person obstinately 
determined to say as little as possible. He became more distinctly delirious 
towards evening ; and the next day his pulse and breathing were both so frequent 
(148, and 78, in the minute respectively), that he was thought to be dying. A 
distinct bellows-sound was audible near the left mamma. This state continued, 
with slight fluctuations, till the 8th, when his condition appeared somewhat more 
hopeful. He was calm, had no dyspnoea, and conversed more readily, — saying 
sometimes that he felt as if he were 'dead;' sometimes that he was 'burnt up.' 
He complained, for the first time, of pain in the right temple; his gums were 
slightly under the influence of mercury; his pulse scarcely exceeded 100; the 
bellows-sound was very manifest. , 

" On the 9th he again became, first restless, and then violently and wildly 
delirious, screaming out, refusing to take medicine, or to open his mouth when 



HEAD SYMPTOMS. 



705 



it was offered ; yet he evidently knew what was said to him. During the night 
general convulsions came on in occasional spasms, of a tetanic character: in the 
intervals between them he lay in a state of coma. He survived in this condition 
till the 12th. 

" I was present at the inspection of the body ten hours after death. Some of 
his family insisted on being in the room with us; but we were able to make an 
accurate examination of the head, and of the heart. 

" The veins of the brain seemed somewhat fuller of blood than is common. 
The arachnoid was slightly elevated by a clear serous fluid collected in the pia 
mater. There was but a small quantity of a similar fluid in the lateral ventricles. 
The lungs appeared quite healthy. 

"There was no fluid in the pericardium. Its surface was everywhere exceed- 
ingly vascular, but it presented no appearance of lymph, except where it adhered 
to the posterior side of the heart, over a space about two inches and a half in 
length, and upwards of an inch in breadth. The lymph which formed the me- 
dium of connection was firm, but evidently of recent formation; and a very slight 
degree of force sufficed to separate the adhering membranes. The heart was 
rather small, and the left ventricle had a singular wrinkled appearance externally. 
Towards the edge of the mitral valve there was a profuse crop of little wart-like 
vegetations, of the size of millet-seeds ; and numerous red lines converged towards 
them from the base of the valve. The aortic valves all presented curious festoons 
of similar excrescences, larger, however, and more prominent, than those upon 
the mitral valve. 

"In the- beginning of the year 1832, a girl nineteen years old, Frances Kirk 
by name, was a patient of mine in the hospital, with acute rheumatism of the 
joints, and carditis, manifested by many of the most usual symptoms — by pain 
in the situation of the heart, dyspnoea, great frequency of pulse, and a distinct 
bellows-sound. She lived two months from the commencement of the cardiac 
disease. During that period she was at times wildly delirious — -at times stupid, 
taciturn, and almost idiotic — and at times quiet and rational. The brain in that 
case was found perfectly healthy, except a slight serous effusion beneath the 
arachnoid. The pericardium was everywhere adherent to the heart. By some 
mismanagement the opportunity of inspecting the inner membrane of the heart 
was lost. 

" In each of the three last-mentioned cases there was more or less serous fluid 
found in the meshes of the pia mater, and in the lateral ventricles. You may ask, 
perhaps, whether this effusion was not good evidence of previous inflammation 
there ? whether it did not show that the metastasis, which I have spoken of as 
seldom happening, really did happen in these very cases ? 

" I apprehend not ; and for the following reasons. — In one only of these cases 
was the amount of the serous accumulation at all considerable. There was no 
other trace of inflammatory action in any of them ; no redness, nor pus, nor 
lymph ; none of the unequivocal products of inflammation. What quantity of 
serous effusion beneath the arachnoid, or in the ventricles of the brain, is requisite 
to~ establish its morbid origin — within what limits such effusion may be considered 
natural — whether it may not be ascribed wholly, or in part, to mechanical trans- 
udation after death ; these are questions which have not yet been definitely settled 
among pathologists. For my own part, whenever I see the veins of the pia mater 
full of blood, I expect to find serum between that membrane and the arachnoid. 
How much of it may have been poured out before death, and how much after- 
wards, it would be difficult to estimate. In each of the cases before us there was 
evidence, not to be mistaken, of cardiac inflammation. Now that acute inflam- 
mation, fixing itself upon some portion of the heart, should embarrass its action, 
and modify the condition of the circulation through the cerebral blood-vessels, is 
not only conceivable, but highly probable. Any retardation of the venous circu- 
lation in the head — any engorgement or congestion of that- system of vessels- 
would be likely, if we may reason from the analogy of other parts, to produce 
45 



706 



RHEUMATIC CARDITIS, 



effusion. I have seen, in the brain of a criminal who had been hanged while fn 
a state of perfect health, as much serum collected in the same parts as we found 
in the patients whose cases 1 have been relating. It is possible that, in them, the 
disorder of the sensorial functions depended upon simple disturbance of the cere- 
bral circulation ; it is possible that the same disorder depended upon the serous 
effusion ; and it is possible, and (I think) probable, that it depended in part upon 
both these causes. It is very certain that similar symptoms have occurred in 
similar cases, when there was no appreciable effusion ; and, apparently, from 
mere derangement of the natural circulation of the blood in its vessels. On the 
other hand, we know that an equal, or a greater amount of effusion, has often 
been observed, when no such cerebral symptoms had manifested themselves. I 
conceive, therefore, that the symptoms referable to the brain, and the quantity of 
serum found effused there (whether these bear to each other the relation of cause 
and consequence, or not), are both to be regarded as secondary effects of the 
cardiac disease ; that they denoted no inflammatory condition of the brain, or of 
its membranes, but were the common result of that inflammation of the heart, 
concerning the existence of which the inspection of the bodies left us no room to 
doubt. 

" That this view of the matter is correct, is the more probable because (as I 
just now stated) the same symptoms have been known to accompany carditis, 
although no serous effusion was met with in the head. There was none in the 
case of the girl Rankin ; none in a case related by Dr. Davis ; none in a remarka- 
ble case detailed by Dr. Latham ; none in a striking example of a similar kind 
■which fell under the observation of that accurate and most accomplished patholo- 
gist, Andral. I shall take the liberty of citing these two instances. 

" 'One of the children of Christ's Hospital,' says Dr. Latham, 'had, in the 
opinion of all who saw- him, the severest inflammation of the brain. The attack 
was sudden, with great heat and frequency of pulse. He had delirium and con- 
vulsions, and pointed to his forehead as the seat of his pain. In three days he 
died, and, upon dissection, not a vestige of disease was found within the cranium ; 
"but the heart was exclusively the seat of the disease, and no other part of the 
body discovered the slightest morbid appearance. The disease of the heart was 
not confined to its investing membrane. It was the most intense inflammation 
pervading the pericardium and the muscular substance.' 

" Andral's case, which is referred to by Dr. Latham, occurs in his Clinique 
Medicale. 

" A woman, twenty-six years old, was brought to La Charite, in a state of de- 
lirium, and no account could be obtained of her previous condition. The delirium 
was remarkable for the obstinate taciturnity which attended it. When questioned, 
the patient turned a fixed gaze upon the person who spoke to her, but made no 
reply. Her face was pale ; her pulse small and frequent. During the two fol- 
lowing days the head was frequently drawn backwards, the trunk was shaken at 
intervals by convulsive movements, and she had subsultus tendinum; but she now 
spoke, and appeared to comprehend what was said to her, but talked incoherently. 
The pulse was very frequent, and intermitting. On the fourth day the delirium 
ceased ; she complained of nothing but great debility. The muscles of the face 
were almost continually agitated by convulsive twitchings, and the arms from time 
to time presented a sort of tetanic stiffness. On the fifth day the delirium re- 
turned ; the patient then fell into a state of coma, and died the next morning. 

" Neither the brain, nor the spinal marrow, nor their membranes, presented 
any appreciable morbid appearances. The pericardium was lined by coagulable 
lymph, and its opposite surfaces were connected, in some places, by recent bands 
of adhesion. It contained also some ounces of a greenish flaky serum. No other 
trace of disease was discoverable. 

" Now if you are not made aware beforehand of this strange course of the 
symptoms arising, sometimes, out of rheumatic carditis, you will be apt to over- 
look the cardiac affection, and to direct your remedial measures wide of the mark. 



HEAD SYMPTOMS. 



707 



III a second instance mentioned in Dr. Latham's essay, ' the whole force of the 
treatment was directed to the head, from a belief that the brain was inflamed. 
Upon dissection the brain and its coverings were found in a perfectly healthy and 
natural state; and the pericardium, towards which during life there was no symp- 
tom to direct the slightest suspicion of disease, discovered the unequivocal marks 
of recent and acute inflammation.' Dr. Davis, also, in reference to a case pub- 
lished by him so early as 1808, has the following remark: — ' The restlessness in 
the case of Miss H. C. was also attended with delirium, a symptom not previously 
noticed as belonging to pericarditis by any writer whom I have consulted. It 
was so prominent a feature of the disease under which this young lady laboured, 
as to divert the attention of her medical attendants from its actual seat' 

" This occurrence, in the course of rheumatic carditis, of cerebral symptoms 
calculated to perplex and obscure the true nature of the disease, is probably not 
so rare as has been supposed. In less than three years three instances of it have 
fallen under my own notice ; and I have been informed by a medical man residing 
in the neighbourhood, that a friend of his, who has a very large general practice 
among the middle and lower classes, attended within the last year or two not less 
than twenty cases of acute rheumatism, in which a metastasis, or an extension of 
the inflammation, appeared to take place to the brain. 

44 In all the detailed cases of this kind that I have met with, and in those which 
I have myself watched, there were certain general points of similarity, which you 
will do well to bear in mind. In all of them the pulse was extremely rapid; the 
delirium, though violent and active at intervals, was characterized for the most 
part by a singular, and, as it seemed, perverse taciturnity : even when the patient 
was evidently able to speak, and understood the questions that were put to him, 
he maintained a sullen silence. In most of these patients, also, not long before 
the fatal event, a brief interval of amendment took place, and encouraged some 
hope of recovery. In many of them various convulsive movements were ob- 
served ; and in two of the cases the head symptoms, and probably the heart disease 
also, supervened a*fter a relapse of the rheumatism of the joints." 

It is a curious circumstance that rheumatic carditis is sometimes the first step 
in the whole disease; the cardiac symptoms will sometimes, I mean, precede those 
of the joints; even by two or three days. For example. A lad was brought to 
the hospital with acute articular rheumatism, and with unequivocal symptoms, 
which I need not detail, of carditis. He gave the following distinct history of his 
illness : — He had been on a visit into the country several days before, and there, 
after having felt poorly for nearly a week, with a sensation of " sinking within 
him," he ate largely of oysters, and drank more porter than he was accustomed 
to. On the same day he was seized with pain in the left side of the chest, and 
violent beating of the heart. The attack was probably a severe one, for he applied 
to a medical man, who immediately bled him. In the course of the ensuing night 
he began, for the first time in his life, to feel some stiffness beneath and about his 
knees, but he was able to walk about the next day. On the evening of the second 
day the joints became so painful and swollen, that he could not leave his bed, and 
then the pain of the side and the palpitation diminished. This boy has several 
times since returned to the hospital with acute rheumatism, and on each occasion 
presented manifest indications of some permanent affection of the heart, — slight, 
probably, in amount, but aggravated upon every return of inflammation of the 
joints. 

I have met with one or two other instances in which the cardiac disease ap- 
peared to have preceded the arthritic; but none so well made out as that I have 
just related. Dr. Duncan, in the Edinburgh Medical and Surgical Journal for 
1816, gives a case of " inflammation of the heart" which began with symptoms 
of pectoral inflammation, succeeded the next day by rheumatic affections of the 
joints. 

One law respecting the connection between the cardiac and the arthritic symp- 



708 



RELATIONS OF CARDITIS WITH 



tarns may be stated with confidence, namely, that the younger the patient is whc? 
suffers acute rheumatism (and I have seen it so early as the third or fourth year) 
the more likely will he be to have rheumatic carditis. The chance of the combi- 
nation appears to diminish, after puberty, as life advances. I have known only 
two persons pass through acute rheumatism with an untouched heart prior to the 
age of puberty ; and in these two I am by no means certain that the articular dis- 
ease was genuine rheumatism. In each of them, the large joints became painful* 
and swelled, for a day or two only, towards the close of scarlet fever:- — a circum- 
stance not, I believe, unusual. I was dreadfully apprehensive of carditis, but it 
did not occur. 

I have observed, also, that when a patient has come under my care who has 
had repeated attacks of acute rheumatism, in him I have generally found reason 
to believe that some organic affection of the heart was present. Probably the dis- 
position to such repetitions of the disease, so remarkable in some individuals, may 
be kept up by the cardiac complication. 

With respect to the period of the actual attack, and the circumstances under 
which the extension of the disease to the heart occurs, no fixed law has been ob- 
served. Sometimes the cardiac affection declares itself as the inflammation of 
the joints declines. Quite as often, however, they proceed together, and are 
aggravated or mitigated simultaneously. On this point my own experience nearly 
agrees with that of Dr. Latham, who says : — " It (the cardiac affection) is incident 
to all the degrees and all the stages, and all the forms (?) of acute rheumatism. It 
is not more to be looked for when the disease is severe than when it is mild ; more 
at its beginning than during its progress and decline ; more when it is shifting and 
inconstant in its seat, than when it is fixed and abiding.' 7 

There are some other symptoms that I must not omit to mention as occuring 
in some cases of pericarditis. In one of the fatal instances which fell under my 
own notice, there was a very strong purring tremor felt by the hand placed upon 
the region of the heart. This is not a constant, nor even a frequent, symptom ; 
but it has a certain degree of corroborative value when it does'occur. 

When the fluid products of the inflammation predominate, when there is much 
serum poured out, the symptoms, as well as the danger, will be different from 
those which are remarked when there is not so much serous liquid. If the peri- 
cardium be distended, percussion will furnish a dull sound over an unusually large 
space; much beyond the natural limits of the precordial region: and you may 
often measure the amount of the effusion, and its daily increase or decrease, very 
accurately in this manner. But the general symptoms will vary also. The pulse 
will be feebler, and more disposed to falter and to become irregular, in proportion 
as the liquid effusion is large; and at the same time the patient will frequently be 
fixed in one position, and unwilling or afraid to change it, lest that small exertion 
should further excite the action of his heart, and hurry his respiration. He will lie* 
perhaps, always upon one side ; or he will remain immovable on his back, with 
his head elevated ; or he will sit up continually, with his body leaning forwards ; 
and he will not dare to alter his posture. But when the solid products of the 
inflammation predominate ; when there is coagulable lymph, and but little serum ; 
when the pericardium, instead of being distended, becomes attached to the heart; 
then the pulse will retain that force and regularity with which the disease com- 
menced, the dull sound yielded to percussion will not transgress the precordial 
limits, and the patient will not in general experience any absolute necessity of 
accommodating his body to one constrained position. 

Of a merely adherent pericardium there are no diagnostic signs to which, so far 
as I know, we can trust, either auscultatory or general. None, I mean, presented 
by the body at the time. If we are accurately acquainted indeed with the history 
of the patient's disease, and if we know that, at any time, a to and fro sound 
existed, which to and fro sound soon ceased, and has never recurred; then our 
conclusion that the pericardium is adherent will scarcely be open to any source 
of fallacy. 



ARTICULAR RHEUMATISM. 



709 



When the opposite surfaces of the membrane have been once united, they never 
separate again ; the adhesion remains for life. But the lymph interposed between 
them, if the inflammation be not renewed, becomes less and less thick; until at 
length, in some cases, a mere layer of firm, but thin, areolar tissue is left, through 
which the heart is visible. 

But when inflammation has stiffened the valves of the heaTt, or studded them 
with little wart-like masses of fibrin, how far do these morbid states admit of 
perfeet recovery ? It is not so easy to say. I am not aware of any facts, which 
would forbid altogether the hope that here, as in iritis, the re-absorption or removal 
of the lymph may be total, and the restoration of the parts complete. On the 
contrary, the ce?npmrative infrequency of wart-like excrescences in the slowly fatal 
eases of rheumatic carditis leads to the opinion that such deposits may disappear 
as readily and entirely from the valves of the heart as from the iris. 

Since I lectured upon this subject last year, two examples of rheumatic carditis 
have occurred among my hospital patients, differing in some remarkable points from 
any that 1 had ever seen. A brief description of them will complete my personal 
experience of this terrible disease* 

The histories of the two cases are curiously similar. The patients were 
young women ; their ages respectively twenty-one and twenty-two. They were 
admitted during the same week ; one a day after the other. Both were suffering 
under a first attack of rheumatic fever; both had also acute pleurisy, with effusion 
into the chest ; and both died; one of them three weeks, the other a month, after 
her admission. In both cases there were symptoms referable to the heart; pain, 
and unnatural sounds; but in neither case was there any friction-sound; nor were 
any traces of pericarditis discovered after death. But the inflammation had fallen, 
partially, upon the aortic valves; whence it had extended (so I imagine) to the 
muscular substance. I show you the morbid appearances represented in these 
drawings, made by Mr. Lonsdale at the time : and, better still, I show you the 
parts themselves, which are preserved in our museum. 

The whole of one of the aortic valves was, in each case, a mass of ragged 
ulceration; and the adjacent portions of the two other valves were, in a slighter 
degree, implicated in the mischief. What remained of the tattered valve was 
covered with rough irregular shreds of lymph, or vegetations. In one of the cases, 
the ulcerating process had penetrated through the valve, and into the muscular 
substance beyond, and had eaten a hole completely through the septum. A portion 
of lymph protruded just below the valve of the pulmonary artery through the 
channel of communication thus formed between the left and right sides of the heart. 
In the other case, an abscess as large as a hazel-nut was found in the muscular 
substance of the septum, immediately opposite the disorganized valve. 

Till i met with these cases, I was not aware that this destructive incrustation 
of the cardiac valves with wart-like excrescences was ever the result of acute 
inflammation. Chronic changes of that kind are not uncommon. Suppuration 
in the heart is very rare. In these two instances, the eardiae affection was com- 
plicated with aeute pleurisy. I should have mentioned before, that the pleura 
very often participates in the inflammation when pericarditis oecurs. You will not 
wonder at this if you consider the close vicinity, and the similarity in texture, of 
&hese two serous membranes. 

I must defer what I have to say respecting the treatment of acwte pericarditis 
2&d endocarditis f to the next lecture* 



710 



ACUTE PERICARDITIS. 



LECTURE LXII . 

Treatment of Acute Pericarditis, and Endocarditis : blood-letting ; mercury $ 
blisters. Chronic and partial Inflammation of the Pericardium. Disease of 
the Aorta. Thoracic Aneurisms ; their various situations, and symptoms s 
plan of treatment. 

I trust that I made distinctly apparent, in the last lecture, the great danger 
which belongs to every case of acute inflammation of the pericardium. First, there 
is the danger of speedy death. If the inflammation goes to the extent of effusion, 
and the collection of serous fluid be large, and the pericardium be distended by it, 
the action of the heart is so much oppressed by the liquid surrounding it, that it 
falters and flutters, and at length stops, and goes on no more. Secondly, there is 
the danger that (the pericardium having become adherent) other structural changes- 
will, soon or slowly, develop themselves ; and first render life burdensome and 
full of suffering, and then consign the patient to an earlier grave than might else 
have awaited him. 

Now what can we do to prevent, or to diminish, these evils ? I once thought 
that if we caught the inflammation at its very commencement, we might calculate 
upon a perfect cure, by first bleeding the patient freely, and by, secondly, putting 
him as speedily as possible under the specific influence of mercury. I am sorry 
to be obliged to say, that the more I see of this formidable malady, the more reason 
I find for fearing that it is seldom within the possibility of thorough repair. Bring 
the inflammation to a stop, you perhaps may ; or nature will do it for you ; and 
you may greatly assist the natural powers in effecting this. But that alone can 
be called a cure, which either leaves the structure of the part affected in its original 
integrity ; or, at any rate, leaves no spring or source of further changes for the 
worse : and such complete recovery as this I seldom dare to hope for in cases of 
acute and general pericarditis. 

There can be no use ih deceiving ourselves in this matter; but we may very 
easily deceive ourselves. In a large proportion of cases, whether they be treated 
well, or ill, or not treated at all, the patients will seem to recover. But I say 
that the recovery is so far unreal, that it involves the germ of future destruction. 
If any of you have read Bouillaud's heavy, yet instructive work on diseases of the 
heart, you will know that he boasts of the success of his treatment in acute peri- 
carditis. He delcares that by the bold use of the lancet he extinguishes the 
inflammation; jugulates (as he calls it) or slaughters the disease at its birth ; and 
restores the patient to the full condition of health, or to the state fn which he was 
before the disease came on. You must hereafter judge of this question for your- 
selves ; but it is my duty to caution you against crediting these statements. Not 
that I would insinuate a doubt of M. Bouillaud's veracity ; but I believe that he 
has been deceived by false recoveries ; and I would not have you beguiled, by his 
representations, into the indiscriminate adoption of that "enlightened hardiness'* 
which he endeavours to inculcate. 

But if we look closely at his statements, we do not find, after all, any such 
wonderful success. Of 18 patients, 6 died ; a very large proportion, 1, viz. in 3. 
To be sure, with some ingenuity he makes the proportion to be 1 in 7. For 
three of the fatal cases occurred, he says, before he took to his heroic plan of 
blood-letting; and excluding these 3, he has 15 cases, and only 3 deaths ; or 1 in 
5. But one of these three proved fatal from the supervention of tetanus ; therefore 
setting that also aside, there will be 14 cases of the disease and 2 deaths. Now, 
I have not, hitherto, been able to look through my case-books in reference to this 
point, but I am quite certain that the mortality in the Middlesex Hospital has 
been nothing like so great as that — the immediate mortality, of course, I mean-— 



ACUTE PERICARDITIS. 



711 



Either among my patients, or among those of my colleagues ; and I know that, 
until within the last twelve months, Dr. Latham had not lost a single case of 
rheumatic pericarditis in the course of the first attack of that disease for several 
preceding years. 

But what I mast doubt about, is the true recovery of Bouillaud's surviving 
patients. I say such patients do apparently get well. In some of them, indeed, 
a bellows-sound remains, sufficiently indicative of the damage that the organ has 
sustained : and I have already told you that any amount of change, however small, 
which alters the healthy proportion of the cavities and their outlets, or which inter- 
feres with the natural play of the heart, is a seed from which further changes will 
at length be found to grow. But patients will get so far well that you can detect 
nothing wrong about them. Follow them, however, in their subsequent lives; 
and you will learn that many of them very soon begin to find that they are incapable 
of doing or enduring all that they could do or endure before their illness : and if 
this does not soon happen, it does at last. The disease of the heart (rf~the patient 
be not cut off by some other malady) becomes at length obvious ; and when he 
dies, the source of the ultimate changes is commonly to be detected. There is 
an adherent pericardium ; or there is disease of the valves ; of which no other 
account can be given than that it had continued to exist since the primary symp- 
toms of carditis ceased; and that it had caused all the rest—the hypertrophy, to 
wit, and the dilatation. 

The remarks that I have now been making bear upon the question, to what 
amount blood-letting should be carried in acute pericarditis. If the general symp- 
toms teach you that it exists, and yet no sound of attrition is heard, you may, in 
that case, if in any, hope to arrest the inflammation, and to achieve a complete 
cure, by early and copious bleeding. But if the to and fro sound has been audible, 
I do not think the consequences of the inflammation can be so abolished. I believe 
that the best event which can then happen is adhesion. We must, however, in 
many cases, take blood by the lancet from the arm, or by leeches from the pre- 
cordial region ; yet not in the lavish manner recommended by Bouillaud. I know 
that his treatment has been fairly tried in this country, and has failed. And I 
think (but this I only offer as an opinion) that there is a peculiar risk in frequently 
bleeding to syncope in this affection. There is, almost always, endocarditis (in 
rheumatic cases at least) coincident with the pericarditis ; and there is a readiness 
or tendency toward a deposition of the fibrin of the blood, in the shape of minute 
vegetations, upon the inflamed valves : and it is probable that this tendency may 
be favoured by a retarded movement of the blood over them ; and still more so 
by its temporary stagnation. In the experiments on the ass, referred to before, 
the circulation (kept up by artificial breathing) became languid and sluggish, and 
vegetations were deposited upon those valves which had been irritated by the wire. 
Hence there is, I think, a danger in bleeding to such an extent in these cases, as 
to bring the heart's action to a pause in deliquiurn. Bleed, therefore, (if you 
deem it requisite to bleed at all,) till some effect upon the pulse has been accom- 
plished, and then stGp : and renew the venesection, or refrain from it, according to 
circumstances. But you may freely cup the precordial region, or cover it repeat- 
edly with leeches : and to this mode of abstracting blood, from the neighbourhood 
of the inflamed part, my own experience would assign the preference. In fact, 
I seldom open a vein in such cases. 

At the same time, you will endeavour to get the gums tender with mercury.. 
And it is most unfortunate that, in .this disease, the system frequently resists, with 
great obstinacy, the influence of that mineral. Sometimes, do what you will, you 
fail to attain your object. A knowledge of this fact may render you less scrupulous, 
than you would otherwise be in the use of the remedy. Not only should calomel 
be given in frequently-repeated doses, guarded, if need be, by opium : but mer- 
curial inunction should also be had recourse to, in these perilous cases, from the' 
first. When the gums do begin to rise, there will always be, according to myr 
experience, a manifest subsidence of the distress, and mitigation of the symptoms., 



712 



ACUTE PERICARDITIS. 



There will be less pain, less palpitation, less dyspnoea. The mouth should be 
kept sore for some time together; for supposing the membranes to adhere, it does 
not follow that the inflammatory process should thereupon cease. 

When you learn, from symptoms and signs already described, that the pericar- 
dium is distended by liquid effusion, I would advise you to lay a large blister over 
the precordia. The diminution, or complete disappearance of the liquid, under 
this treatment, is often rapid and striking. 

Even when all the symptoms have vanished, previous disappointments have 
taught me not to be sanguine as to the permanency of the recovery. I believe 
that months, and years even, may elapse before the secondary effects of the mis- 
chief left behind by the inflammation begin to be palpable. But in many instances, * 
they show themselves very early. Others have noticed all this : especially Dr. 
Latham, who truly remarks, tha*t " in acute pericarditis there is no medium between 
complete cure and certain death.' 7 He deemed, at the time when the lectures 
from which I quote were given, that the early and vigorous use of mercury would 
be equal to the complete cure. I think I may venture to say that he has since 
seen reason to doubt on that point. I have several times already expressed my 
own belief, that where the to and fro sound has manifested itself, that is, where 
the inflammation has gone so far as the effusion of coagulable lymph, if the patient 
does not die outright, he survives at the expense of an adherent pericardium ; and 
he survives only for a time. Hseret lateri lethalis arundo. But I am also of 
opinion, that by the cautious employment of the lancet and of leeches, and by the 
early and unshrinking use of mercury, the mischief may be greatly limited, and 
the consecutive changes staved off to a distant period. The final catastrophe 
arrives much more slowly where there is mere adhesion of the pericardium, than 
where that condition is complicated with permanent disease of the valves within 
the heart. I need scarcely say that other, minor expedients are to be put in force ; 
strict abstinence I mean, perfect quiet, and an occasional purgative to clear out the 
alimentary canal. 

' When the pericardium has once become adherent, if (as is very likely) the 
patient again suffers acute rheumatism, he may again have heart symptoms. Not, 
of course, the to and fro sound ; but pain, palpitation, and dyspneea. Now it is 
of some practical importance to be aware that this renewal of morbid action does 
not require that active treatment which the primary inflammation demanded. The 
effect of such renewal will be to augment the existing mischief; but the morbid 
process is much less vigorous, and much more easily subdued. It will generally 
yield to the repeated application of leeches, or of blisters, over the situation of the 
heart, and to the moderate exhibition of mercury. 

Although acute inflammation in this, as in other serous membranes, shows 
generally a strong disposition to spread all over the affected surface ; yet does the 
pericardium seem readily susceptible of slight and partial inflammation. You 
will very frequently indeed see, upon laying the bag open, a white spot, as big as 
the finger-nail, upon the surface of the heart. I have examined these spots very 
often; and I believe they almost always consist of a thin flake of lymph lying 
sometimes beneath, but oftener upon, the membrane. They may, in fact, be 
peeled off sometimes, and the subjacent membrane left smooth and sound. On 
one occasion, I met with a long riband of lymph passing from the centre of one 
of these white spots, to connect itself with the loose bag of the pericardium. I 
conclude, therefore, that these spots are really the result of a very limited inflam- 
matory process: but under what conditions they arise, or whether during their 
formation they furnish any symptoms, I do not know. 

Such is the view which I had long taken, and taught, of these white spots upon 
the surface of the heart; and I am glad to have it confirmed by the observation of 
Mr. Paget, who has recently adduced (in the twenty-third volume of the Medico- 
Chirurgical Transactions) conclusive evidence, both of their frequency, and of 
their inflammatory origin. 



DISEASE OF THE AORTA. 



713 



So much then for the heart itself, and its membranes. There still remain to be 
considered the morbid conditions of the great vessels that spring from it, and lie in 
the thorax, and especially of the aorta; those morbid conditions I mean, which de- 
clare themselves by symptoms, and which become the object of medical treatment. 

The aorta is very frequently indeed found diseased, and its disease, as I have 
already explained, is a common cause of organic changes in the left ventricle of 
the heart. You will find that its inner membrane, instead of being smooth, 
and of a uniform yellowish-white colour, is rendered very uneven by a great 
number of yellow opaque projections, of cartilaginous consistence, lying imme- 
diately beneath the membrane. And in a more advanced stage of the same diseased 
condition, you may perceive that some of these projecting little masses consist of 
irregular scales of bone, having sharp edges ; and sometimes these plates of ossific 
matter are quite bare ; the inner membrane is gone, and the exposed bone is washed 
by the current of blood. Now the necessary effect of these changes is to dimi- 
nish and destroy the natural elasticity of the vessel ; and as there is a perpetually 
recurring strain upon it, by the blood sent out from the heart, the vessel dilates, 
becomes larger than it should be. This, if you please, you may call aneurism ; 
but a simpler name is dilatation. In other cases, the enlargement is not general, 
but partial. A pouch is formed on one side of the artery, and this pouch may be 
very small or very large. It appears to result from the giving way, the rupture in 
short, or the ulceration, of the inner and middle coats of the artery, and then the 
blood, passing through the broken part, presses against the cellular coat of- the 
vessel, and distends it into a sort of bag. There have been curious discussions 
as to what should be called true aneurism, and what should be called false aneurism ; 
discussions upon which I have neither time nor taste for entering. It is enough 
for all practical purposes to state, that the artery sometimes dilates only, sometimes 
throws out a pouch. I know that you have received, or will receive, from my 
colleague, Mr. Arnott, all the information that is requisite concerning the modes 
in which aneurism may arise. These are matters of the highest interest in sur- 
gery, for surgery can cure an aneurism ; an achievement which is but seldom 
within the skill of physic. 

I have known two cases in which the diseased artery all at once cracked across — 
its inner and middle coats, I mean — and death very rapidly ensued. In one of 
these instances, the crack extended round a considerable part of the circumference 
of the aorta. It looked exactly like a clean cut made by a sharp knife. The 
blood, in this example, dissected its way (if I may so say) between the middle 
and external coat of the aorta, and got at last into the pericardium, and coagulated 
round the heart in a uniform layer : so that a bag of coagulated blood was enclosed 
in the bag of the pericardium. Of course, nothing can be done for such cases as 
these. 

Most commonly the aneurismal tumour goes on enlarging; and often it becomes 
lined, and sometimes it is nearly filled up, by layers of coagulated blood, which 
form in its interior. At length the tumour bursts, and the patient perishes. 

Aneurisms of the thoracic aorta are met with chiefly in the earlier portions of 
that vessel, in its ascending part, and in its arch. There seem to be two reasons 
for this. One is, that the diseased state of the coats of the artery (to which the 
rupture and subsequent aneurismal pouch, or the dilatation, as the case may be, 
are owing,) is more common, and more advanced generally in that part of the 
aorta; and another reason is, that the momentum of the blood, as it is forcibly 
propelled from the left ventricle, is sustained chiefly by the same part. 

Mere disease or dilatation of the commencing aorta, affords, as I formerly endea- 
voured to explain, a physical impediment to the due emptying of the left ventricle. 
It is a common cause, therefore, of hypertrophy and dilatation of that ventricle; 
and consequently, the signs of hypertrophy and dilatation of the left ventricle of 
the heart will at length result from disease and enlargement of the aorta near its 
mouth. 

When aneurismal pouches form, as they often do, at the very entrance of the 



714 



THORACIC ANEURISMS i 



aorta, or in the coronary arteries, they often defy detection. I, at least, know of no 
sign of their existence upon which a physician can rely, or which can lead him 
even to suspect such a state of matters. But all at once the patient drops down 
dead : and upon searching for the cause of this sudden extinction of life, you find 
the pericardium distended with blood, and the source of that blood you find to be 
the ruptured aneurismal pouch, so near the root of the aorta, as to project within 
the pericardium. In the preparation which I hold in my hand, an unbroken aneu- 
rism actually bulges into the right ventricle of the heart. 

When the aneurismal tumour occupies a portion of the ascending aorta a little 
more distant from the heart, or is formed at the arch itself, it sometimes attains a 
large size, and the evidence of its existence is derived from the effects its enlarge- 
ment produces on the surrounding textures ; and these effects are apt, for a while, 
to be obscure and equivocal, until an external pulsating swelling makes its appear- 
ance, or a sudden gush of arterial blood through the mouth discloses the true 
nature of the malady. 

In these cases we infer the existence of aneurism sometimes from peculiar 
symptoms. Aneurism at the arch of the aorta may come to press upon the 
trachea, and impede the breathing ; or by its effect upon the recurrent nerves, it 
may cause a very accurate mimickry of laryngitis. The operation of tracheotomy, 
as I told you before, has more than once been performed, to relieve the supposed 
inflamed condition of the larynx, while the sole disease was aneurism at the arch 
of the aorta. Such mistakes are always discreditable; and the lesson they fur- 
nish should not be lost upon us. Whenever we find that a wheezing dyspnoea 
has gradually arisen, which no apparent affection of the air-passages satisfactorily 
accounts for, and the patient has a sense of pulsation within the thorax, we may 
suspect that an aneurism is at the bottom of these symptoms. 

The effect of aneurismal enlargements of the artery in causing absorption of 
the neighbouring tissues, upon which the tumour presses, is very curious. You 
know that even the solid bone is removed, worn away as it were, before an 
advancing aneurism. Hence it not unfrequently happens that the trachea, or 
some of the larger bronchi, are at first flattened, and then give way ; the Aneurism 
breaks into the air-passages ; and the patient, overwhelmed by a torrent of blood 
into and from his lungs, perishes in a few seconds. Or the tumour may contract 
adhesions with the pulmonary tissue, and destroy it to a certain extent, and so 
cause mortal haemoptysis. But such cases are not always fatal at once. 

Again, according to its situation and extent, an aneurism of the thoracic aorta 
may press upon the oesophagus, and cause the ordinary symptoms of stricture of 
that tube. Hence cardiac disease, and pulsation within the chest, accompanied 
at length by the signs of a constricted oesophagus, form strong presumptive indi- 
cations of the existence of an aneurism ; and in such cases, the oesophagus may 
at last ulcerate through, and then copious and fatal hemorrhage ensues. Haema- 
temesis it may be called, though the blood is vomited not from the stomach, but 
from the gullet. A patient in the Middlesex Hospital, with symptoms of stricture 
of the oesophagus, one day brought up from the throat a red mass, which, at the 
moment, was supposed to be a bit of meat that he had been trying to swallow. 
It really was part of the clot from an aneurism ; and it was speedily followed by 
a stream of red blood, and by death. 

Again, aneurism of the thoracic aorta does frequently obstruct, by its juxta- 
position and pressure, the vena cava superior; nay, it may even obliterate that 
vessel, of which I have seen two instances. To one of these cases I alluded 
before, as a most curious example of dropsy. It illustrated exceedingly well the 
effect of venous obstruction in causing serous effusion. The man was a patient 
of Dr. Hawkins. He presented a most extraordinary spectacle. His face, neck, 
and arms, were tumid and anasarcous to an enormous degree ; while there was 
not the least trace of swelling or oedema anywhere below the ribs. He looked as 
if his upper half had been stuffed ; and except that it was distressing, his appear- 
ance was extremely comical.. His countenance was livid ; his eyes seemed starting 



THORACIC ANEURISMS. 



715 



from their sockets ; and even the areolar tissue beneath the conjunctiva was (Ede- 
matous. The integuments of his neck and chest were quite brawny ; and his 
arms were so swollen that they projected from his sides. The surface of the 
thorax in front was embossed by numerous veins, which were turgid with blood; 
and here and there patches of ecchymosis were visible. You may form some 
notioii of the degree of mechanical congestion that existed, when I tell you that, 
upon the scarificator being applied, after a cupping-glass was taken off, upwards 
of twenty ounces of blood escaped in two minutes. The epigastric veins were 
visible and tortuous, and a free communication by anastomosis existed between 
these veins ascending from the inguinal region, and the mammary veins. There 
was a bellows-sound, which increased in loudness and harshness, from the root 
of the aorta to the top of the sternum. The patient soon died ; and a large aneu- 
rism of the aorta was laid open by lifting up the sternum, to which the artery had 
adhered, and into which, indeed, it had eaten a little. Not far above the right 
auricle, the vena cava was totally impervious ; its sides having been gradually 
pressed together, as the tumour grew. The other case, of the same kind, which 
occurred in one of my own patients, I shall have occasion to refer to hereafter. 

But aneurism of the thoracic aorta may exercise its pressure in another quarter, 
and wear away the bones of the vertebras, and cause pain in the back, and ulti- 
mately palsy of the parts below that portion of the spinal cord ; so that pain in 
the back, with pulsation, may justly awaken suspicion of aneurism making its 
way backwards. I remember hearing Dr. Farre describe a case of this kind, to 
inculcate the necessity of paying attention to the sensations of a patient. A man 
came to him for advice, having been told by another physician that there was 
nothing the matter with him — that he was fanciful. But when an adult person 
makes constant complaint of certain morbid feelings in a part, the probability is 
that he has something the matter, and we must investigate the case with what 
helps we can get. In the instance in question, there were two signs of disease, 
and two only ; a white tongue, and pain in the back. The whiteness of the tongue 
soon disappeared under the use of some medicine addressed to the digestive 
organs. The pain in the back remained. Dr. Farre interrogated the patient mi- 
nutely every time he visited him, till at last the man got vexed and tired, and said, 
pettishly, " I know that if you split me down the middle, I am sound on my right 
side, and diseased on my left." Very soon after, he was found dead in his bed. 
What he had said was perfectly true : there was an aneurism pressing on the left 
side of the dorsal vertebras. 

Another consequence of an enlarging thoracic aneurism, sometimes observed, 
is pressure upon the thoracic duct, causing engorgement of the absorbent vessels 
and glands, and inanition. In short, whatever parts the aneurism may reach, and 
subject to its pressure, may have their function thereby-suspended or disturbed, 
or their structure spoiled. 

One sign, which I have myself frequently verified, of aneurism of the arch of 
the aorta, is a difference in the force of the pulse in the two radial arteries. The 
pulse in the one wrist will be extremely feeble, or even disappear. This hap- 
pens when the state and position of the arteria innominata, or of the left subcla- 
vian artery, become altered in consequence of the enlargement of the aorta ; and 
sometimes the one or the other of these arteries is completely closed up. But 
inasmuch as a similar difference of the pulses may arise from other causes, we 
can only look upon this symptom as one which may help to solve an ambiguous 
case. To give you an example of a difference in the beating of the arteries in 
the two wrists from other causes, I may mention a case in which the subclavian 
artery was thrown forwards, and compressed by an exostosis on the first rib. The 
case is mentioned in Mr. Mayo's Pathology. It occurred in a patient of mine, 
the husband of a nurse in my family. I had a girl for some time in the hospital, 
in one of whose arms no artery could be found to pulsate. Why, we none of us 
could make out. 

Very lately, a surgeon from the country came to my house, desirous (he said) 



718 



THORACIC ANEURISMS. 



to consult me about a sense of discomfort in his head ; and particularly about the 
state of his vision. When erect, he saw things obscurely. At three yards' dis- 
tance he could see my face, but could not distinguish the separate features. What 
he thought very strange was that he could see perfectly well when in the hori- 
zontal posture. 

On my proceeding to feel his pulse, he said, in a careless manner, «« By-tlre-by, 
that is another thing wrong with me ; I have no pulse." Nor could I detect any, 
in either arm. He then told me that, four or five years previously, a medical 
friend, intending to feel his pulse in the left wrist, could find none. He was con- 
fident pulsation had existed a short time before that. After a while, the move- 
ment of the radial artery returned, in a very slight degree ; and then finally ceased. 
Within nine or ten months of this discovery, the right pulse, after growing less 
and less distinct by degrees, had vanished also. Though somewhat weak, and 
subject to faintness, this gentleman had not wasted ; nor had the muscles of his 
arms lost either bulk or vigour. Their veins were full enough of blood. His 
hands were often cold ; and he felt altogether worse during cold weather. 

Failing to detect any pulsation in the brachial and subclavian arteries, I next 
felt for the carotids : but I could perceive no beating in the track of their course. 
I had placed my finger, for a few seconds only, in front of the left sterno-mas- 
toid muscle — when I saw that his head drooped, his cheeks became white, and 
he was on the brink of fainting. But he recovered immediately. Then I made 
similar pressure, for a moment, on the right side of the neck, and the same phe- 
nomena were instantly repeated, with the addition of convulsive jerking move- 
ments of the head and arms. He rallied again directly upon my removing rny 
finger, and was scarcely aware of what had happened. For a second or two he 
had been unconscious. His femoral arteries throbbed as usual. 

I next examined his chest. There was no external irregularity or want of sym- 
metry. Percussion gave a clear resonant sound everywhere in front. The heart 
was heard, beating with frequency, but without any bruit, over the greater part of 
the thorax. Its impulse in the precordial region, below the nipple, was feeble : 
but a strong jarring impulse was communicated to the ear when the stethoscope 
was applied to the upper part of the sternum. 

The patient complained of pains affecting his shoulders, clavicles, and the back 
of his neck ; and of slight difficulty of swallowing. 

From the intelligent physician who had attended this gentleman in the country 
I learned the instructive fact that, twenty months before, a loud rasping bruit had 
been audible, without impulse, at that part of the sternum where he, as well as I, 
now found no bruit at all, and a very considerable impulse. 

I cannot doubt that in this painfully interesting case there is aneurismal disease 
of the aorta, interfering with and lessening, but not absolutely excluding, the 
stream of blood through the arteries which spring from its arch. 

In the numerous specimens upon the table, you will find ample evidence and 
illustration of almost every one of the effects which I have described as apt to 
result from the pressure of thoracic aneurisms of the aorta. But similar effects 
would ensue from the same degree of pressure, however caused ; and other mor- 
bid tumours, cancerous tumours in particular, are not uncommon within the tho- 
rax. Hence these same effects, considered as symptoms, are in themselves, of 
equivocal import. If they occur in conjunction with signs of disordered circula- 
tion, or of a diseased heart, we may reasonably conjecture that they are produced 
by an aneurism. But we can seldom be quite sure of this, until the advancing 
aneurism comes near the surface, and causes an external prominence or tumour 
which pulsates visibly, or of which the pulsations are perceptible by the touch. 
And even then it may require some care and tact, to avoid mistaking an enlarged 
gland, or a malignant growth, lying over a sound artery, and receiving an impulse 
from it, or communicating to it some unnatural sound, from the diseased vessel 
itself. 

The pulsating tumour, if Jhe aneurism has formed in the ascending aorta, makes 



THORACIC ANEURISMS, 



717 



its appearance, usually, on the right side of the sternum. If the aneurism is 
situated in the forepart of the arch, it produces a bulging at the sternal extremities 
of the upper ribs on that side. When it springs from the summit of the arch, the 
tumour rises above the sternum, and the sternal ends of the clavicles ; and when 
the disease occupies the descending portion of the thoracic aorta, it will sometimes 
destroy the ribs and the bodies of the vertebras, and push forward the lower part 
of the left scapula: or it may show itself in front, beneath the left clavicle. 

When such a tumour presents itself, and is attended with a steady, heaving 
pulsation, synchronous with the systole of the heart, the doubt and obscurity 
which may have previously hung over the nature of the patient's disorder is 
cleared away. A little attention to all the circumstances of the case, will gene- 
rally suffice to determine its true character. 
. There are, however, some errors prevalent respecting these pulsating tumours, 
which errors I shall glanoe at in passing. In the first place, the pulsation of the 
tumour is frequently, most frequently, attended with a rough bellows-sound ; and 
some persons rely upon this as distinctive of the nature of the pulsating tumour. 
They hold that this harsh bellows-sound is always discernible in an aneurismal 
tumour; and that when such a sound cannot be heard, the tumour is not an 
aneurism. But this is a mistake. There have been in the Middlesex Hospital 
within the last six months (1837), two instances of pulsating tumours in the fore 
part of the thorax, unattended with any bellows-sound ; yet they were both ascer- 
tained, after death, to be aneurismal tumours. One of the aneurisms is before you. 
In the case of the country surgeon, a bellows-sound was present at a certain period 
of the disease, and absent at a more advanced period. I may say the same of the 
purring thrill. It is a common, but by no means a necessary attendant upon 
thoracic aneurisms. Again, much stress was laid by Laennec, upon the circum- 
stance of the aneurismal pulsation being single, being unattended by any second 
sound. But this is not a true rule if taken universally. In the instance which 
furnished this very preparation, the sounds were double, just like those of the 
heart. The second sound heard is, no doubt, the second sound of the heart, con- 
veyed from the place of the aortic valves, where it originates, along the course of 
the vessel, to the aneurism ; which often indeed lies in contact with the heart, and 
could scarcely fail to have the diastolic sound propagated through it. It is a fact 
not so easily explained, yet it certainly is a fact, that a double sound may be 
audible in aneurisms very distant from the heart. Dr. Davies states, that he 
never heard a second sound in abdominal aneurisms ; yet I presume that, under 
favourable circumstances, the sound of the closing of the floodgates at the root of 
the aorta, may be heard far along its channel. I can account in no other way for 
the second sound, heard by myself and by many others, in a popliteal aneurism. 
I mentioned before, a patient whom I saw in St. Bartholomew's Hospital, and 
in whom an exceedingly loud diastolic sound, like the sharp whining note of a 
dog, was audible by the ear placed upon his arm, over the brachial, and even over 
the radial arteries. 

There are some very judicious remarks made by Dr. Hope upon the sounds 
that are apt to be heard in these pulsating aneurismal tumours to the right of the 
sternum ; showing how they may be distinguished from the natural sounds of the 
heart itself, conveyed to that spot through some dense conducting medium. He 
observes (and all that I have seen has been consonant with this observation), that 
the first of the aneurismal sounds, when there are two, the sound that coincides 
with the pulse is always louder than the natural systolic sound of the heart, and 
generally louder than any of the morbid systolic sounds ; and that instead of in- 
creasing in intensity, as the stethoscope is moved gradually towards the precor- 
dial region (as it ought to do, if it were the conducted sound of the heart itself), it 
diminishes in loudness, until it is gradually lost in the actual systole of the heart. 
Whereas the second sound heard over the tumour does augment as we get nearer 
the heart, for it is, in truth, the diastolic sound of the heart, and therefore is more 
audible as we approach the point where it is generated. The sounds of aneurisms 



718 



THORACIC ANEURISMS. 



of the aorta are usually audible in the back also; and if a very loud bellows-sound 
be heard there, where the natural sounds, if heard at all, are always much abated, 
that circumstance furnishes a strong additional ground for suspecting the presence 
of an aneurism, or of some great change in the aorta. 

To give you some notion of the course which aneurism of the thoracic aorta 
may run, I will describe another instance of that disease which occurred under 
my own observation. The subject of it supplied the preparation to which I last 
referred. 

He was a stout, healthy-looking man, forty years old, a private coachman. 
He became my patient in the hospital on the 8th of September, 1836. He com- 
plained of pain and tenderness around and above the right mamma. The pain 
was increased by a full inspiration; and when lying on the opposite side, he felt 
as though he was tied in the painful part. 

He had been ill a month only. His illness commenced with severe rigors, 
and fever, and sudden pain in the side, for which he was bled three times with 
much relief. He attributed the attack to having lain, upon his right side, in a 
damp bed. 

There was scarcely any projection at the spot where the pain and tenderness 
were experienced. By careful examination several times repeated, I satisfied 
myself upon the following points. 

On the right side of the thorax no vesicular breathing could be heard ; and the 
whole was dull on percussion. On the left side percussion gave a hollow sound, 
and the respiratory murmur was clear and strong. In the tender spot, an inch 
and half above the mamma on the right side, a strong pulsation could be felt, and 
two sounds were distinctly audible, the first of them keeping time with the pulse 
at the wrist. But there was no bellows-sound. M. Sanson, the celebrated French 
surgeon, was then in London, and went round with me one day, and examined 
this patient; and he expressed his opinion that it was not a case of aneurism, 
because there was no whiz or bellows-sound to be heard. Of course his exami- 
nation was a cursory one, and I mention this circumstance merely to show you 
what importance is attributed to the presence or absence of a bruit de soufflet in 
such cases. M. Sanson suggested that the heart might be displaced, and pushed 
over to the right side. However, it was clear to me that this could not be the 
case, because the breathing was deficient, not on the left, but on the right side ; 
and, above all, because the apex of the heart could be both seen and felt beating 
in its proper situation, in the precordial region on the left side. Also on the left 
side, percussion made on the edge of the ribs gave a tympanitic sound, indicating 
the place of the stomach; on the right a dull sound, pointing out the situation of 
the liver; so that it was not a case of transposition of the viscera, such as had 
been found, not long before, in one of my patients. In the course of the disease, 
a slight bellows-sound did become perceptible over the right mamma, when the 
patient sat up ; but even then the natural sounds of the heart, without any morbid 
quality, could be heard in the natural position of that organ. (Egophony was 
audible at the back part of the right side of the chest. 

This patient had repeated attacks of pain, dyspnoea, restlessness, and inability 
to lie down ; and these attacks were always most sensibly mitigated by the appli- 
cation of leeches to the diseased part. By the 11th of October he was so com- 
fortable that he wished to go out ; and he went to his master's in Connaught 
Place. 

Two days afterwards, he sent to beg that I would go and see him there. He 
had brought up, on the preceding evening, during a paroxysm of coughing, about 
a pint of bright red blood; and he had continued to cough, and to expectorate 
small quantities of blood. I had him again brought to the hospital on the 14th of 
October, where he remained, apparently much the same as before he went out. 
But on the 19th he suddenly expired. The whole duration of his illness had been 
nine or ten weeks. 

We found the heart natural in size and in appearance; the pericardium healthy, 



THORACIC ANEURISMS. 



719 



and containing no more than the usual quantity of serum. All the cavities were 
natural in their dimensions, and in the thickness of their walls ; and all the valves 
healthy, excepting one white spot on the mitral valve, which could not have inter- 
fered with its motions. 

The aorta at its origin was also natural in size ; but it began to dilate just before 
it escaped from the pericardium, and the dilatation continued to the giving off of 
the left subclavian, where the vessel resumed its proper capacity. The arteries 
arising from the aorta did not partake of the dilatation ; but the sac overlapped and 
adhered to the external surface of the innominata, for about a quarter of. an inch 
from its origin. This explained a symptom I omitted to mention, viz.: that the 
right radial artery beat much more feebly than the left. 

The pouch formed by the aneurism adhered in front, for the space of two 
inches, to the inner surface of the third rib ; and close to the edge of this adhesion 
there was a small irregular aperture about two lines in diameter, by which the 
interior of the pouch communicated with the right pleural cavity. Nearly a pint 
of loosely coagulated blood was found -in that cavity, together with a greater 
quantity of serous fluid than could have belonged to the coagulum. Just above 
the adhesion to the rib, the pouch adhered to the substance of the lung, over a 
space about an inch square ; and here the parietes of the artery seemed wholly 
wanting. This, doubtless, had been the channel of the copious haemoptysis a 
week before his death : and it is interesting to observe that the opening of the 
aneurism into the lung was not immediately fatal. The artery was much diseased, 
in the usual manner. The right lung was nearly all of it " carnified" by the com- 
pression it had undergone. 

If this case had not terminated as it did, no doubt the aneurism would have 
made its way outwards through the ribs, as happened in the very remarkable spe- 
cimen before you ; in which you see that the sternum and five of the ribs have dis- 
appeared before the pressure of an aneurism in the ascending portion of the aorta. 
Sometimes, the tumours that form in this manner, project and attain the size of 
the head of a full grown foetus before they burst. 

What can we do in these melancholy cases? Not much. Certain points of 
practice are so obvious that it is almost superfluous to mention them. I mean the 
observance of quiet, and the religious avoidance of every thing likely to excite or 
quicken the circulation : bodily exertion, therefore ; straining of all kinds ; mental 
emotion ; stimulating food and drink. These are not only likely to aggravate the 
"existing mischief, but prove often the immediate cause of the rupture of the aneu- 
rism, and of sudden death. 

I mentioned, in describing the morbid anatomy of aneurism, that when the dis- 
eased vessel began sensibly to dilate, and more especially when it was protruded 
into a sack or pouch, the blood began to coagulate upon the diseased membrane. 
And it continues to do so, from time to time, in successive layers, so that upon 
dividing the aneurismal sac, you will see concentric laminae of firmly coagulated 
blood, This is clearly a strengthening of the weak place — a reparatory and com- 
pensating process analogous to others which we have already had occasion to 
notice. And our object, here as in other cases, must be, not to interfere with the 
natural attempts towards repair, but to assist and promote them, if we can. 

This principle has long been distinctly recognized in the treatment of aneurisms 
that are incapable of relief by surgical means. 

But it is much to be doubted whether the principle, so sound in itself, has been 
judiciously followed out. You have probably heard, or will hear, a good deal of 
Valsalva's and Albertini's mode of treating aneurisms. It was simply that of 
bleeding the patient repeatedly, and keeping him upon as low a diet as was barely 
enough to prevent his perishing of inanition. The object of this plan of treat- 
ment was to facilitate the coagulation of the blood by diminishing its force and 
velocity, in the hope that at length such a solid barrier might be built up and 
organized, as might, in some sort, furnish a new wall to the artery in the dilapi- 
dated part. When this object had had the best chance of being accomplished ; 



720 



DISEASES OF THE VEINS. 



when the patient had been so reduced as to be scarcely able from weakness to 
raise his hand from the bed, to which he was strictly confined ; then Valsalva 
increased his quantity of nourishment by degrees, until the necessary strength was 
restored. 

Now I quite agree with Dr. Copland in thinking that this practice may be car- 
ried, and has been carried, to a hurtful extent. He says that he has seen cases 
44 in which aneurismal tumours had existed for some time without any increase, 
so long as the patient avoided any marked vascular excitement, and continued his 
accustomed diet; but when repeated depletions, and vegetable or low diet were 
adopted, great augmentation of the tumour, and fatal results, soon followed." 

In truth, we shall perceive reason to expect that this would be the case, when 
we consider, first, that the starving system, and the frequent abstraction of blood, 
diminish the quantity of fibrin in that fluid, rendering it more watery, and less 
disposed to coagulate ; and, secondly, that what is called reaction — or a violent pal- 
pitating action of the heart — is very apt to follow repeated losses of blood ; and 
this forcible action of the heart must tend rather to sweep away the existing coag- 
ula, than to cause an additional deposit. 

A more reasonable and hopeful plan of management, therefore, would, in my 
opinion, be one which should keep the action of the heart gentle and moderate, 
and the motion of the blood as slow and languid as possible, without impoverish- 
ing that vital fluid. We should husband the materials of repair, and promote the 
deposit of them where they are wanted. A nutritious but unstimulating diet; 
perfect repose of mind and body ; and a due regulation of the natural functions ; 
with the abstraction of -so much blood only as may be necessary to alleviate pain, 
or to subdue excessive arterial action, or to unload vessels which are manifestly 
oppressed by their contents ; — these, I humbly conceive, constitute the most 
rational means of furthering the endeavours of nature towards a cure. Few cures, 
indeed, can be hoped for in any way. Yet life may be prolonged in these cases, 
by great care ; and the extension of existence even for a month or two, or a week, 
or a day, may sometimes be an acquisition of the greatest moment. 

I have little to say concerning particular drugs. Digitalis may, perhaps, be 
sometimes of use ; and the acetate of lead is well spoken of by those who have 
tried it. I have not had sufficient experience of either of these remedies in the 
treatment of aneurism, to enable me to state any thing to you, confidently, in 
respect to their value. 



LECTURE LXIII. 

Diseases of the Veins. Phlebitis; adhesive, and suppurative : consecutive scat- 
tered Abscesses. Treatment of Inflammation of Veins. Effects of the gradual 
obstruction of large Venous Trunks. 

Yesterday I concluded what I had to say, as a physician, respecting diseases 
of the arteries: and this seems as fitting a time as any for taking a final notice of 
some of the morbid conditions of the veins — especially of their inflammation. 
Already, more than once, brief reference has been made to this important subject: 
important, whether we consider the large amount of mortal disease which it com- 
prehends, or its wide and intimate relation with general pathology. I should 
have done better if I had given you, in an earlier part of the course, a more com- 
plete and connected account of phlebitis, and its consequences. It is this malady 
which gives to many fatal injuries, and to many, nay to most, of the fatal opera- 
tions of surgery, their mortal character: it is of surpassing importance, therefore, 
to the surgeon. The same malady lies at the bottom of the deadliest cases of 
puerperal fever: it is consequently of the deepest interest to the accoucheur. It 



PHLEBITIS. 



721 



occurs also, not seldom, in the practice of the physician, appalling him by its 
insidious, its rapid, and too frequently its resistless course. Moreover, its patho- 
logy, which has been successfully investigated only within these few years, fur- 
nishes a key to that of other morbid conditions of great moment. 

The first effect of inflammation of a vein is to impede, or arrest, the passing 
blood, which, coagulating upon the inflamed surface, adheres to it. In some 
instances the inflamed coat of the vessel is merely (as Mr. Hunter said) furred 
over: in others its channel is completely dammed up. The obliteration of a small 
vein in this manner can seldom have any serious consequence; but much suffering, 
and distress, and even death itself, may result from the sudden and continued 
obstruction of one of the large venous conduits. For example, the painful dis- 
order, called phlegmasia dolens, is caused by a stoppage of the blood in the 
femoral vein. A similar arrest of its current in the sinuses of the brain, is a 
mortal change. 

This adhesive form of phlebitis is a local disease. Whatever ill effects it may 
produce are purely mechanical ; and depend upon the closure of the canal. If the 
organ mechanically affected by it be not a vital organ ; — if the system can await 
the development of a collateral venous circulation ; — all, at length, may end well. 
Sometimes, indeed, as the inflammation gradually subsides, the coagulum is soft- 
ened and partly reabsorbed, the blood drills for itself a fresh passage through the 
centre of the plug, and the circulation is restored in its accustomed channels. 

This is, fortunately, the commoner fprm of phlebitis: but sometimes the in- 
flammation advances beyond the adhesive, and into the suppurative stage. Even 
then the disease may remain a local one. The adhesive process may bound and 
isolate the suppurative in both directions : and an abscess in the part is then the 
usual result. 

But if the suppurating surface of the vein be not so shut off, and pus mingle 
and circulate with the blood, the disorder is no longer merely local. The con- 
taminated blood is conveyed to distant parts, and the whole system tainted. The 
malady has become general, and of the most formidable character. 

It had long been noticed, as a matter of fact, that collections of pus were not 
uncommon in various parts of the body, when death had followed mechanical 
injuries, or great surgical operations. Abscesses in the liver, in particular, were 
known to be associated with mortal fractures of the skull. Very fanciful reasons 
were assigned for this coincidence. By degrees it was ascertained that these 
scattered collections of matter — occurring most commonly in the lungs and liver, 
but not unfrequently in or near the joints also, in the serous cavities, among the 
muscles, in the brain, in the eye, and elsewhere — were connected with the intro- 
duction of some 'vitiating secretion, and especially of pus, into the current of the 
venous blood. 

And this step having been gained, fresh speculations arose, concerning the 
manner in which the internal collections of pus were formed. In the viscera they 
were usually small, well-defined, surrounded by the healthy tissue of the organ, 
and several in number. Some maintained, that the pus, in substance, was carried 
to the parts in which it was found, and there simply deposited. Others were of 
opinion that the tainted blood created in the system a general tendency to inflam- 
mation, which was developed in many places simultaneously. Neither of these 
suppositions was quite true, neither of them quite false. The pus discovered in 
the serous cavities was accompanied by unequivocal traces of inflammation in 
those parts. This alone rendered it probable that the smaller purulent collections 
were not merely dropped there by the blood in its course, (a thing very difficult 
to conceive,) but were the products of actual inflammation, excited somehow in 
those very spots. And it is now believed that these abscesses of as well as in, a 
part, proceed from suppurative inflammation, provoked by the presence of parti- 
cles of pus, brought thither with the circulating blood. 

I told you before, that foreign substances, entering the blood, and failing to pass 
out of it again through the natural emunctories of the body, are liable to be stopped 
46 

\ 



722 



DISEASES OF THE VEINS. 



when they arrive at the first network of capillary vessels that lie in their course. 
Now the blood, circulating in the veins, reaches (much of it at least) in each of 
its circuits, two such great networks, the hepatic and the pulmonary. Through 
the pulmonary network all the blood must pass; through the hepatic some of it ; 
and it is there, in the capillary tissue of these organs, that particles of pus, and 
other material substances, foreign to the blood, and incapable of elimination with 
the customary excretions, are apt to stick, or be entangled, and to excite inflam- 
mation. Some of them, however, in general, pass on, and arriving at the left side 
of the heart, are transmitted, with the arterial blood, to various parts of the body, 
there to exercise a similar deleterious influence. 

Such was, and is, the theory : and it has been tested and confirmed by direct 
experiment. Inasmuch as the conveyance of the pus cannot be traced by the eye, 
nor the manner of its being collected into an abscess demonstrated, except by 
inference, Cruveilhier introduced quicksilver into the veins of animals ; a metal 
which is liquid, and divisible into very minute particles, and which exerts no 
chemical agency upon the vital fluid. When the mercury was inserted into the 
veins which concur to form the vena portae, the whole, or the greater part of it, 
was arrested in the liver. In that organ, the animal being killed a certain^ime 
after the introduction of the metal, small, roundish, red spots were always dis- 
coverable, which passed gradually into little abscesses surrounded by a halo of 
inflammatory redness ; and in the centre of each red spot, and of each abscess, lay 
a minute globule of mercury. A few similar points of suppuration were usually 
to be seen in the lungs also* But when the quicksilver was put into the blood in 
its direct course towards the vena cava, then it was in the lungs that these points 
were either exclusively detected, or at any rate most numerous. 

You must, I think, perceive how strictly these experiments bear upon the 
rational humoralism acknowledged at the present day. If pus, and mercury, may 
thus be distributed to particular organs, and thus excite circumscribed inflamma- 
tion, so doubtless may other extraneous impurities — -introduced by the poison of 
what is called good living, by the respiration of foul air, and in various other ways 
— reach and settle in different parts of the body (the liver, the lungs, the kidneys, 
the joints), and there produce, if not inflammation and pus, yet such changes at 
least as spoil the texture of the organ, and pervert its healthy office. That cancer 
is propagated in this way we have heretofore seen reason to believe. In all proba- 
bility the deposition and increase of tubercles fall under the same law. There is, 
however, this remarkable difference between tubercles and phlebitic abscesses, that 
the former occupy chiefly the upper portions of the lungs, while the latter are 
generally most numerous in their lower lobes. 

Suppurative phlebitis — with all its horrible effects — is liable to arise, not only 
after severe but also after slight injuries; from the trivial as well as the grand ex- 
ploits of surgery; nay, spontaneously, as it were, without any local hurt, under 
the agency of natural causes, such as exposure to cold. And the part in which 
the phlebitis occurs has some influence, as you will now understand, in deter- 
mining the principal seat of these scattered abscesses. When they succeed ampu- 
tation of a limb, or fracture of the skull, or the interference of surgery with 
varicose veins, or (as they may) even the simple operation of phlebotomy, they 
are likely to be most numerous in the lungs. But they are more conspicuous to 
hasty observation in the liver than in the lungs ; and that is why hepatic abscess 
was supposed to have some special connection with injuries of the head. Mor- 
gagni, however, long ago pointed out the fact, that other parts also were affected 
in those cases. Again, we may expect to find these disseminated abscesses 
chiefly in the liver, when suppurative phlebitis occurs in any of the tributary veins 
of the vena portae : when it supervenes, therefore, upon operations on the bladder 
or on the intestines — operations for the removal of stone, for the release of hernia, 
for healing fistula in ano, for the cure of piles. 

It is, however, very common for the poison to pervade the whole body, and for 
abscesses to form in various other situations, as well as in the lungs and liver. I 



PHLEBITIS. 



723 



once saw a young woman die, in the Middlesex Hospital, from phlebitis, with 
large abscesses in many parts, and especially in the joints, after the simple exci- 
sion, with scissors, of some small spongy irritable growths about the orifice of her 
urethra. 

Two or three instances of suppurative phlebitis, unconnected with any known 
hurt, and originating apparently in exposure to cold, have fallen under my own 
observation: but I prefer giving you the following short case, with the details of 
which I have been favoured by Dr. Maiden, of Worcester. 

Miss , a teacher in a Ladles' School, was attacked, after exposure to 

wet and cold, with acute pain, heat, and redness, in the front of the left forearm. 
Mr. Cole, an eminent surgeon, of Bewdley, by whom she was at first attended, 
discovered inflammation following the course of the cutaneous veins. Upon its 
subsidence the veins were left like hard cords. Soon after the right arm was 
affected in a similar way: and next, both the lower extremities, which became 
anasarcous. All this was attended with paroxysms, simulating those of tertian 
ague; exhausting sweats, diarrhoea, and a frequent feeble pulse. At the end of a 
month, deep-seated fluctuation was detected in the right thigh, three inches below 
Pou part's ligament. The abscess gradually approached the surface, and was 
opened, and more than three pints of very fetid pus were discharged. The 
wound never closed, and she sank, exhausted, a month after it was made. 

There was no pain, premonitory or attendant, connected with this formation of 
matter. 

The abscess was traced, after death, upwards, behind the muscles of the 
pelvis, as far as the sacro-iliac symphysis, where the bones were extensively 
carious. 

Many of the superficial veins, both of the upper and lower extremities, were 
found to be completely obliterated by adhesive inflammation, or sealed up by coa- 
gula of blood. 

This spreading and morbiferous inflammation of veins is sometimes so remark- 
ably prevalent, as to partake of the character of an epidemic disorder: and this, 
its occasional prevalence, appears to be owing to some peculiar condition of the 
atmosphere — or rather to some predisposition of the human body, engendered by 
the operation of influences which are probably atmospheric. During such periods 
prudent men refrain, if they can, from the performance of surgical operations. 

The view which I have now set before you of suppurative phlebitis, and of its 
distant effects, involves some apparent difficulties, and some curious questions. 
A short consideration of these may serve to throw a clearer light upon the main 
subject. 

First, then, how is it — if indeed the disseminated abscesses result from the 
introduction of pus into the blood — how is it that we do not meet with them 
oftener? Pus is absorbed, in numberless instances, without the occurrence of 
any such formidable consequences. We see great abscesses disappear sponta- 
neously, and yet no other smaller scattered abscesses ensue. Does not this fact 
invalidate the theory of the cause and formation of such distant points of suppu- 
ration? No. It seems, that for their production, pus as such, pus in substance, 
pus in the mass, must be received into the veins, and circulate with the blood. 
The pus which is taken up by ordinary absorption, is altered, probably, by that 
process, before it reaches the blood: at any rate it has not the same mischievous 
and fatal effect. 

You may here inquire in what manner pus gets into the circulation, in conse- 
quence of an amputation ? Is it not absorbed from the suppurating stump ? I 
conceive not. Supposing the amputating knife to cross and sink into an existing 
abscess, and to divide a vein — then, indeed, pus might be sucked into the vein, 
and the usual consequences follow. But the veins that lead to, or rather from, a 
stump, become blocked up, and impervious, from adhesive inflammation, or from 
mere coagulation and adhesion of the blood in them, before the stump has had 
time to suppurate. How then does the pus ever find admission ? No doubt it is 



724 DISEASES OF THE VEINS. 

a product, in this case also, of phlebitis. The interior of a vein inflames, and 
goes on to suppuration; and the pus which it pours forth mingles, as pus, with 
the circulating stream. * 

Indeed these scattered abscesses appear to originate always in phlebitis. Such 
is the opinion of my colleague, Mr. Arnott, who has contributed a valuable paper 
on this subject to the Medico- Chirurgical Transactions. Such is also the opinion 
of M. Cruveilhier. It has been objected that, in some fatal cases of this kind, no 
phlebitis could be detected : that the principal veins have been diligently traced, 
yet no vestige of suppuration, nor even of adhesive inflammation, has been visible. 
To make this objection valid, all the veins throughout the body should be scru- 
tinized ; and that has seldom, I fancy, been done. I have known several instances, 
in which most of the larger trunks were searched in vain, till at length, a short 
tract of one of them, an inch or two perhaps, was found, bearing marks of having 
been inflamed. You must not conclude therefore against the antecedent existence 
of phlebitis, until you have examined every vein in the soft parts of the body: no, 
nor even then. You must go deeper than the more obvious veins. There is good 
reason for believing that the bones and their veins are often the seat of the primary 
mischief, the fountain from which the pus, which thus renders the blood a poison, 
first proceeds : the veins, for example, of the diploe of the skull, when scattered 
abscesses ensue upon injuries of the head; the veins of the bones of the extremi- 
ties after unsuccessful operations. There is yet another explanatory supposition 
applicable to some cases. All local traces of the primary inflammation may 
vanish before death, while the vital powers are being undermined, and about to 
sink under its secondary effects. 

Cruveilhier repeatedly performed the following experiment, and always with 
similar results. He introduced crude mercury within the hollow shaft of the 
thigh bone of a living dog. When the quantity was considerable, death occurred 
in a few days, and the metal was found strewed thickly through the lungs, each 
globule occupying a capillary branch of the pulmonary artery, and surrounded 
by a small sphere of inflammatory redness. When the quantity was minute, the 
animals lived longer, and little abscesses, enclosing each a particle of mercury, 
were then discovered in the same organs. The mercury he supposes to have 
found a direct entrance into the blood, in these cases, from the cancellous portion 
of the bone : and through the same channel it seems to be that pus often enters 
the circulation. You may remember my relating some fearful examples of scat- 
tered abscesses, supervening upon chronic disease of the bones of the ear. Cru- 
veilhier states that having been present at the examination of the body of one 
who had sunk after amputation of the leg, and whose lungs were full of little 
abscesses, he sought, without success, for some inflamed vein : but upon dividing 
the tibia and fibula, he found the spongy extremities of these bones infiltered with 
pus. Here, beyond question, had been the source of the visceral mischief. 

The local phenomena, when a superficial vein of some magnitude is inflamed, 
are pain and tenderness in the course of the vessel, which, in the adhesive variety 
of the complaint, is soon converted into a tangible, hard, and sensitive cord. 
Whether the vein be near the surface or deeply seated, there is usually more or 
less (edema of the areolar tissue of the part. Phlebitis of this kind has been 
sometimes confounded, I believe, with inflammation of the lymphatic absorbent 
vessels. You distinguish the latter by the slenderness of the painful cord; by its 
position, which is still more superficial than that of a subcutaneous vein ; by the 
number of little knots which diversify its course; and by the streaks and patches 
of bright inflammatory redness which appear along the same track. Dr. Graves 
Temarks (Clinical Medicine, p. 454), that inflammation of the lymphatics "is 
seldom continuous, but is developed at certain insulated points." 

In the suppurative form of phlebitis the general symptoms take the lead. The 
formation of pus in separate and often distant parts is rapid, and frequently unan- 
nounced by any local pain. When, however, the joints, or parts near the joints, 
are the seat of suppuration,- much soreness is complained of, and the malady is 



PHLEBITIS. 



725 



liable to be mistaken for rheumatism ; and when the serous cavities are implicated, 
the pain is sometimes severe. Suppurative phlebitis is commonly attended in its 
progress with repeated shiverings, and with profuse sweats, and occasionally with 
copious and very unnatural discharges from the bowels. These last have been 
noticed in animals soon after the introduction of pus, or of putrid matters, into 
their veins. Nature seems to attempt to eliminate the poison in this way : and 
where the quantity of pus so introduced has been small, the attempt is now and 
then successful. But in general there is a continual supply of the noxious sub- 
stance, and the system is irrecoverably infected. Typhoid symptoms occur in 
most cases, but not in all. Very constantly there is great agitation, and a marked 
disturbance of the nervous system. 

I have called this purulent infection of the blood a formidable disorder : in truth 
it is almost always a fatal disorder. Yet that it is not inevitably mortal I know 
by a case which has recently occurred in Mr. Arnott's practice at the Hospital, 
and which he permits me to mention. He had occasion to amputate the forearm 
of a man whose hand had been crushed by machinery. Two or three days after 
the operation, the patient's pulse quickened, and he had a severe rigor. These 
two circumstances led Mr. Arnott to apprehend the supervention of phlebitis ; and 
accordingly one of the large, superficial, visible veins of the forearm became 
swollen, hard, and tender. Leeches were applied along. its course; and the parts 
were kept covered with the water dressing. In no long time an abscess formed 
in the other arm ; next, a large one in the back, from which twenty ounces of pus 
were evacuated ; then one beneath the glutei muscles of the buttock, on both 
sides — each of these two contained about sixteen ounces. In short, dating between 
the beginning of October and the middle of December, no less than seven col- 
lections of matter presented themselves in various places. The last of them was 
in a very unusual part, beneath the man's tongue, in the ordinary situation of 
ranula, for which, indeed, it was at first mistaken. In every instance the pus 
was let out as soon as possible, and the main feature in the general treatment was 
the administration of opiates, and of wine, with a liberal allowance of good beef- 
tea in the earlier stages, and of meat afterwards. This man recovered ; and was 
seen in the month of May following, in perfect health. The case is extremely 
Interesting. It shows, I say, that suppurative phlebitis, even when it dissemi- 
nates consecutive inflammation and suppuration throughout the body, is not abso- 
lutely and hopelessly fatal. Whether abscesses, from this cause, distributed in 
the lungs or liver, are capable of repair, I cannot tell you. Under the treatment 
employed, the inflammation of the vein in the arm gradually subsided. All out- 
ward evidence at least of its existence, all induration even, disappeared ; and pre- 
sumptively all inward evidence too. So that had this patient sunk, late in the 
course of his disorder, under the multiplied secondary abscesses, his venoug 
system might probably have been searched in vain for any remaining traces of 
phlebitis ; and yet we know that at one time he had phlebitis, more severe and 
extensive than belongs to the natural and kindly healing of every stump. 

The treatment found most suitable in phlebitis has just been briefly indicated; 
local depletion when the inflamed vein is accessible ; regulation of the bowels ; 
strong animal broths and wine to support the strength. Our object is in the first 
place to subdue and resolve the inflammation ; or at any rate to prevent its passing 
beyond the adhesive stage. To this end, the vein being obvious and superficial, 
we apply leeches, cold lotions, or fomentations. During the progress of the 
malady, especially when suppurative phlebitis is prevalent, it would be unsafe to 
cut into a large vein, lest by that slight violence we establish a fresh local phle- 
bitis. Indeed, after the suppurative form has once been set up, general blood- 
letting does no good; but, on the contrary, impairs the power of the system at, 
large to struggle against the disease.. 



726 



DISEASES OF THE VEINS. 



The obliteration of a large vein, whether by adhesive phlebitis or in any other 
way, is perilous in proportion to its magnitude, and to the rapidity with which its 
complete occlusion has been effected. The gradual stoppage of even the largest— 
the primary venous trunks, the venae cavae — admits of some degree of compensa- 
tion. In one instance of this kind, which I briefly described yesterday, and which 
I myself witnessed, the superior cava was flattened, and its channel completely 
effaced, by the pressure of an aneurismal tumour: in another, which I mentioned 
formerly, on Mr. Kiernan's authority, an immense varix of the superficial veins 
of the abdomen supplied to the returning blood the passage denied to it, in its 
natural course, by the partial obliteration of the inferior cava. To impress upon 
your recollection the ordinary phenomena that result from these grave derange- 
ments in the hydraulic machinery of the body, I will state here, from my hospital 
case-book, the outlines of two additional examples of a similar character. 

James Buck, aged thirty-three, was admitted on the 8th of March, 1838. The 
appearance of this man was very remarkable. His countenance was swollen and 
livid ; his eyeballs projected ; his lips, the end of his nose, and the rims of his 
ears, were of a deep purple colour. It was manifest that the blood did not freely 
descend from the head. Further evidence of this became apparent when the trunk 
of his body was uncovered. The throat was very full and tumid, like that of a 
goitrous person, yet the swelling was not owing to enlargement of the thyreoid 
gland, nor to oedema ; but felt firm and fleshy. The jugulars were distended; 
and the whole surface of the thorax in front, with that of the shoulders, and of 
part of the abdomen, was thickly overspread with a network of prominent veins. 
The external mammary veins were seen to communicate freely with veins pro- 
ceeding from the neck on each side, with the veins of both the upper extremities, 
and with the epigastric veins from beneath. Here and there were patches of 
minute purple varicose branches, crowded closely together. 

He told us that whenever he stooped down, to tie his shoe-strings, for instance, 
he became giddy, his head swelled, and his face and ears grew black: that he 
was very nervous, easily flurried, and dreamed much, thinking that he was flying 
in the air, falling down precipices, and the like. He had not noticed any swelling 
of the face or throat until three weeks previously ; and he had never, he said, had 
a day's illness before. He knew of no cause for the complaint ; had been making 
no extraordinary bodily effort ; had never suffered rheumatic fever. He professed, 
also, temperate habits, but he had been a soldier, and afterwards a pugilist, and 
his wife informed me that he had led an irregular life. 

The evidence I say was strong, of some obstruction to the return of the blood 
through the superior cava. Now such obstruction is most commonly produced 
by intrathoracic tumours — sometimes by carcinomatous ; much oftener by aneu- 
lismal tumours. There were no circumstances to make it likely that malignant 
growths existed; but there were circumstances which corroborated my first sus- 
picion, that the symptoms were dependent upon aneurism of the aorta, or of one 
of its primary branches. 

There was indeed no external prominence, no pulsative or other swelling, no 
aneurismal whiz, to guide us to this diagnosis. Upon careful and repeated aus- 
cultation of the chest, the murmur of respiration was found to be in some parts 
feeble and unequal. This might consist with the presence of any kind of tumour. 
The heart's action was heard r and felt, strong and heaving, in the proper place, 
beneath the left nipple. To the right of the sternum also, and near the middle of 
its upper portion, one's ear was distinctly jarred at each systole of the heart, 
though with less force than in the precordial region. But in the space interme- 
diate between these two spots, no such jarring sensation was perceptible, although 
the heart could be heard, beating with a slight bellows-sound. Moreover, the 
right radial artery was considerably weaker and smaller than the left. This 
showed that the innominata was interested in the disease. The symptoms, taken 
together, left no doubt on my mind that there was an aneurismal pouch beneath 
Ihe sternum, where the jar was experienced. I have gone somewhat into parti- 



OBLITERATION OF VEINS. 



727 



culars to show you how confidently sometimes, by close observation, you may 
pronounce upon the condition of parts which you can neither see nor touch. 

All that could reasonably be hoped for from medicine, was postponement of the 
evil day. To relieve the oppressed blood-vessels by taking away part of their 
contents, by freely purging the patient, and by setting his kidneys to work — this 
was what was to be attempted ; and this was done. He was repeatedly cupped, 
and always with most sensible relief to his feelings, the blood flowing copiously. 
Purgatives and diuretics also acted well ; and so much was the man benefitted by 
these measures, that twice he left the ward, and became an out-patient. 

About the middle of June a new symptom arose — severe pain extending from 
the right collar-bone across the shoulder. He died on the 10th of July. Three 
or four days before his death, he had rigors and extreme dyspncea, complained of 
pain over the whole thorax, and declared that his " heart seemed on fire." These 
symptoms were caused by the supervention of pericarditis, which proved speedily 
fatal. A thin layer of recent, reticulated lymph was found covering a considerable 
extent of the surface of the heart. 

The body was examined by Mr. Shaw, after injection of the veins, and of the 
thoracic duct. 

There was a large aneurism of the arteria innominata; of which I omit all par- 
ticular description, my present object being to draw your attention to the state of 
the veins. The two great trunks that, coming from either side, unite to form the 
vena cava superior, were completely closed up, as well as the corresponding por- 
tion of the cava itself, which was lost and confounded in the walls of the aneurismal 
sac. The subclavian veins were pervious up to the point where they joined the 
internal jugulars, but no further. The preparation of these parts, which is before 
you, and the rough diagrams which I here exhibit, will aid your comprehension 
of the mode whereby the blood descending from the head, found its way at length, 
through many circuitous channels, to the heart. The larger deep-seated com- 
pensating veins were not greatly magnified, but the number of the smaller branches 
was much augmented. The vena azygos, for example, was very little above its 
usual size ; yet it was apparently provided with a greater number of considerable 
branches than are commonly observed under natural circumstances. 





A, Obstructed veins. 

B, Seat of the right auricle. 

C, Thoracic, pectoral and mammary veins convey- 

ing the blood in a contrary course to its usual 
direction, and anastomosing with the intercostal 
and epigastric veins. 



DISEASES OF THE VEINS. 



As the veins into which the trunks of the absorbent vessels discharge their con- 
tents were obliterated, it became interesting to examine the state of these vessels, 
and of the lymphatic glands. But the condensation and confusion of all the parts 
around the tumour rendered it difficult to trace the thoracic ducts. The glands 
were remarkably large, of a purple colour, and gorged with bloody serum. The 
fulness of the neck, noticed during life, was occasioned by this tnrgescence of the 
glandulse concatenate. Large glands were seen studding the walls of the aneu- 
rism, and adhering to the great vessels connected with it : i. e., in situations where, 
under ordinary circumstances, such glands, from their minuteness, can scarcely 
be detected at all. 

With this case, contrast the following : — 

Harriet Baldwin, thirty-three years old, was admitted, December 29, 1840, 
anasarcous as high as the hips, and with an enlarged abdomen. The swelling had 
begun, she said, a fortnight before. 

She complained of cough, and of expectoration, which was sometimes tinged 
with blood. She could not lie down in bed for dyspncea. Her urine was scanty 
and dark-coloured. 

She told us she had dropsy, quite as bad, five years ago, of which she was cured 
in St. Bartholomew's Hospital. 

All this we learned in the admission-room. The next day, when she was in 
bed, we learned a good deal more. 

The large abdomen did not owe much, if any, of its bulk to ascites. It con- 
tained a palpable tumour, filling the right hypochondrium, and extending thence 
far beyond the umbilicus to the left, and into the right groin. This tumour, from 
its situation, and from the continuous dullness elicited by percussion from the right 
mamma downwards over its whole extent, was evidently formed by the liver, 
much enlarged, and out of its place. 

But besides the tumour, the abdomen presented on its surface a very singular 
appearance. Two zig-zag lines of large, varicose veins ran up its middle, near 
the right edge of the linea alba. These, which were evidently the epigastric 
veins, inosculated above with the mammary. Large, but straighter veins, wan- 
dered over the front of the thorax on both sides. 

The swollen legs of this woman were quite purple from innumerable clusters 
of small varicose veins. 

Other symptoms also there were, but I pass them by as irrelevant to my 

present subject. It was plain that the current 
of the blood along the vena cava inferior was 
suffering impediment. That vessel was pre- 
sumably compressed, perhaps rendered totally 
impervious, by the superjacent tumour. The 
existence of the tumour; the great oedema of the 
legs, compared with the slight amount of liquid 
in the cavity of the belly ; the varicose state of 
the cutaneous veins of the legs ; and, above all, 
the remarkable condition of the superficial veins 
of the abdomen: — these were the evidences. 
The blood from the lower extremities passed 
mainly by the way of the intercostal and subcla- 
vian veins, to the heart. Death took place on 
the 19th of January, 1841. A part of the liver 
appeared perfectly healthy, another part con- 
tained a prodigious quantity of hydatids. When 
removed from the cyst which had contained 
them, they filled a large wash-hand basin. The 
sides of the inferior cava were pressed together by the tumour, and its channel 
was thus completely closed up for the space of three inches. 

In each of these two cases,, the closure of the great venous trunk was gradually 




ASTHMA. 



729 



effected, as the compressing tumour augmented; and time was afforded for the 
development of collateral supplementary channels. In both cases the superficial 
veins of the thorax and abdomen contributed largely to supply the growing needs 
of the system : but the stream of returning blood ran oppositely in the two cases ; 
from' above downwards in the first, from below upwards in the second. The 
direction in which the blood in the veins is moving can, of Course, be always rea- 
dily ascertained; and this might furnish a test, were other tokens wanting, 
whereby to determine whether the obstruction lay in the superior or in the infe- 
rior cava. And there is another circumstance worthy of remark, and of which 
the same use might be made. In the first case, the dilated veins of the thorax 
were tortuous, those of the abdomen direct. In the second this was reversed; 
the epigastric veins were singularly sinuous, the mammary veins were straight. 
In other words, those veins were, in each instance, contorted and winding, in 
which the actual course of the blood was retrograde. The vessels were bent and 
twisted as the current forced its backward way against the opposing but ineffec- 
tual barrier of the valves. 

It is impossible, I think, to find more clear evidence than these interesting cases 
exhibit, of the power inherent in the animal body of rectifying, to a certain ex- 
tent, its own accidental derangements. You cannot, under such circumstances^ 
overlook the existence, or mistake the tendency, of a vis medicatrix natures. 




LECTURE LXIV. 



Asthma : its nature ; complications ; exciting causes ; and treatment. Dis- 
eases of the Oesophagus : Inflammation; Stricture; Spasm; Dilatation. 

I must not leave the subject of thoracic disease without saying a word or two 
respecting asthma; a complaint which might have been properly arranged among 
the nervous spasmodic diseases, in a former part of the course. But I purposely 
deferred speaking of it, because, though in many instances purely spasmodic, 
and independent of any discoverable faulty structure, it is still more often con- 
nected with organic diseases of the heart, or of the lungs ; which diseases had 
not then been described. 

I scarcely need caution you against the vulgar error of calling all kinds of diffi- 
cult breathing by the name of asthma. You will be constantly meeting with per- 
sons who, labouring under some permanent embarrassment of the respiration, 
tell you they are asthmatic. They conceive that asthma is simply an inconve- 
nient, and not at all a dangerous affection : and they please themselves with the 
notion— -consumptive patients and their friends do this continually-— that they are 
merely asthmatic. Asthma is dyspnoea, but dyspnoea is not necessarily asthma. 

Asthma may be defined as being — great difficulty of breathing: occurring in 
paroxysms ; accompanied by a loud wheezing sound of respiration ; going off, 
after some hours, with more or less mucous expectoration ; and unattended with 
fever. And these paroxysms of dyspnoea are believed to depend upon a spas- 
modic constriction of the bronchial tubes. 

To go rather more into detail : the phenomena which constitute and charac- 
terize a fit of asthma, are somewhat as follows : — The patient, if he have pre- 
viously suffered under the disease, has usually some well-understood warnings 
that an attack is hanging over him. Loss of appetite ; frequently much flatulence 
and eructation : languor, irritability, drowsiness, oppression, chilliness ; and he 
goes to bed ill and uncomfortable. The dyspnoea comes on generally after mid- 
night, about two or three o'clock in the morning ; often during sleep ; and the 
patient wakes with a sense of tightness and constriction about the chest, and an 
inability, as it seems to him, freely to expand it. He is obliged at once to rise 



730 



ASTHMA. 



up; and he sits, leaning forwards, with his knees drawn up,Jiis elbows on his 
knees, and his head supported by his hands, labouring for his breath, and making 
such a loud wheezing noise as to be audible at a considerable distance. He ex- 
periences a strong desire or necessity for fresh air: opens the door of his room 
and goes out upon the stair-case, or flies to an open window, even in very cold 
weather: and remains there, with his head out, sometimes for hours. That he 
can do so with impunity is a strong presumptive proof that it is the nervous sys- 
tem which is principally affected in these cases. His extremities at the same 
time are usually cold, and his countenance is distressed and haggard: while the 
trunk of his body may be wet with perspiration. Sometimes the face is a little 
flushed and turgid : but more commonly, it is somewhat pale, and shrunk. The 
pulse is often small, feeble, and even irregular; and in many instances there is 
much palpitation of the heart. At other times the pulse remains undisturbed. 
If urine be passed, as it frequently is, at the beginning of a fit of asthma, it is 
copious and watery, pale, and without smell, like the urine of hysterical women. 
The bowels are also sometimes relaxed, with " something (as Dr. Forbes ob- 
serves) of the impatient hurry and imperfection of spasmodic action." There 
may be some propensity to coughing, but the patient can hardly achieve a cough; 
and is so occupied with his breathing, that he can speak in an interrupted manner 
only, with difficulty and uneasiness. He has not, however, in general, any mis- 
givings about the event of the attack, but looks forward with hope to the expected 
termination of the paroxysm. 

" These symptoms often continue for many hours together; and particularly 
from midnight till morning is far advanced. Then, commonly, a remission takes 
place by degrees. The breathing becomes less laborious, and more full; so that 
the person can speak or cough with more ease. And if, as is usually the case, 
the cough brings up some mucus, the remission becomes immediately more con- 
siderable, and he falls into a much-wished-for sleep." 

Paroxysms of this kind will often continue to recur for many nights in succes- 
sion : remitting at length in their severity; and ceasing for a period, altogether. 

During the intervals between these paroxysms, in the day-time, the patient may 
be perfectly well ; but he seldom is so; though so great is the difference between 
his condition during the remissions, and in the paroxysms, that he declares, and 
perhaps fancies, that he is quite well. You will mostly find, however, that he is 
short-winded ; that he does not utter many words of a sentence before he pauses to 
take breath; that slight bodily exertion hurries his respiration ; and that he is not 
easy in a horizontal posture, with his head low. 

Although the dyspnoea is thus intermittent, or remittent, you are not to suppose 
that the paroxysms recur with the regularity of those of ague. The interval is 
of uncertain duration ; and the circumstances of the paroxysm differ in different 
instances. I may remark also, .that when the paroxysm ceases with little or no 
expectoration, the case is said to be one of dry asthma ; when expectoration is 
copious, it is humid, or humoral asthma. 

Now this, I say, is looked upon as being essentially a spasmodic affection. 
Upon what grounds ? 

Why, in the first place, .the patients have a sensation of constriction in the chest. 
An old gentleman whom I saw lately, and who is subject to fits of asthma, made 
use of the term cramp when he described what he felt about the thorax ; and his 
attacks were always accompanied or succeeded by actual cramp of the muscles 
of the calves of his legs. This is no uncommon circumstance, this co-existence 
of decided spasm in other parts ; and it throws some light upon the nature of the 
disorder. Again, the rapidity with which the dyspnoea comes on, and the sudden- 
ness with which it often abates, resemble the caprice of spasm. The supervention 
of extreme, sometimes enormous flatulence, and the secretion of hysterical urine, 
mark also the nervous character of the symptoms. So likewise do the juvantia 
and the Isedcntia, as I shall presently explain further; the affection being suddenly 
produced by certain causes of irritation, and even by mental feelings— suddenly 



/ 



ASTHMA. 



731 



relieved, sometimes, by medicines which are reckoned antispasmodic. If we add 
to these considerations the fact that patients dead of asthma have often, on being 
examined, presented no vestige whatever of disease, either in the lungs or in the 
heart, we obtain very strong presumptive evidence, that the phenomena attending 
a fit of asthma are often the result of pure spasm. 

But if this be so, what are the muscles thus fixed in spasmodic contraction ? 

You are doubtless aware that the air-tubes are encircled with a series of little 
fibres, or bundles of fibres. I have more than once shown you these, exaggerated 
by hypertrophy, in the larger bronchi. They have been traced, by Reissessen, 
in tubes of a very small diameter. Laennec states that he had distinguished them 
in bronchial ramifications less than one line across. Now, supposing these cir- 
cular fibres to be muscular, it becomes at once, and a priori, likely that they, no 
less than other muscles, should be liable to spasm. And the phenomena of 
asthma prove, to my mind, that they are so. Analogy would say that the fibres, 
thus disposed, are slender muscles, similar to those which surround the intestines 
and the urinary bladder : and the microscope, scrutinizing their minute texture 
and appearance, asserts that they are actually muscles, of the unstriped kind ; like 
other involuntary muscles subserving the organic life. This fact — which I know 
has been doubted — I state upon the authority of Professor Todd and Mr. Bowman ; 
both known to you all as faithful and expert observers. But a test, less fallible than 
the microscope, has practically settled the question. Dr. Williams has recently 
demonstrated, by a set of ingenious and satisfactory experiments, that the lungs 
and air-tubes are actually contractile to a very considerable degree, under electri- 
cal, chemical, and mechanical stimuli. The contractions take place steadily and 
deliberately ; and are followed, as soon as the stimulus is withdrawn, by an equally 
gradual relaxation. This is very like tonic spasm. The contractions were ren- 
dered apparent by means of a bent glass tube, containing coloured liquid, and 
adapted to the wind-pipe of an animal just deprived of life. The column of liquid 
in the glass tube would of bourse be readily movable by any contraction of the 
lungs and air-tubes, causing pressure of the included air against it. In one of the 
experiments, "on passing a galvanic current from the margin of the lungs to the 
insertion of the tube in the trachea, the fluid rose quickly, but gradually, nearly 
two inches; sunk speedily on breaking the contact; again rose upon completing 
it; but fell slowly when the current was continued for some seconds ;" i.e., when 
the irritability of the tissues was temporarily exhausted. Temporarily, I say, for 
on waiting two or three minutes between each application of the galvanism, the 
liquid was raised again and again for upwards of an hour; till, in fact, the organic 
life was extinct. Is not all this exceedingly like the behaviour of parts acknow- 
ledged to be muscular, under similar influences? 

The phenomena were not occasioned by any general shrinking of all the pul- 
monary tissues. For when the lungs were cut across by sharp scissors, at right 
angles to the air tubes, and the open sections of these tubes were galvanized, they 
were seen to contract to one half of their former diameter; and even to become 
smaller than that. The contraction was the most distinct in the middle-sized 
tubes, being about the bignesss of a straw : but it was sensible enough in the 
trachea, which was sometimes so far reduced in dimensions, that the ends of its 
cartilaginous rings came together. 

A foreign experimenter, M. Valentin, carries us a step nearer to the full solu- 
tion of this interesting question. He found that the rings of the trachea could be 
made visibly and distinctly to contract, by irritating the par vagum. 

Upon the whole, we may safely conclude that asthma is one of the spasmodic 
disorders of the excito-motory system of nerves. I believe, moreover, that, as in 
most other disorders of the same class, the spasm may be of centric, or of eccen- 
tric origin. In the eccentric form, the par vagum is doubtless the afferent nerve; 
and the impression it conveys to the medulla oblongata is reflected, through asso- 
ciated motor nerves, upon the bronchial muscles. The centric variety results 



732 



ASTHMA. 



from a similar impression originating in the nervous centres : which respond, 
mysteriously, to certain feelings of the mind. 

I have never had a favourable opportunity since I became aware of the value 
of auscultation, of listening to the sounds of the breathing during a paroxysm of 
pure spasmodic asthma. But they who have enjoyed such opportunities declare 
that no respiratory murmur, or very little indeed, can be heard. And an attentive 
inspection of the outside of the chest shows, that amidst all the tugging and heav- 
ing for breath, the expansion of the thorax is very limited. The patient cannot 
open his lungs as it were : and what air does get in, has a difficult and narrow 
passage, as the wheezing noise demonstrates. Laennec affirms, that if the patient, 
after holding his breath nearly as long as he can, attempts a quiet and gentle inspi- 
ration, the spasm may often be overcome as if by surprise ; and, for a few seconds, 
the entrance of the air into the cell may be heard in a clear and even puerile sound. 
If this be true, it is a strong additional proof that the obstruction to the admission 
of air was really owing to a tonic contraction of the little muscular fibres of the 
bronchi and their ramifications. 

The hereditary nature of asthma is perfectly consistent with the same theory. 
It is one of the maladies which are distinctly transmitted — the disposition to them, 
I mean — from parents to children. And like other spasmodic disorders, it facili- 
tates its own return. When it has once occurred, it seldom fails to happen again 
and again. 

But though I believe, for the reasons I have now mentioned, that asthma, in 
the restricted sense of that term, is purely a spasmodic affection ; yet I know also 
that it is very frequently indeed combined with organic alterations within the 
thorax. These changes of structure are to be regarded as so many strongly pre- 
disposing causes. They induce a readiness to take on spasmodic action : and 
some of them are perhaps aggravated, or even produced, by the fits of asthma, 
upon which they afterwards react injuriously. Judging from my own experience, 
I should say that genuine uncomplicated spasmodic asthma was rare. 

The organic diseases with which spasmodic asthma is often found connected, 
are .principally emphysema of the lungs, and structural changes in the heart and 
great blood-vessels. It is extremely probable that the first step towards the pro- 
duction of the spasm, consists in some altered condition of the circulation through 
the lungs. The chilliness of the surface, and the sensation of want ef air, make 
it likely that the blood accumulates in the lungs at those times : that there is con- 
gestion of the membrane, as well as spasm of the circular fibres. And it would 
seem that, in the humoral asthma, the congestion is relieved by a copious secre- 
tion of mucus ; and that, with the congestion, the spasm also subsides and disap- 
pears. You will observe that very generally the paroxysms come on during the 
first sleep : at which time, as Dr. Alison has suggested, " the blood is perhaps 
in fullest quantity, its movements slow, and its congestion in internal parts easiest, 
because it is least solicited to the organs of sense or locomotion." But there 
seems to be another reason for this remarkable circumstance. Respiration is 
mainly an automatic act; yet it also obeys the will. During sleep this moderat- 
ing influence of the will is suspended. Those changes of posture, and those 
voluntary alterations in the rate of breathing, which are wanted to balance and 
correct the commencing derangement of the pulmonary circulation, and which 
are prompted at once during the waking state, do not occur: until at length the 
derangement reaches that pitch at which it provokes spasmodic contraction, and 
rouses the sufferer. 

This same congestion, leading to spasm, sometimes passes into a slight form 
of inflammation ; and we have symptoms of bronchitis. And these symptoms 
may remain manifest even during the intervals of the paroxysms. It appears 
probable also that the vesicular emphysema of the lungs, which so often accom- 
panies asthma, is increased by the paroxysms, even if it be not, in all instances, 
originally induced by them. In either case, there will be some abiding dyspnoea 
between the fits. 



ASTHMA. 733 

Many of these asthmatic patients have just healthy lung enough to breathe 
with, in tolerable ease and comfort, under ordinary circumstances ; and dyspnoea 
is brought on whenever even a slight additional demand upon the respiration any- 
how arises. Hence, as I stated before, flatulent distension of the intestines, undue 
repletion of the stomach by an excessive meal, the recumbent posture, all of which 
cause pressure against the under surface of the diaphragm, may suffice to bring 
on the fit. Hence, also, probably, in part, its frequent occurrence in the night- 
time. 

In like manner, any extraordinary task imposed upon a heart which is barely 
equal to its functions while the body is in repose, may induce a paroxysm of 
asthmatic dyspnoea. 

Asthma is a disorder which is incident to both sexes, but it is much more common 
in men than in women. It is incident to all ages also ; but it belongs more to 
adolescence, and to the middle portion of life, than to its extremes. It is not, I 
think, a common disease prior to the age of puberty : yet instances of it do occur 
at an earlier period than that. I have lately seen a boy of eight or nine, who has 
had several well-marked attacks of pure asthma. Nor does it often begin to show 
itself in old age. Sometimes, after plaguing the subject of it for several years, it 
leaves him altogether. The chronic dyspnoea, with occasional irregular exacer- 
bations, which is. so frequent a disorder among old people, and which always 
depends upon organic disease, is not to be confounded with true asthma. It is 
said that asthmatic persons are exempt from phthisis: and I understand that one 
physician in this town, who announces that consumption is curable, maintains 
the doctrine of the incompatibility of phthisis and asthma; and endeavours to 
bring about the latter, that he may protect his clients from the former. It may 
be that persons affected with genuine asthma seldom become the victims of pul- 
monary consumption : but I am sure the rule is not universal. One of my earliest 
friends had from time to time, while we were school-fellows, and long afterwards, 
the most exquisite fits of spasmodic asthma. At length, when he was between 
thirty and forty years old, they wholly ceased : whereupon he greatly congratu- 
lated himself. But they only yielded before a worse disease. He began, in a few 
months, to spit blood : and in a few months more he died of well-marked phthisis. 
Our lamented principal, the late Mr. Rose, afforded another sad example of the 
same sequence. And I have known two or three families in which one individual 
was subject to asthma, while others were scrofulous and phthisical. 

The exciting causes of the asthmatic paroxysm are manifold ; and some of them 
curious. They seem to be reducible to two classes. 1. Particular states of the 
atmosphere, which irritate or offend the mucous surface of the air-passages ; or 
rather, some of the fibrils of the par vagum. 2. Certain subtle influences which 
affect in a peculiar manner the nervous system. All the known exciting causes 
of catarrh are therefore likely to bring on attacks of asthma in the predisposed. 
But there is a singular caprice in asthmatic patients in this respect. Some per- 
sons, subject to the disorder, are unable to breathe in the thick smoky air of Lon- 
don ; require a high and clear situation; and respire easiest in " the difficult air of 
the keen mountain-top." Others can nowhere breathe so comfortably as in low 
moist places : in some of the streets by the water-side in the city, for instance. 
The friend to whom I lately alluded lived at Newmarket ; a most exposed and 
bleak spot. But if he left it, and attempted to sleep in a strange place, he never 
was certain that he should not be assailed in the night by his well-known enemy. 
So that there were towns in which, after experiencing the effects of their atmo- 
sphere, he dared not sleep ; and there were others in which he knew he might go 
to bed in security. It would have been difficult, I believe, to point out any essen- 
tial difference between some of those localities. His lungs, however, formed an 
infallible eudiometer. Another college acquaintance of mine, much tormented by 
asthma, is equally sensible to these inscrutable influences. Two inns in Cam- 
bridge are named respectively the Red Lion, and the Eagle. He can sleep in one 
of them, and not in the other. Nay he is thus variously affected within much 



-c 



734 



ASTHMA. 



narrower limits. He assures me that, when in Paris, he never escapes a fit of 
asthma if he attempts to sleep in the back part of Meurice's Hotel, and never 
suffers if he sleeps in a front room. Dover Street suits him ; Clarges Street does 
not. He cannot rest in Manchester Square. This he attributes to its being built 
upon piles. Whether it really has such a foundation I do not know. And 
agencies still more slight and subtle are enough to set the springs of these seizures 
in motion. The mere absence of light, for instance. Laennec speaks of a man 
who invariably was roused from his sleep by a paroxysm of asthma, if his lamp 
was extinguished ; or if his chamber-door was shut. The consciousness that 
the customary preventive remedy was not at hand, has, apparently, brought on a 
fit. 

There are many persons who never fail to become asthmatic if they inhale 
certain effluvia. Particles of ipecacuan floating in the atmosphere, or (what is 
perhaps the same thing) its mere odour, are insupportable to many. They are 
thrown into a paroxysm of dyspnosa if they enter an apartment where that drug 
is under preparation. I think I mentioned before a certain laboratory-man at St. 
Bartholomew's Hospital who possessed this peculiar and inopportune suscepti- 
bility : he was obliged to fly the place whenever ipecacuan was about. Most 
persons, probably, who have had much experience in druggists' shops, are ac- 
quainted with similar examples : so that the influence of ipecacuan in exciting fits 
of difficult breathing, resembling asthma, is undoubted, and common to many 
constitutions. We might as well speak of ipecacuan asthma, as of hay asthma, 
which is a precisely analogous affection. Dr. Marshall Hall calls attention to the 
familiar but interesting fact, that the same 4rug, ipecacuan, acting upon the gastric 
branches of the par vagum, excites the reflex spasmodic act of vomiting. 

I have said, that the relief afforded by antispasmodic remedies affords pre- 
sumptive evidence of the spasmodic nature of these attacks. If asthma supervene 
upon manifest bronchitis, or if there be any signs of congestion about the head, it may 
be prudent to abstract blood : but this measure will not in general be requisite, and 
when not requisite it should be avoided : for whatever tends to debilitate the patient, 
or to lower his vital powers, tends, at the same time, to augment his susceptibility 
to the exciting causes of the disease. The dyspnoea may frequently be moderated 
or altogether assuaged by some form of narcotic. Now opium is the narcotic to 
which we most trust for the mitigation of spasm in general: and opium is of vast 
service in paroxysms of asthma. But there is also another of the vegetable nar- 
cotic substances which has obtained an especial repute for its effect in quieting the 
difficult breathing in these cases ; and that is stramonium. This herb, the datura 
stramonium, and another species of the same genus, the datura ferox, had long 
been employed in India as a remedy for asthma. And when it was introduced 
into this country, about the beginning of the present century, it was cried up as 
a specific ; and every body who called himself asthmatic began to smoke stramo- 
nium : for that is the way in which it has been chiefly employed. The leaves 
and stalks are cut and put into a pipe, and smoked like tobacco. The smoke de- 
scends of course, into the lungs : and when the saliva is swallowed, the remedy 
is introduced into the system in that way also. 

Stramonium thus used, sometimes fails altogether: sometimes calms the parox- 
ysm like a charm. The late Dr. Babington told me of a patient of his who had 
been grievously harassed for a series of years, by asthma, but who declared to 
him, after he had made a fair trial of stramonium, that he no longer "cared a fig" 
for his asthma; which he could always stop in a moment. So a Mr. Sills, in a 
collection of communications relative to the datura stramonium, published in 
London in 1811, states, that he had been a great sufferer from asthma: that the 
fits usually continued, with short interruptions, from thirty-six hours to three 
days and nights successively ; during which time, he had often, in the seeming 
agonies of death, given himself over, and even wished for that termination of his 
miseries. But having at length discovered the virtues of stramonium, he uses 
this strong language: — "In truth, the asthma is destroyed. I never experienced 



ASTHMA. 



735 



any ill effects whatever from the use of the remedy ; and I would rather be with- 
out life than without stramonium." 

This, then, is an expedient which it will always be well to suggest, for reliev- 
ing the urgent distress of the paroxysm of asthma. But most patients subject to 
that complaint, try it of their own accord. We have still to learn why it is so 
efficacious in some cases, and so entirely useless, or even hurtful, in others. This 
probably depends something on the presence or absence of organic disease in the 
lungs or heart : but more accurate observations are wanted on this point. 

Some of the animals upon whose lungs Dr. Williams performed his experi- 
ments, had been killed by poison. In two instances stramonium was .the poison 
employed; and it is interesting to know that scarcely any contraction of the air- 
tubes could be produced by the galvanic apparatus. The trachea, at the same 
time, was lax. It is requisite to notice the condition of the wind-pipe in these 
experiments ; for the same want of contractility would be apparent, supposing 
the parts to be already in a state of tonic spasm, from the operation of the poison. 
This seems to have been the case when conium was used: the fluid in the glass 
tube indicated scarcely any compression of the air contained in the lungs ; but 
then the wind-pipe was so far contracted, that the extremities of its rings met. 
There was but little contractility, and a lax trachea, after death by belladonna; 
and after death by the meconate of morphia. The contractility was slight when 
life had been destroyed by strychnia; but the condition of the trachea is not 
reported. 

Experiments of this kind appear to be well worthy of careful repetition. 

I have found a mixture of opium and sulphuric aether of great service in tran- 
quilizing the breathing in asthma. And in one case, which was under my care 
for some time, I made comparative observations respecting opium and stramonium. 
Both gave much relief ; but stramonium the most, and the most certainly, if it were 
applied in time. This patient was in the habit of being roused from sleep by the 
supervention of the paroxysm : and if he had the means of lighting his pipe 
instantly, he could stave the fit off. But when once it had attained its full inten- 
sity, he was unable to smoke. Under such circumstances, he would swallow the 
morphia and aether ; and the effect of this depended also in a great measure upon 
the period at which it was taken. It would stop a commencing paroxysm; but 
had little influence over one that was fully formed. 

It has been suggested, as one clue towards determining the particular kind of case 
to which the stramonium is applicable, that it succeeds if it produces expectoration ; 
and not otherwise. But I doubt about this. The relief is sometimes too sudden 
to admit of its being so explained. Dr. Forbes quotes the following passage of a 
letter from an old and intelligent asthmatic to himself. "Smoking tobacco or 
stramonium is sure to give relief, if it produces expectoration ; and it will gene- 
rally do so if, the moment I awake (i.e. in the incipient paroxysm), I begin to 
smoke, and continue to do so for three or four hours. Smoking, I am able to say, 
after fifteen years' practice, and suffering as much as mortal can suffer and not 
die, is the best remedy for asthma if it can be relieved by expectoration. I have 
been in the hands of all the doctors of the place for fifteen years; and still I say, 
smoke," 

The lobelia inflata has of late been much lauded for its beneficial operation upon 
dyspnoea of all kinds, and upon asthma in particular. I believe its virtues have been 
overrated. It sometimes, like stramonium, has an almost magical effect; but 
frequently it fails to do the smallest good ; and I know that sober practitioners 
who have employed it more than I have, have thought that it may occasion dan- 
gerous symptoms. Of my own knowledge, I have nothing worth communicating 
to you of this drug. 

Strong coffee is a common domestic remedy for asthma. The friend and school- 
fellow already mentioned used to take it in considerable quantities, and, as he as- 
sured me, with very great benefit. It is a safe, and simple, and grateful remedy, and 



736 



DISEASES OF THE (ESOPHAGUS. 



has numerous testimonies from medical practitioners in its favour. But it is much 
less sure than the stronger narcotics. 

Ipecacuanha, which is so frequently the cause, has also been recommended for 
the cure of asthma; and a host of drugs besides, with which I have no intention 
to weary you. Among the rest, the application of galvanism was once in great 
vogue. In the only patient who ever tried it under my own eye,-— and he insisted 
upon being galvanized when his fits were quite absent, — the galvanism brought 
one on immediately. 

If we can shorten or mitigate the paroxysms we do our patient a most essential 
service, and spare him a great deal of suffering. And during the intervals be- 
tween the fits, we must endeavour to prevent their recurrence. 

For this purpose, I can only just hint at the principle on which we should go. 
In the simple form of the complaint, when it is apparently uncomplicated with 
any organic disease, we must caution the patient against whatever has a tendency 
to disturb the general health. He must be temperate in all things; he must pay 
attention to the regulation of his digestive organs ; he must discover what kind of 
situation suits him best; and avoid those which experience has shown to disagree 
with him. And if any one remedial measure be likely to fortify him against his 
malady, I believe that measure will ofienestbe found in the shower-bath, employed 
in the way which I formerly recommended. 

If the asthma occurs in connection with any obvious pulmonary or cardiac 
disease, we must, in addition to the means I have now been adverting to, apply 
ourselves to the mitigation of such superadded disease. And in respect to this I 
have nothing more to offer. 

I go next to the morbid conditions of the oesophagus, so far as they concern 
the physician ; and these morbid conditions are not many. The oesophagus lies 
partly in the chest, and partly in the belly, and therefore may very properly close 
the subject of thoracic diseases, and introduce those of the abdomen. 

The oesophagus is less liable to disease than any other part perhaps of the ali- 
mentary canal. It differs in structure somewhat (as you know) from all other 
parts. Its mucous membrane is provided with a thick epithelium, which extends 
a little beyond the cardiac orifice of the stomach. Beneath lies a dense web of 
areolar tissue, and two layers of muscular fibres ; the one layer being disposed 
circularly around the tube — the other longitudinally, in the direction of its axis. 
In some cases there are pouches found in the sides of the oesophagus, formed 
apparently by a kind of hernia of the mucous membrane, between the separated 
fibres of the muscular coat. These are not common, however, and scarcely worth 
mentioning, except that their existence has been supposed to have a possible con- 
nection with a curious phenomenon, peculiar to some persons ; the power, viz., 
of ruminating ; the power of bringing into the mouth again, by a voluntary effort, 
food which has been for some time swallowed, as cows, and the rest of the rumi- 
nantia do. There are but few individuals of the human species who possess this 
faculty; there are but few who have appendices to their oesophagus. Whether 
the phenomenon in question belongs to these last few has never been determined; 
but as the possible connection of the two circumstances has been suggested, it is 
well for you to be aware of it, that you may refute or verify the notion in case 
you ever have the fortune to examine the dead body of a person who had the 
power of ruminating. 

The covering of cuticle protects the oesophagus from the injurious influence of 
matters passing over it, which might otherwise be hurtful. The morbid state for 
which we are most often consulted is stricture, actual or spasmodic. I believe 
that the oesophagus is very little subject to inflammation, except from mechanical 
violence or chemical injury. I have seen a few cases, however, in which I infer- 
red a spontaneous inflammatory condition of the tube, from the symptoms com- 
plained of ; which were a sense of heat and pricking exactly in the course of the 
oesophagus, and felt between the shoulders, and precisely in the part (the patients 



DISEASES OF THE (ESOPHAGUS. 



737 



said), where a potato, swallowed too hot, gives pain while it is descending into 
the stomach. With these symptoms there was some degree of dysphagia, not 
explained by any thing visible in the throat or pharynx : and some degree of 
fever. In all the instances of this kind that I have met with, the symptoms have 
yielded in a few days to abstinence, purgatives, and the application of leeches 
along the track of the oesophagus. 

This part of the alimentary canal often suffers severe injury from the degluti- 
tion of certain poisons, especially the corrosive poisons ; the strong mineral acids, 
for example; or the caustic alkalies. We have, in the museum of the college, 
some very interesting specimens of the effects of these destructive substances. 
Sometimes, when the quantity of the poison has been small, and its transit rapid, 
the cuticular lining alone of the gullet is destroyed. It is shriveled up, broken 
into fragments, abraded. At other times, the subjacent textures are affected, and 
ulceration takes place, which at length heals, and leaves a permanent, and gene- 
rally a progressive constriction of the oesophagus : and sometimes the whole of 
.the internal membranes slough away, and are discharged in one continuous tube, 
from the mouth ; and yet the patient survives for some time. My colleague, Dr. 
Wilson, had a case of that kind. The patient, a young woman, swallowed about 
a tablespoonful of oil of vitriol. A week afterwards, she brought up, during a 
paroxysm of choking cough, a complete cast of the gullet, with ragged ends ; or 
rather the gullet itself. Some of the muscular fibres of the oesophagus were 
plainly visible on the outside of this tubular slough, in its recent state. She lived 
eleven months afterwards, swallowing all that time with difficulty and pain, and 
subsisting on slops and soft food. Yet at one period she certainly gained flesh. 
After her death, the channel, as it remained after the injury, was taken out and 
examined. They are both before you; — the original slough, and the ultimate 
gullet. The latter was formed by a surface which consisted of an irregular 
cicatrix. The tube was contracted considerably in the lower two-thirds of its 
course. 

When patients have suffered inflammation and ulceration of the oesophagus 
from these causes, and do not perish at the time, they are very liable indeed to 
have their existence abridged by the occurrence of stricture of the gullet, which 
goes on slowly increasing, until no food can pass it, and then, of course, the 
patient dies of starvation. I show you here an (esophagus taken from a man 
whose case I had opportunities of observing from the beginning. He was under 
the care of Dr. Macmichael, in the Middlesex Hospital. He was brought there 
in November, 1830, having swallowed, half an hour before, a solution of the 
impure carbonate of potass, which had been made for the purpose of cleaning- 
paint, and which he had mistaken for beer. Not more than a tablespoonful 
passed the fauces, and probably none of the poison reached the stomach. He 
suffered severely, and was in considerable peril for several days, in consequence 
of inflammation of the fauces and epiglottis ; but this gradually subsided, and he 
went out apparently well. From what I knew of the result of such cases, I ven- 
tured, however, to predict that this man would, sooner, or later, come back with 
stricture of the oesophagus. He had always pointed out a spot about half way 
down the sternum, where he said the oil of tartar had caused him extreme pain, at 
the very first, and below which he had not felt it. 

Accordingly, I was not surprised to see the poor fellow at the hospital in Feb- 
ruary, 1834, attending as an out-patient. He came there, he told me, because in 
eating some soup, he had accidentally swallowed, without chewing it, a piece of 
carrot, which lodged in its way down, and which it became necessary to push 
onwards into the stomach by means of a probang. Morsels of food had stuck in 
the same spot before ; and it was the very spot where he telt the effects of the 
caustic at the time of the accident. He looked tolerably stout and healthy ; but 
said that, since swallowing the potass, he had never been the man he was before. 

He continued to make his appearance, from time to time, at the hospital, with 
similar symptoms, till the 5th of last December (1836), when he was brought 



738 



DISEASES OF THE (ESOPHAGUS. 



there insensible, and evidently dying. We could obtain no satisfactory account of 
his recent symptoms. He had the mark of a blister, however, on his left side ; 
and upon closely examining him it was plain that that side was full of fluid. It 
was perfectly motionless in respiration ; it was palpably larger than the right side ; 
it yielded everywhere a dull sound on percussion ; and no vesicular breathing 
whatever could be heard there by the ear. The respiration on the right side was 
puerile ; and the beating of his heart, with a systolic bellows-sound, was audible 
on the right of the sternum. 

Although I was certain that the left pleura was full of liquid of some kind, I 
did not have the thorax punctured : because, in the first place, he was manifestly 
in articalo mortis, and I thought that his death, which was certain, might be 
attributed to the operation ; and secondly, because he w-as not dying of suffoca- 
tion. His breathing was not laborious or much distressed; but he was dying of 
coma, and his extremities were already cold, and his pulse was fluttering. I con- 
jectured that an ulcer of the oesophagus had made its way into the pleura, and 
caused inflammation there. But my conjecture was wrong. 

I will mention the main particulars of the examination of the dead body, be- 
cause the case was, in several respects, an interesting one. 

There was a considerable quantity of serous fluid in the meshes of the pia 
mater, beneath the arachnoid ; and there was some liquid of the same kind in the 
lateral ventricles. No other diseased condition could be detected in the brain. 
The effusion was sufficient, supposing it to have come on suddenly, to explain 
the coma. 

I had the ribs sawn away on the right side, leaving their cartilages attached to 
the sternum ; and then we saw plainly that the heart and mediastinum were 
thrust over, about four inches by measurement, beyond the mesial line on the 
right side. The body was on its back. It was easy to perceive how a pleura 
thus full of fluid must oppress the lung of the other side, especially when assisted 
by the force of gravity. The left cavity was distended by a grayish-coloured and 
most offensive fluid, of the consistence of gruel; the pleura pulmonalis was 
covered by a layer of coagulable lymph; and the lung was flattened against the \ 
vertebral column. We could not discover any communication between the cavity 
of the pleura and the oesophagus or air-tubes. 

About the middle part of the oesophagus there was a distinct stricture, occupying 
about half an inch of the tube. Through this portion it was impossible to push 
one's little finger ; which elsewhere found a loose and ready passage. 

In this case, the man did not die of the stricture ; but he would have done so, 
had not another disease carried him off. I do not know why the constriction, 
after it has once taken place, should go on continually increasing; yet it seems to 
be so. In his Surgical Observations Sir Charles Bell mentions three cases like 
that just described. In one of them, where soap-lees had been the substance 
swallowed, death took place by starvation from stricture of the gullet, twenty 
years afterwards ; and Sir C. Bell had no doubt that the stricture originated in the 
chemical injury inflicted by the soap-lees. 

When the symptoms of stricture come on in these cases, physic can do almost 
nothing. Surgeons pass bougies into the gullet, and attempt to dilate the striclured 
portion, or to prevent any further narrowing. But this expedient is usually of 
temporary benefit only ; and the patient dies at last of inanition. His miserable 
existence may perhaps be protracted a little, by injecting nutritive enemata into 
the rectum. Sometimes the oesophagus ulcerates through, and a communication 
is formed between it and the neighbouring parts. 

But the oesophagus, like the urethra, and like the bronchial tubes, — like every 
canal, indeed, in the living body that is surrounded by circular muscular fibres, — 
is liable to temporary constriction and closure, by the spasmodic action of its own 
muscles ; and this affection is, of course, a far less formidable one than the last. 

Patients who are subject to spasmodic stricture of the oesophagus experience 
occasionally, in some point or other of that tube, a sensation as if there were a 



DISEASES OF THE (ESOPHAGUS. 



739 



knot; or sometimes a feeling as if some solid substance was ascending from the 
stomach towards the pharynx. If they happen to be then engaged in eating, the 
morsels of food, after mastication, readily pass the pharynx: but, at a certain 
distance down the gullet, they stop, and occasion pain which is felt between the 
shoulders, or distinctly in the passage itself. Great anxiety and distress accom- 
pany this stoppage : and the food is often rejected by a reversed action of the 
CBSophagus. 

The symptoms, in fact, are identical with those which result from permanent 
stricture of the gullet, except that they are not permanent. When the stricture is 
organic and abiding, the symptoms occur during or after every meal. When it is 
simply spasmodic, they come and go, capriciously, we often cannot conjecture 
why or wherefore ; after the fashion of other spasmodic ailments. 

Spasmodic stricture may be independent of any disease of structure in any part 
of the body ; but it is of some importance to be aware that it may* also be symp- 
tomatic of very serious organic changes. Mr. Mayo relates the case of a young 
man " who had difficulty of swallowing; he could get down liquid food only ; and 
that not without an effort. A bougie being introduced, some resistance was found 
at the upper opening of the oesophagus, but it yielded : the resistance was spas- 
modic, and depended upon neighbouring irritation caused by ulceration in the in- 
terior of the larynx. The use of the bougie for a few days, with appropriate re- 
medies to the larynx, removed the dysphagia." 

The purely spasmodic cases occur principally in persons of a movable con- 
stitution : in young women whose uterine functions are deranged, and who are 
liable to hysteria. The remedies for hysteria will prove remedies for the spasm 
of the oesophagus also. And whatever is calculated to excite ordinary hysterical 
symptoms, whatever tends to render the system w r eak and irritable, will tend to 
aggravate the oesophageal stricture. I alluded to such eases in a former lecture. 
I give you another, related by Sir Benjamin Brodie. A lady consulted him, 
unable to swallow the smallest morsel of solid food; and swallowing liquids not 
without great difficulty. The symptoms had been coming on upwards of three 
years. A full-sized oesophagus bougie being introduced, entered the stomach 
without meeting the slightest impediment. This lady's faee was pale and 
bleached: her feet were ©edematous. She had long laboured under internal piles, 
from which repeated discharges of blood had taken place. Under the use of 
remedies which relieved the piles and the bleeding, the difficulty of swallowing 
went away. 

It is a singular, and it might, if more frequent, be a puzzling circumstance, that 
very nearly the same symptoms which occur when the oesophagus is permanently 
or temporarily constricted, happen also sometimes under a totally opposite con- 
dition of that tube; I mean its dilatation into a large, inelastic, inert bag. One 
remarkable example of this I witnessed in a woman whom I attended in conjunction 
with Mr. Mayo, some years ago, in the Middlesex Hospital. The case has been 
fully described by Mr. Mayo, in the third volume of the Medical Gazette; and more 
briefly in his Outlines of Pathology. She was thirty-three years old. She was 
brought to the Hospital in a state of extreme feebleness and emaciation. They 
who brought her said that for the preceding month she appeared to keep down 
nothing. What she took as food seemed to her to stop in the gullet; and, after a 
few minutes, it returned. A large oesophagus bougie passed readily into the 
stomach. She could swallow liquids more easily than solid food. When she 
took a small quantity, it did not feel to her as if it reached the stomach ; and in 
three or four minutes it was invariably rejected. The vomiting was not preceded 
by nausea, although in its progress it had the appearance of ordinary retching. 
She craved for food and drink, and seemed literally starving. The complaint had 
begun ten years before, during her pregnancy, and had gradually got worse. The 
belly was so shrunk that the umbilicus was not more than an inch distant from 
the spine. There was no enlargement nor hardness about the stomach; no par- 



740 



DISEASES OF THE (ESOPHAGUS. 



ticular tenderness on pressure of the epigastrium ; nor any uneasiness there. She 
died, utterly extenuated, sixteen days after her admission. 

The stomach was found small, and contracted at its middle to the breadth of an 
inch and half. The upper part of the duodenum was but half the ordinary size 
of the ileum. The oesophagus I show you, turned inside out. 

It is enlarged to an extraordinary degree of dilatation, as you perceive. It was 
healthy, and of its natural size, at and near each extremity. Intermediately the 
lining tunic was thickened and opaque, with numerous depressions in it. The 
muscular fibres, which appeared to have multiplied with the expansion of the 
canal, were of their natural colour and thickness. 

Here is another preparation: a dilated oesophagus with cancerous degeneration 
of the cardiac orifice of the stomach. I do not know its history ; but the me- 
chanism of such dilatation is intelligible enough. The food, unable to pass out 
of the gullet into the stomach — or passing slowly and uncertainly — the tube be- 
hind it is habitually distended, and loses at length its proper contractility. I saw 
last summer, in consultation with Mr. Mayo, an old gentleman, of seventy, who, 
for two years, had experienced difficulty in getting food into his stomach. He 
would eat a few mouthfuls very well ; and, then, of a sudden, the next mouthful, 
after passing the pharynx, would stop just short of the stomach ; and a sensation 
of swelling would arise in the lower and middle part of the oesophagus ; and pre- 
sently up the mouthful would come again. Sometimes, by waiting quietly a little 
while, the morsel would go on ; sometimes he could wash it forwards by a gulp 
or two of drink : but if once the food got fairly into the stomach he had no further 
irouble with it. This gentleman had no discoverable disease of the heart or lungs. 
He gradually grew worse. At last he began to vomit grurnous matters, resem- 
bling coffee-grounds, and soon died. He was at some little distance from London 
at the time, and the body was not (I believe) examined. I have no doubt that he 
had malignant disease of the cardia; and I think it probable that his oesophagus 
-was dilated. I had a female patient about two years ago in the hospital with very 
similar symptoms ; and her stomach was found to be full of cancerous disorgani- 
zation. The state of her gullet is not recorded. We are apt, in such cases^to 
satisfy ourselves with ascertaining the gastric disease, without carefully examining 
that part of the alimentary canal which lies above. 

For maladies like these medicine has no cure. Opiates may give comfort, and 
promote the euthanasia: and that is all.* 

* [During the period of infancy the mucous membrane of the oesophagus is not nnfrequently 
the seat of inflammation, of a diphtheritic, follicular, or erythematic character. The disease, 
however, is not very often detected during the life-time of the patient, in consequence of 
the symptoms by which it is accompanied being those which are common to many of the 
.affections of the earlier months of existence. In fact, almost the only symptom in many 
cases of oesophagitis in the infant is frequent vomiting; — immediately after the deglutition 
of drinks j or of aliments of any kind, these are discharged by vomiting, without having 
undergone any change. The infant usually refuses the breast and fluids generally, evi- 
dently from the pain excited by the act of deglutition; occasionally, however, he will swal- 
low, without much difficulty, half solid aliment when given in small quantities at a time. 
-If the stomach be affected with inflammation at the same time with the oesophagus, the 
undigested food and drinks discharged by vomiting, will be, occasionally, mixed with the 
morbid secretions of that organ. The disease is seldom attended by any degree of febrile 
excitement — The infant is, usually, fretful and restless, and becomes rapidly emaciated. 
Whenever an infant rejects the breast, or any species of fluid aliment, vomits frequently, 
and discharges whatever he swallows in the same state nearly as when it was taken, it is the 
duty of the practitioner to institute a minute examination in order that he may detect the 
inflammation of the oesophagus if it exists. It is probable that pressure along the whole 
track of the oesophagus will excite the cries of the child, when we can have no hesitation 
as to the diagnosis. If this does not happen, we may nevertheless be tolerably certain as 
-to the existence of the inflammation, if the infant be labouring at the time or has very re- 
cently been labouring under one or other of the forms of stomatitis. If the inflammation is 
confined entirely to the mucous membrane of the gullet, and is not aggravated by improper 
food or drinks, it will often subside, after a few days, spontaneously; but when it is con- 
nected, as is very generally the case, with inflammation of the stomach or intestines, it is an 



DISEASES OF THE ABDOMEN. 



741 



LECTURE LX V. 

Diseases of the Abdomen ; sometimes difficult to identify. Method of investi- 
gating these diseases ; by the eye, the hand, the ear. Inflammation of the 
Peritoneum* its symptoms; and causes. Puerperal Peritonitis. Peritonitis 
from Perforation. ' <" 

I am about to consider the diseases of the abdomen. The organs contained ia 
this cavity of the body are not vital organs in the same sense in which the brain, 
the heart, and the lungs, are vital. That is to say, the functions of the abdominal 
viscera will bear to be suspended for some considerable time, without the extin- 
guishment of life. But these /parts are subject to numerous diseases, some of 
which are apt to be quickly fatal, and others carry with them a vast amount, and 
very severe kinds, of suffering. 

The parietes of the fore part of the belly being soft and flexible, you miglU 
naturally suppose that the physical morbid conditions of the organs they covei* 
would submit themselves to an easy diagnosis.; that the sense of touch, exercised 
through these yielding walls, would detect alterations of bulk, of form, or of place, 
in the subjacent viscera, with much facility and exactness. But the truth is, that 
since the discovery of the method of auscultation, the diseases of the abdomen are 
much more hard to discriminate than the diseases of the thorax. The reason of 
this is to be fouiid in the number and complexity of the parts contained in the 

affection difficult to control, and usually fatal. In perhaps the majority of cases, oesophagitis 
in the infant is preceded by erythematic, diphtheritic, or follicular stomatitis. 

The frequency with which inflammation attacks the mucous membrane of the oesophagus 
in the infant, is evidently due to the predisposition which exists, at this period, to disease of 
all the mucous surfaces from their constant state of hyperemia; it is liable to be excited by too 
much or improper food, or that which is too hot or stimulating. In infants confined to the 
breast, it may be occasioned by the bad quality of the mother's milk, or by some temporary 
morbid change occurring in the latter — and which maybe produced by a variety of causes. 
Oesophagitis has been known to result from the reprehensible nursery practice of admin- 
istering to infants, infusions of spices or even gin and water, for the purpose of expelling 
wind, or to relieve the colicky pains with which they are so frequently affected. — In 
common with all the affections of the mucous membrane in early life, inflammation of the 
oesophagus occurs most frequently, and is the most difficult to manage in infants exposed 
to the baneful influence of personal and domestic filth, and a confined and impure air. 
According lo Billard, the affection of the gullet is almost invariably preceded by stomatitis — ■ 
particularly, we may add, of a diphtheritic or follicular character. 

The pathological changes detected after death in cases of oesophagitis, are stated by 
Billard, to be vivid- redness, with destruction of the epithelium, of some portion of the mu- 
cous membrane of the oesophagus, especially of its upper portion; in some cases, a curd- 
like exudation, more or less extensively diffused is present; in others follicular ulcerations; 
a separation of portions of the epithelium, often in large shreds, is occasionally met with; 
numerous red or dark-coloured striae occurring where the epithelium is not destroyed; large, 
irregular eschars of a black colour, with intervals of deep, bright-red excoriations are occa- 
sionally met with, and, in some cases, gelatinous softening of nearly the entire thickness, 
of the oesophagus. 

When an infant is affected with oesophagitis there should not be given to it any simu- 
lating or hot drinks — k will be proper, however, to supply it, at short intervals, with a 
small quantity of some perfectly biand mucilaginous fluid, as gum water, or an infusion of 
the pith of sassafras, or of the inner bark of the slippery elm, given cold; the throat should be 
covered externally with a soft, emollient poultice, especially when the inflammation of the 
oesophagus has succeeded to stomatitis; — a few grains of calomel may also be administered, 
and followed by injections of milk with the addition of sugar. If it be found necessary, the 
strength of the infant may be supported by injections of milk and broth, or milk with rice 
Sour, tapioca or arrow root. We have derived advantage in cases presenting the symp- 
toms of oesophagitis, from a few leeches applied along the sides of the neck, and internally 
a teaspoonful, every three hours, of a solution of four grains of the acetate of lead in one 
&unce of water, with the addition of a few drops of strong vinegar, — C] 



742 



DISEASES OF THE ABDOMEN. 



abdomen ; the loose manner in which some of them are packed ; and the conse- 
quent readiness with which they pass out of their proper and natural situations. 
It is necessary that I should say a few words, but I shall not detain you long, 
respecting the mode of examining the abdomen, with the purpose of investigating 
its diseases. 

In the description of symptoms, we are often obliged to speak of particular 
portions of the abdomen: and it will be of future convenience to us if we make 
ourselves acquainted, at starting, with such a superficial map, marking out the 
topography of the belly, as I exhibited to you sometime since, in reference to the 
chest. Draw ~a horizontal line round the body, touching the extremity of the 
ensiform cartilage ; and this will form the superior boundary of the abdomen, thus 
roughly defined for practical purposes. Draw another such line round the body, 
horizontally, touching the lower edge of the last false ribs: and a third touching 
the crest of each ilium. We then have three horizontal zones formed. These 
must be further divided by vertical lines: one on each side from the anterior 
spinous process of the ilium perpendicularly upwards. Each zone will thus be 
subdivided into three regions. The middle region of the upper zone is the 
epigastric region; on either side are the hypochondria. The middle region of 
the middle zone is the umbilical region ; the iliac regions or the flanks lie to the 
right and left of it. The hypogastric region is the middle region of the lower- 
most zone ; and the inguinal regions are contiguous to it. This is all the division 
which is necessary. 

Now independently of the general signs of diseases that have their seat in the 
abdomen, we are greatly assisted in many cases by the physical signs. I shall 
take a very brief survey of the modes by which these physical signs are collected. 
They are derived from the exercise of the three senses of sight, of touch, and of 
hearing. 

The sense of sight supplies, occasionally, very valuable information ; and in all 
serious and equivocal cases we must not dispense with its use. We are not, 
indeed, to make an ocular inspection of the naked abdomen unnecessarily : and I 
hold it superfluous to admonish you that when we do avail ourselves of that mode 
of investigation, especially in the case of females, we are bound to do so with the 
most careful attention not to offend the patient's delicacy. W e may sometimes 
ascertain all that is required concerning the movements, size, and shape of the 
abdomen, without removing the under garments. 

This rule applies, indeed, to all parts of the body that are ordinarily covered by 
the dress. 

I was lately consulted by a lady, who told me she had, on the rear of her per- 
son, a painful boil. She thought any physician ought to be competent to prescribe 
for a boil, without wanting to see it. But she seemed very ill, and her sister told 
me that the boil had lasted a fortnight, and was a very large one ; so that I was 
obliged to press for an inspection. And I found — a boil sure enough, but of that 
gigantic and formidable species which we call carbuncle. 

M. Rostan relates a case still more in point. Going round the wards of his 
hospital, he came to an old woman, who was complaining of severe pain in the 
abdomen, towards the left iliac region. Her face was flushed, her skin hot, her 
pulse strong and frequent, her tongue dry ; and she was very thirsty. The abdo- 
minal pain was exasperated by pressure, and by the movements of the patient. 
Upon these data Rostan founded his diagnosis. He concluded that the case was 
-one of acute abdominal inflammation; and he prescribed accordingly; and with 
befitting energy. One of the pupils, however, lingered behind him : and having 
'removed the woman's chemise, in order to examine the seat of the pain, he dis- 
covered that all the symptoms proceeded in reality from a very harmless, though 
troublesome, disorder, herpes zoster; what is vulgarly called the shingles. 

Vestis adempta est, 
Qua posita, nudo patuit'cum corpore crimen. 

In the second place, we gather very important intelligence by the sense of 



PERITONITIS. 



743 



touch. We learn the existence and the size of tumours; we approximate to a 
knowledge of their nature, whether it be solid or fluid ; we determine whether 
they are movable or fixed, painful or indolent, hard or soft, smooth or uneven, 
pulsating or not. We ascertain whether the surface be hot or cold. In order to 
make palpation most effectual, the patient should be placed in the most favourable 
posture for its performance ; i.e., he should lie on his back, with his head a little 
raised, and his knees up. In this position, the abdominal muscles are relaxed 
and unstrung : and the patient is to be cautioned not to do any thing which may 
make them tense. Sometimes, in spite of this caution, and in spite, probably, of 
the patient's endeavours to obey it, the recti muscles remain so tightly contracted 
as to prevent any satisfactory examination of the parts beneath them. The very 
occurrence of this instinctive striving against the pressure of our hand may be 
taken as a ground of suspicion that those parts are not in a healthy state. We 
must take care, when the muscles are thus obstinately rigid, not to mistake the 
swelling central portions of the recti, or their well-defined edges, for tumours, or 
for indications of an enlarged stomach or liver. By a peculiar management of 
the palpation, we often satisfy ourselves at once of the presence of liquid in the 
cavity of the peritoneum, or in a cyst: we obtain that sensation which we call 
fluctuation. 

The exploration by the sense of touch is very much aided — often confirmed, 
sometimes corrected — by that which addresses itself to the sense of hearing. 
Sometimes we listen to the natural sounds through a stethoscope ; and we may 
thus decide the important question, whether a pulsating tumour be or be not an 
aneurism ; or the question, sometimes scarcely less important, whether a different 
kind of tumour encloses another living being or not. But, for the most part, our 
information respecting the maladies of the abdomen, collected by the sense of 
hearing, is obtained by listening to sounds which we ourselves produce ; in one 
word, by percussion: and mediate percussion, percussion performed through the 
finger as a ready pleximeter, is particularly applicable to the disorders of the 
abdomen. By this expedient we can tell whereabouts the intestines lie ; whether 
the parts beneath the place percussed be hollow and filled with air, or solid ; or, 
though naturally hollow, distended with liquid. By making the patient change 
his posture, we are enabled often, through the aid of percussion, to trace fluid 
effusions hither and thither, when they have changed their relative situation, by 
reason of the force of gravity ; and then we know that they occupy the cavity of 
the peritoneum. All these points I pass over cursorily, because I must advert to 
them again when speaking of particular diseases. And I shall proceed, on that 
account, without further delay, to the consideration of those special diseases. 

Consulting your convenience, and my own, rather than any scientific order, I 
shall take, in succession, the several parts and organs contained in the cavity of 
the belly, and inquire separately into their diseases ; inflammatory, organic, and 
functional. And I begin with the peritoneum; the great serous sac which lines 
and constitutes the cavity of the abdomen, and in which most of its viscera are 
wholly or partially folded. 

Like the serous membranes in general, the peritoneum is very ready to take on 
inflammation, upon the operation of certain exciting causes. Acute inflammation, 
beginning in one spot, is almost sure to transfer itself to any other spot that hap- 
pens to lie in contact with the first ; and is very apt to extend itself rapidly to the 
whole membrane. The inflammation tends to the effusion of serum, and of 
coagulable lymph ; it is of the adhesive kind : and its effects are those of dis- 
tending the peritoneal cavity with fluid — or of gluing its opposite surfaces together 
so as to obliterate that cavity — or of forming partial attachments. Jn all these 
respects, the analogy between inflammation of the peritoneumn and inflammation 
of the serous membranes of the thorax — the pleura, and the pericardium — is per- 
fect: and therefore these are points which I shall not dwell upon, except where 
specific differences arise, from original diversities of structure or function in the 
parts affected. I may observe at once, that the morbid conditions which are apt 



744 



DISEASES OF THE ABDOMEN. 



to remain after peritonitis, are sometimes, like those which follow pericarditis, 
inceptive of further disease; sometimes, like those of the pleurae, final, and 
limited to their immediate influence upon the health and comfort of the indivi- 
dual : or even protective against some worse evil. 

Acute inflammation of the peritoneum is characterized by pain in the abdomen, 
increased on pressure, and attended with fever. But as these symptoms are 
common to almost all the imflammatory conditions of the parts contained in the 
abdomen, we must look for more distinctive circumstances. Cullen defines the 
disease in this manner : " Pyrexia : dolor abdominis, corpore erecto auctus, ab- 
sque propriis aliarum phlegmasiarum abdominalium signis." He concludes that 
it is the peritoneum simply that is inflamed, when the specific symptoms that 
indicate inflammation of particular organs are wanting. It is not inflammation of 
the liver, for there is no pain of the right hypochondrium in particular, increased 
by lying on either side, no pain of shoulder, no jaundice, no vomiting perhaps : 
neither is it inflammation of the bowels or stomach, for there is no disturbed 
function of the alimentary canal to denote such inflammation. 

The pain, Cullen says, is increased if the patient sits up. He might have 
added, that it is increased also by drawing a long breath, by coughing, sneezing, 
or straining, and by pressure made with the hand upon the belly. All these cir- 
cumstances resolve themselves into the same obvious principle ; viz., that of 
pressure aggravating the pain of an inflamed membrane. The erect posture 
throws the weight of the viscera upon the peritoneum, and tends to stretch parts 
of it. The pain occasioned by pressure is often excessive; the patient cannot 
even bear the weight of the bed-clothes. Though the pain is, at first, sometimes 
confined to particular spots, yet it generally soon extends over the whole abdomen ; 
and this is a circumstance of some importance as respects the diagnosis. But 
before the inflammation has become universal, while it is yet restricted to particu- 
lar spots, the pain is often much increased by pressure made on other parts of the 
abdomen. In truth, in a shut sac of that kind you cannot compress any one part 
without exercising pressure indirectly upon every other part. The patient cannot 
sit up, nor, usually, lie on his side ; but remains always upon his back: in which 
position you will perceive that the pressure made by the viscera upon the perito- 
neum is a minimum; is the least possible. He draws up his legs too. And he 
lies still; for movements cause pressure, and therefore pain. The descent of the 
diaphragm in inspiration presses also upon the membrane ; and the patient not 
only complains of the pain thus produced, but in order to avoid it gets into away 
of breathing by means of his ribs only. So that upon inspection of the abdomen, 
it is perceived that, instead of rising and sinking alternately in respiration, it 
remains motionless. The phenomena of thoracic respiration is a symptom of 
peritonitis. The breathing is necessarily shallow in these cases, and less air- 
being admitted a teach movement of respiration, the number of those movements 
therefore is increased : the breathing is quick as well as shallow : there are per- 
haps forty, or even sixty respirations executed in a minute, instead of eighteen or 
twenty. When we find a personlying only on his back, with his knees up, breathing 
in this manner, and complaining of tenderness of the belly on pressure, and fever- 
ish withal, we may be tolerably sure (unless that person be an hysterical girl) that 
the peritoneum is inflamed, whatever else may be the matter. 

The pain in peritonitis is generally sharp, cuttiug, or pricking in its character. 
And independently of any pressure made from without, or caused by any change 
of posture, this pain is apt to be much aggravated at intervals. This, when the 
inflammation is general, is sometimes owing to the passage of flatus along the 
bowel, partially distending it, and stretching the inflamed membrane ; so that here, 
also, it is really pressure which augments the pain. 

When you explore the abdomen by pressure, take care not to make the exami- 
nation unnecessarily a source of pain. Press first gently, with the open flat 
hand ; and keep your eyes on the patient's face at the same time. You wiU 



PUERPERAL PERITONITIS. 



745 



perceive by the expression of his features, whether you are hurting him ; even 
before he takes to verbal complaining. 

Acute peritonitis generally sets in with well-marked symptoms : sharp rigors, 
and high fever, with a hard and strong pulse, which very soon becomes frequent, 
and often becomes feeble, and is sometimes small from the very first. After the 
disease has continued for a certain time, it is attended with tension and swelling 
of the belly. The tension and swelling are tympanitic in the earlier stages. You 
learn this with certainty by mediate percussion. As the disease advances, the 
enlargement is sometimes occasioned, in part at least, by the effusion of serum : 
of the presence of which infallible indications may be obtained by the joint em- 
ployment of the finger and the ear ; by palpitation and auscultation ; and by notic- 
ing the difference, as to the results of percussion, caused by alterations of posture. 

When the disease is advancing towards a fatal termination, the abdomen often 
becomes greatly distended; the pulse is exceedingly frequent and feeble; the 
countenance (which in all the stages of the disorder is expressive of anxiety) 
becomes pinched and ghastly ; cold sweats ensue ; and the patient dies at length 
by asthenia : death beginning at the heart. The mind is often clear to the very 
last. 

Such is the ordinary course of peritonitis. But other symptoms, which I have 
not mentioned, do sometimes accompany it; arising out of the peculiar circum- 
stances of different cases. Thus sickness and vomiting occur very frequently : 
and these symptoms are supposed to denote that the peritoneal covering of the 
stomach is especially implicated: but I question whether this is always a correct 
inference. When strangury happens, which is not uncommon, that part of the 
membrane which is reflected over a portion of the bladder is probably involved 
in the mischief. Inflammation of that part of the peritoneum which lies in the 
immediate vicinity of the kidneys, may cause, Dr. Abercrombie thinks, suppres- 
sion of urine. 

Peritonitis is apt to arise under the influence of cold, like other internal inflam- 
mations : especially when cold combined with moisture is applied, under certain 
conditions, to the surface of the body. It is occasionally produced by mechanical 
injuries inflicted upon the abdomen. It often prevails epidemically, and produces 
great mortality, among parturient women : and there is ground for believing that 
this form of the disorder is propagable, and often propagated, by contagion. 
Besides this, a very terrible kind of peritonitis is a frequent result of the extra- 
vasation of the contents of the alimentary canal, or of urine, or of bile, into the 
cavity of the membrane ; through apertures that are sometimes made by external 
violence, but more often are the consequences of the progress of previously-exist- 
ing disease. 

I shall make a few observations in respect to one or two of these points, and 
but a few. 

That awful disorder, puerperal fever, is more frequently accompanied with 
inflammation of the peritoneum, than with any other inflammation. This, variety 
of peritonitis necessarily engages the attention of the accoucheur; and it doubtless 
is more fully considered in the lectures of the Professor of Midwifery than I pro- 
pose to consider it. Indeed, if you would understand puerperal fever as a whole ; 
its shifting aspects, its single source, and its appropriate management; you must 
study Dr. Ferguson's masterly and conclusive essay on that subject. 

Of forty-four fatal cases of well-marked puerperal fever which fell under the 
observation of Dr. Robert Lee, and in which the bodies were carefull}' examined, 
the peritoneum and uterine appendages were found inflamed in thirty-two : i. e., 
in eight cases out of every eleven. The inflammation commences, no doubt, in 
the uterine portion of the membrane, and spreads thence over the larger part of 
its surface. Now this peritoneal inflammation, occurring in women after child- 
birth, may be accidental and sporadic ; or it may prevail in a district epidemically. 
And a most dreadful and deadly affection it may then become. In either case, 
the peritonitis may commence a few days, or even a few hours after parturition* 



746 



DISEASES OF THE ABDOMEN. 



The pain generally begins low in the abdomen, in the situation of the uterus; 
which may be felt through the abdominal parietes, and is tender on pressure: but 
soon a universal swelling takes place, and the womb can no longer be distin- 
guished. Cases of this kind arise sometimes, apparently from cold; and exhibit 
no peculiar feature. It is just what we might expect when a female, in a state of 
weakness and irritability, happens to be exposed to the exciting causes of inflam- 
mation. In such a state, a less degree of the exciting cause would be sufficient 
to produce the inflammation : and probably a less degree of inflammation may 
prove fatal. 

But when peritonitis is frequent among women after childbirth in a particular 
neighbourhood, or in a lying-in hospital, it is marked by greater depression of 
the vital powers, and runs a more irregular course. The nervous system suffers, 
the sensorium is apt to become affected, and the complaint assumes rather the 
character of continued fever than of simple inflammation of the peritoneum. 
And no wonder; since this variety of peritonitis forms part of a disease which, 
like continued fever, is a general disease, and results from contamination of the 
blood. This, Dr. Ferguson has clearly established. The contamination may 
originate in the body of the patient herself: the noxious material being supplied 
by putrid coagula, or portions of placenta, remaining in the uterus. Or some of 
the products of inflammation may enter the blood-vessels, and constitute the poi- 
son. And this it may be difficult, or impossible, to prevent. But, on the other 
hand, the contamination may arise in the way of contagion: this horrible malady 
may be communicated from one lying-in woman to another by the intervention 
of a third person; and doubtless it is so carried and propagated, in many instances, 
by midwives and accoucheurs. Now this source of the disorder may be obviated ; 
and therefore it is of the utmost importance that it should be clearly recognized, 
in order that it may be carefully provided against. 

You must know, however, that great differences of opinion have existed, and, 
I believe, still exist, in respect to the contagious quality of certain forms of puer- 
peral peritonitis; just as great differences exist as to the contagiousness of conti- 
nued fever, of cholera, of the plague. There are parties who regard the whole 
notion of contagion as a mere bugbear: and there are others who embrace in their 
allegations of contagion many more diseases than can be proved to be so caused. 
The same strong assertions are made, the same kind of eagerness is displayed 
(the same party-spirit, I had almost said) as mark the strife of ordinary politics. 
It is our serious duty, however, to inquire what is the truth in this matter: for 
the safety of individuals, and the happiness of whole families, may often hang 
upon our opinions. I must trouble you, therefore, with a few facts that bear 
closely upon the subject. - 

We possess some valuable and highly instructive accounts of epidemics of the 
kind I am alluding to. One by Dr. Gordon, on the epidemic peritonitis after 
childbirth, which took place at Aberdeen, in the years 1789, 1790. Another by 
Mr. Hay, on that which happened at Leeds from 1809 to 1812. And a third by 
the late Dr. Armstrong, on that which was observed in Sunderland and its neigh- 
bourhood in 1813. Dr. Robert Lee has also collected some very interesting facts 
in reference to the spreading of the peritonitis by contagion. Dr. Gordon had, 
he affirms, unquestionable proof that the cause of the disease was 2 specific con- 
tagion, and that it did not arise from any noxious constitution of the atmosphere. 
The disease seized such women only as were visited or delivered by a practi- 
tioner, or taken care of by a nurse, who had previously attended patients affected 
with the same disorder. And Dr. Armstrong observed that forty out of the forty- 
three cases that happened at Sunderland, occurred in the practice of one surgeon 
and his assistant. 

From among other histories — all tending to the same conclusion — brought to- 
gether by Dr. Lee, I take the following : — 

jj On the 16th of March, 1831, a medical practitioner, who resides in a populous 
parish on the outskirts of London, examined the body of a woman who had died 



PUERPERAL PERITONITIS. 



747 



a few days after delivery, from inflammation of the peritoneal coat of the uterus. 
On the morning of the 17th of March (i. e., the next morning), he was called to 
attend a private patient in labour, who was safely delivered on the same day. On 
the 19th, she was attacked with severe rigors, great disturbance of the cerebral 
functions, rapid feeble pulse, with acute pain of the hypogastrium, and a peculiar 
sallow colour of the whole surface of the body. She died on the fourth day after 
the attack, on the 22d of March ; and, between that period and the 6th of April, 
the same practitioner attended two other patients, both of whom were attacked by 
the same disease in a malignant form, and fell victims to it. On the 30th of March 
he bled a young woman who had pleurisy: the wound became inflamed after a 
few days ; erysipelatous redness and swelling extended from it up the arm ; and 
in four or five days that patient died of phlebitis.'' 

Mr. Roberton, of Manchester, states the following facts, in a paper in the Me- 
dical Gazette. — From the 3d of December, 1830, to the 4th of January, 1831, 
a midwife attended thirty patients for a public charity. Sixteen of these were 
attacked with puerperal fever, and they all ultimately died. In the same month, 
380 women were delivered by other midwives for that institution ; but none of the 
380 suffered in the smallest degree.. All the sixteen had inflammation of the 
peritoneal surface of the uterus. So, also, Dr. Robert Lee tells us that, in the 
last two weeks of September, 1827, five cases came under his observation. All 
the patients had been attended in labour by the same midwife : and no example 
of a febrile or inflammatory disease of a serious nature occurred during that period 
among the other patients of the same dispensary, who had been attended by the 
other midwives belonging to the institution. 

Statements of this kind — and they could be largely multiplied — furnish irre- 
sistible evidence, that the peritonitis, which prevails epidemically among lying-in 
women, is of a specific nature, and communicable from one person to another. 
It is observed, also, to reign as an epidemic especially in lying-in hospitals, and 
that it recurs at irregular intervals, sometimes leaving them quite exempt from 
its ravages for years together. 

Indeed, I believe that these cases of puerperal fever occurring in succession to 
the same practitioner, are examples of something more than ordinary contagion, 
operating through the medium of a tainted atmosphere. I believe them to be in- 
stances of direct inoculation. Recollect, that the hand of the accoucheur is 
brought, almost of necessity, into frequent contact with the uterine fluids of the 
newly-made mother. Recollect, — those among you who have examined the in- 
terior of the dead body with your own hands, — recollect, with what tenacity the 
smell, which is thus contracted, clings to the fingers in spite even of repeated 
washings ; and whilst this odour remains, there must remain also the matter that 
produces it. Recollect how minute a quantity of an animal poison may be suffi- 
cient to corrupt the whole mass of blood, and fill the body with loathsome and 
fatal disease. Illustrations will occur to you in the inoculated small-pox, in 
hydrophobia, in the viper-bite, in the scratches and punctures of the disseCting- 
room. Recollect the raw and abraded state of the parts concerned in parturition ; 
the interior of the uterus forming a large wound, and presenting, as Dr. Ferguson 
observes, an exact analogy to the surface of a stump after amputation ; the more 
external soft parts bruised and sore. Bear in mind the remarkable fact, that this con- 
tagion does not affect other persons, but only lying-in women. Reflecting upon 
these facts, you will see too much likelihood in the dreadful suspicion, that the hand 
which is relied upon for succour in the painful and perilous hour of childbirth, 
and which is intended to secure the safety of both mother and child, but espe- 
cially of the mother, may4iterally become the innocent cause of her destruction; 
innocent no longer, however, if, after warning and knowledge of the risk, suitable 
means are not used to avert a catastrophe so shocking. 

I need scarcely point to the practical lesson which these facts inculcate. When- 
ever puerperal fever is rife, or when a practitioner has attended any one instance 
of it s he should use most diligent ablution ; he should even wash his hands with 



748 



DISEASES OF THE ABDOMEN. 



some disinfecting fluid, a weak solution of chlorine for instance : he should avoid 
going in the same dress to any other of his midwifery patients : in short, he 
should take all those precautious which, when the danger is understood, common 
sense will suggest, against his clothes or his body becoming a vehicle of conta- 
gion and death between one patient and another. And this is a duty so solemn 
and binding, that I have thought it right to bring it distinctly before you. 

In these days of ready invention, a glove, I thi-nk, might be devised, which 
should be impervious to fluids, and yet so thin and pliant as not to interfere mate- 
rially with the delicate sense of touch required in these manipulations. One 
such glove, if such shall ever be fabricated and adopted, might well be sacrificed 
to the safety of the mother, in every labour. Should these precautions all prove 
Insufficient, the practitioner is bound, in honour and conscience, to abandon, for 
a season, his vocation. 

That variety of peritonitis which results from perforation of the stomach or 
intestines, and the effusion of their contents into the cavity of the belly, is full of 
interest. The inflammation is violent in degree; universal (generally) in extent: 
and almost always fatal. The attack is characterized by its suddenness. All at 
once intense pain arises in some region of the abdomen, which soon becomes 
tender in every part. The pain is incapable of removal, and generally even of 
mitigation, by medicine, and death takes place in a short time. These are the 
general features of such cases. Occasionally, the symptoms follow some differ- 
ent order. Thus, I have seen a case in which no pain was complained of, and 
the source of the inflammation was not suspected until the dead body was exa- 
mined. This was a case of fever; and it had been attended with much stupor, 
which was probably the reason that no indication of suffering was made by the 
patient. Occasionally, but that is uncommon, the pain intermits. For the most 
part, however, it resists all treatment, and ceases only with life, or a short time 
before life is terminated. 

Most of the instances of this kind of peritonitis that I have witnessed have 
resulted from perforation of the ileum, in the progress of continued fever. You 
are already aware, that the glandulaa agminatae, which are found only in that 
bowel, and the glandulae solitariae, which are scattered over nearly the whole inner 
surface of the alimentary tube, are very liable, in continued fever, to inflam- 
mation, sloughing and ulceration : and sometimes the ulcers go through: the con- 
tents of the gut are poured into the cavity of the serous membrane, and intense 
inflammation is lighted up. I purposely abstain from going into any particulars 
respecting these ulcers. We are no further concerned with them at present than 
as they furnish the channel by which the cause of the peritoneal disease is intro- 
duced. Once, and once only, as I stated before, have I known perforation occur 
from the extension of scrofulous ulceration of the same glands in phthisis. In 
general, in that disease, the ulcer runs a much slower course. As it approaches 
the peritoneum, circumscribed chronic inflammation is set up in that membrane; 
lymph is thrown out; and the bowel becomes adherent to some other portion of 
the canal, or to some of the other viscera of the abdomen. In this way the per- 
foration is prevented; or, should it take place, the escape of the contents of the 
bowel into the peritoneal sac is prevented. Occasionally, when two portions of 
the tube thus adhere together, a communication is formed between them, and the 
contents of the intestine either reach an advanced point of their stated journey by 
a short cut ; or are carried back again perhaps to a spot which they had already 
passed. 

A very curious instance of this latter event has been described by Dr. Aber- 
crombie. A man, fifty-six years old, who had shown oo signs of serious illness, 
but had laboured under impaired appetite, languor, and occasional pain in the abdo- 
men, for two or three weeks, was suddenly seized, while out walking, with vomit- 
ing; and he observed that what he brought up was stercoraceous ; and this occur- 
red again and again, at variable intervals ; the matter vomited being distinctly fecal, 
and sometimes so solid that he was obliged to swallow warm water to soften it s 



PERITONITIS FROM PERFORATION. 



749 



that it might be expelled from the stomach more easily. He never vomited his 
food; and no tumour, or other sign of organic disease, could be detected by ex- 
ternal examination. He lived about three months, and died at last of exhaustion ; 
and then it was discovered that the stomach and the transverse arch of the colon 
were adherent to each other, and that a ragged aperture of communication be- 
tween them existed at the place of adhesion. 

It is a curious fact, that the vermiform appendage of the cascum is not unfre- 
quently the seat of a penetrating ulcer. I have traced little groups of glands in 
that slender tube : and I have known perforation to happen from the specific ulcer- 
ation of continued fever ; and from the accidental ulceration caused by a cherry- 
stone lodged there.* 

Sometimes it is the stomach that is perforated, either by a common or by a 
specific ulcer; and the symptoms are exactly the same as when the bow el gives 
way. Sudden, unremitting pain, tenderness, and tympanitic distension of the 
abdomen ; and early death. 

Perforating ulcers of the stomach are of various kinds. It is not uncommon to 
find one small roundish hole, with edges as smooth and clean as if a piece of the 
stomach had been cut out by a punch, and without any surrounding hardness, or 
other mark of disease. Occasionally the orifice is more irregular, and occupies 
the centre of a thickened and indurated patch of the mucous membrane. Several 
instances of this sort of perforation have occurred under my own eye ; two within 
the last fourteen months (1839). Almost all the patients have been young wo- 
men, plump, and in good condition; who, up to the moment of the fatal seizure, 
either seemed to enjoy perfect health, or, at most, had complained of slight and 
vague feelings of dyspepsia. Ulcers of the stomach are, however, mostly chronic ; 
and the diseased viscus is commonly fenced about and protected by adhesion 
to the neighbouring parts, before its coats are completely penetrated by the ulcer. 
You are probably aware that this happened in the body of Napoleon Bonaparte. 
He died of cancer of the stomach. That organ was strongly adherent to the 
concave surface of the left lobe of the liver, which formed a part of the wall of the 
stomach ; and this adhesion, no doubt, prolonged his life. 

Usually the actual perforation, in cases such as we are now considering, takes 
place merely from the natural progress of the ulcer; but sometimes it would ap- 
pear that the thin membrane which remains is broken by some accidental force 
applied to it. Thus the symptoms have immediately followed the act of vomiting, 
brought on by an emetic. Bouillaud relates an instance in which the perforation 
happened while the patient was straining at stool; and it is conceivable enough, 
that rough pressure of the abdomen might complete the rupture, when the ulcer 
had already eaten through all the coats of the bowel except its peritoneal coal. 

Less commonly than this, in my experience at least, the peritonitis is set up 
by the escape of urine from the urinary bladder, through the extension of an 
nicer, or from a forcible rupture of that bag by a blow or a fall, when it was 
distended with urine. Rupture of the gall-bladder, whether by violence or from 
ulceration, has the same results; so also has, in general, the rupture of the uterus, 
which sometimes takes place during the efforts of parturition. Abscess of the 
liver, bursting into the peritoneum, is another occasional source of severe and fatal 
inflammation of that membrane. Acute and general peritonitis sometimes arises, 
also, in consequence of penetration from without; i.e., it succeeds the puncture 
made by the trocar in the operation of tapping the belly : and these cases, too, are 
almost all of them mortal: chiefly, I presume, because, in nine instances out of 
ten, they occur in an unhealthy and debilitated subject. 

1 formerly offered you some observations respecting a form of hysteria which 

* [Many cases are related of peritonitis from ulceration of the apendicula vermiformis, 
caused by the impaction of some foreign substance within its cavity. A very interesting 
case of the kind is detailed by Dr. Pepper, in the Transactions of the College of Physicians of 
Philadelphia, vol. i., p. 296, in which a grape seed had passed into the apendicula, and was 
the cause of its ulceration and perforation. — C] 



750 



ACUTE PERITONITIS. 



very closely mimics peritonitis, and would most certainly deceive a medical man 
who was not on his guard against it. We judge by the age and sex of the patient 
somewhat ; by the presence of hysteria in other forms, or of the hysteric diathesis ; 
by the excessive tenderness of the abdomen, or rather of its surface ; by the co-ex- 
istence of the same exquisite sensibility in other parts ; and by the incongruity 
and shifting character of the symptoms. The pulse and the tongue will perhaps 
be natural, while the abdominal irritation is at its height. Forewarned, you will, 
seldom find much difficulty in establishing the diagnosis. Of the signs by which 
peritonitis may be distinguished from enteritis, I shall speak when I come to the 
latter disease. 



LECTURE LXVI. 

Treatment of Acute Peritonitis ; Bleeding, Mercury, Opium. Chronic Peri- 
tonitis ; Granular Peritoneum. Ascites ; Ovarian Dropsy ; Diagnosis of 
these diseases. Other forms of Abdominal Dropsy. 

Acute peritonitis, in its simple form, is always a dangerous, yet frequently a 
manageable disease. When it is complicated with other and earlier organic mis- 
chief, and especially when it has been excited by the entrance of foreign matters 
into the cavity of the belly, it is all but hopeless under any treatment. 

In speaking of the mode of cure, I have again to repeat, mutatis mutandis, 
the grand remedies for inflammation, and particularly for the adhesive inflamma- 
tion proper to serous membranes : blood-letting ; mercury. 

It is of the greatest importance in this, as in many other cases of inflammation, 
that the blood-letting should be performed early. You must not be deterred from 
bleeding by the mere smallness of the pulse: a quality which I have frequently 
shown you to be characteristic of acute inflammation within the abdomen ; and 
which, in the disease now in question, is often present from the very beginning. 
If the pulse be wiry and hard, we disregard, in these cases its smallness. Not 
uncommonly it is rendered more full, as well as softer, by venesection; and this, 
when it happens, gives assurance of the propriety of that measure. 

Topical blood-letting is of much efficacy — of greater efficacy perhaps than in 
most other forms of abdominal inflammation. Cupping is out of the question, 
from the tender state of the abdomen. But in adults, after a full bleeding from 
the^rm, such as has produced some sensible impression upon the circulation, or 
brought the patient to the verge of syncope, the surface of the belly should be 
covered with leeches. From twenty to forty may be applied at once : and some- 
times this will make any further loss of blood unnecessary. But in severe cases, 
you may expect to find that repetitions of at least the local bleeding will be 
requisite. 

After the leeches have fallen off, a light poultice may be laid over the abdomen ; 
or it may be assiduously fomented with flannels wrung out of hot water. These 
means will encourage the bleeding from the leech bites; and are generally found 
to afford great comfort to the feelings of the patient. Cold applications have been 
recommended by some practitioners of high authority. Dr. Sutton injected cold 
enemata, and applied cloths, made wet with cold evaporating lotions, to the abdo- 
men with good effect: and Dr. Abercrombie has since reported favourably of the 
same kind of treatment. However, I should think this a more precarious plan 
than the opposite: and I have always observed so much relief to be given by 
warm epilhems that I have never had the inclination, or the courage, to employ 
cold. 

It is extremely desirable, in these cases, to obtain as speedily as possible the 
specific influence of mercury upon the system ; by calomel and opium, or by 



ACUTE PERITONITIS. 



751 



inunction. It cannot be necessary that I should again go over in detail the means 
of following out this indication ; but it is an indication which we must diligently 
pursue. 

The treatment of puerperal peritonitis is much more uncertain and difficult: 
for this reason, that it springs out of an antecedent morbid condition more deeply 
seated, more generally diffused, and less accessible to remedies, than itself. 
Whenever inflammation arises here and there in the body in consequence of a 
vitiated state of the blood, we have not only the inflammation itself to deal with, 
but its physical cause also, which may still be in uncontrolled operation. 

Dr. Ferguson justly remarks that " inflammation being made up of vascular 
and of nervous action, of the afflux of blood to a part, and of pain, it is not irra- 
tional to act on both the elements of the malady at the same time, or in periods 
shortly consecutive of each other." " The abdominal pain that occurs in puerperal 
fever, is accompanied by two very different states of constitution: one in which 
little or no depletion is borne, another in which relief is obtained only by very 
large evacuations of blood." Between these two there is every conceivable gra- 
dation. " In no malady are a cautious boldness, and a sagacious adaptation of 
remedy to constitutional power, more imperatively demanded." 

"If large bleeding be determined on, it must, to be beneficial, be resorted to 
within the first twenty-four hours from the attack. In the second stage of the 
disease it often produces, rapidly, a fatal result." 

In ambiguous cases he gives ten grains of Dover's powder, and covers the 
whole of the abdomen with a large linseed-meal poultice, sufficiently thick to 
retain warmth for four hours. At the end of that time, if the symptoms are 
alleviated, " ten grains more of the Dover's powder, and a fresh poultice, should 
be prescribed. If within four hours from this second medication, the practitioner 
is not satisfied that the malady is yielding, he must at once resort to depletion." 

Of all the means we possess of arresting this malady, bleeding, general or 
topical, is, in Dr. Ferguson's experience, by far the most extensively applicable. 
"But," he says, "while I admit this, I am equally certain that large bleeding 
has not been borne in this complaint, generally speaking, during the last twelve 
years." 

Another most important truth enunciated by our professor is, that " epidemic 
puerperal fever has, invariably, the character common to the ordinary fevers 
raging with it: if the latter require depletion, the presumption is that the former 
will also." 

Undoubtedly the very same species of febrile disease is variously affected by a 
given remedy in different places : and during different periods in the same place. 
There is such a thing as an epidemic state of the human constitution, gradually 
produced by a gradual fluctuation in the influences whereby communities of men 
are surrounded and impressed. The fevers that were cured in London ten or 
fifteen years ago by copious blood-letting, would now be rendered by that mea- 
sure, carried to a like extent, irretrievably mortal. There is scarcely a more 
important object of study to the practical physician than this different capacity, 
exhibited by the average of constitutions at different times and seasons, of bearing 
active depletion. "Nihil mihi prius est," says the wary Sydenham, " quam 
quando novee febres grassari incipiant, cunctari paulisper, et ad magna praesertim 
remedia non nisi suspenso pede, ac tardius procedere ; diligenter interim illarum 
ingenium atque morem observare, quibus itidem praesidiorum generibus a?gri 
juventur vel lsedantur, ut quam primum his repudiatis, illis utamur." The ex- 
citing cause of the fever remains the same ; the system upon which it operates 
undergoes from time to time great changes/, which are brought to light partly by 
the altered phenomena of the disease, partly and chiefly by the effects of remedial 
measures. 

Unless you bear these differences in mind, you will be perplexed and disheart- 
ened by the discrepant accounts given by competent and faithful observers respect- , 



752 



ACUTE PERITONITIS. 



•ing the success of different or even opposite plans of treatment, in the same com- 
plaint. 

Most writers, whose works I am acquainted with, recommejid purgatives as 
highly serviceable in peritonitis. I do not think the good which they are calcu- 
lated to do as antiphlogistic remedies can at all be put in competition with the 
harm that I am persuaded they may produce, by increasing the peristaltic action 
of the intestines, and so causing additional friction and tension of the inflamed 
membrane. I believe that in all cases of well-marked and pure peritonitis, when 
the inflammation is limited to the serous membrane, it is far better and safer to 
restrain than to solicit the internal movements of the alimentary tube. In a pam- 
phlet published several years ago by Mr. Bates, of Sudbury, some striking in- 
stances are recorded of recovery from severe peritonitis, under large and frequent 
doses of opium, and a rigid adherence to the horizontal posture, until all pain had 
subsided. The patients were not allowed to raise themselves, on any account, 
into a sitting position : and the opium was administered sometimes by the mouth, 
sometimes by the rectum. These cases, related in an unpretending manner by a 
practical observer, made a strong impression on my mind when I read them. To 
simple inflammation of the peritoneum, to those perilous forms of peritonitis 
which occur in women after delivery, ana" to those still more terrible cases that 
follow perforation of the serous membrane, this principle of keeping the intestines 
at rest, is alike applicable. I stated a little while ago, that the last-mentioned- cases 
are all but hopeless. That all but I inserted on the strength of some most inte- 
resting facts published by Dr. William Stokes, in the second number of the 
Dublin Journal of Medical and Chemical Science. He truly remarks, that in 
most of these accidents the powers of life sink so rapidly that bleeding, either 
local or general, cannot be attempted. Neither can we employ mercury internally, 
for fear of exciting the peristaltic action of the bowels, which action would tend 
to tear asunder recent adhesions, to keep the communication between the mucous 
and serous surfaces open, and to cause a fresh ingress of fecal or other extraneous 
matters into the sac. Yet in a few instances we find that the patients live for 
several days, and that a process of organization commences in the effused lymph. 
It seems that some years before Dr. Stokes wrote this paper, he had witnessed 
the admirable effects of opium in low forms of peritonitis, as administered by 
Dr. Graves ; who thus saved, without abstracting a drop of blood, two individuals 
in whom that disease followed paracentesis. I cannot refrain from quoting to you 
the particulars of one instance, in which the efficacy of the opiate treatment was 
conspicuous. The well-known symptoms of perforation of the intestines had 
existed for two days; the patient was apparently sinking, "his countenance was 
collapsed, anxious and expressive of dreadful suffering; the extremities were cold, 
and the pulse hardly perceptible. The exhibition of sixty drops, in the twenty- 
four hours, of the preparation called the black drop, was followed by the most 
signal improvement. The pulse regained fullness and softness, the extremities 
became warm, and the countenance had lost the Hippocratic expression. The 
patient could bear pressure on the abdomen, which, the day before, was ex- 
quisitely painful. The same treatment was continued for twenty-four hours 
longer; and by the end of that time every symptom of abdominal inflammation 
had completely subsided. The belly felt natural, there was no tenderness, the 
pulse was good, and the patient declared himself well." At this period of the 
case, Dr. Stokes omitted the opium, and gave the mildest possible saline laxative, 
as there had been no stool for forty-eight hours. Four evacuations took place, 
followed by the immediate return of the symptoms of peritonitis, under which the 
patient rapidly sank. 

" The intestines were everywhere agglutinated together, and adherent to the 
parietal peritoneum, except in the left iliac fossa, where a quantity of yellow puri- 
form matter was collected. On detaching the caput coli from the peritoneum lining 
the right iliac fossa, a small perforation of the gut was discovered, by the escape 
of the contents of the intestines in a jet," &c. &c. 



ACUTE PERITONITIS, 



753 



This example puts in a very strong light the goo d effects of opium; the dan- 
gerous effects of purgatives; and the mode in which recovery from these fright- 
ful accidents may sometimes be brought about. 

Dr. Stokes gives another instance in which the patient did recovery after taking 
105 grains of opium, besides what was administered in injections: and he alludes 
(o a third case, in which the employment of opium was successful, when perito- 
nitis had supervened upon the bursting of an hepatic abscess into the cavity, of the 
abdomen. 

Now I would earnestly recommend you to consider the expediency of apply- 
ing the same principle of treatment, as an auxiliary, when the peritonitis does not 
grow out of previous organic diseases in all cases, in short, of mere peritonitis. 
The opium is not to supersede the bleeding, or the mercury; it is not incompati- 
ble with either of those remedies; and it may, I believe, be most advantageously 
adopted in conjunction with them botru 

I shall relate one example, which has lately occurred to me, of the successful 
use of opium in simple, but severe, peritonitis. Several 0 f y 0U saw tn , s patient. 
His case is published in the appendix to Dr. Ferguson's volume. 

H. Middlehurst, a tailor, seventeen years old, was admitted into the Middlesex 
Hospital on the 17th of September : looking very ill, and complaining of pain in 
the epigastrium, with extreme tenderness over the whole abdomen, which was 
full and tense. He had been ill several days; had shivered in the outset: and 
had vomited frequently, up to the period of his admission. His bowels were con- 
lined; his tongue was dry and white. 

Twelve leeches were placed upon his abdomen, and calomel, in five-grain doses, 
was given two or three times at intervals of four hours. An enema of warm 
water was injected, and retained. In the evening sixteen more leechet were 
applied, and a drachm of mercurial ointment was rubbed into his arm. 

I first saw him on the 18th. His countenance was then pinched and anxious,'* 
and he lay moaning with pain; his knees being drawn up towards his belly, which 
was tense, and exquisitely sensible to pressure. He complained of nausea and 
retching, but had not vomited since his admission. His tongue was thickly 
coated; his pulse small, sharp, 108 in number* No permanent relief had been 
obtained from the leeches. 

I directed immediate venesection; but not more than four ounces of blood 
could be gGt from the arm. Thirty fresh leeches were therefore put upon the 
abdomen, and afterwards a warm poultice to receive the blood from their bites. 
Three grains of calomel, and three of blue pill, were ordered to be given every 
four hours. 

The last leeches mitigated the pain; but it returned in the evening, with in- 
creased severity, and he vomited the pills. He appeared to be in great agony. In 
this state the apothecary gave him twelve grains of calomel, and five grains of 
opium, in one dose. Soon after this he fell asleep ; and slept during the greater 
part of the night. Next morning his countenance had lost in a great degree, its 
expression of anxiety ; his belly was less tender, but still tense; and his tongue 
cleaner. No stool. 

Capiat pilulse saponis cum opio §rr. v.$va. quaq. hora. 

On the 20th, the bow T els were freely open, the dejections dark and watery; 
the abdomen was less tender. Pulse 114. He continued to take a grain of opium 
thrice daily till the 3d of October: the bowels being every day moved ; the pulse 
and tongue gradually improving; and the abdomen painless even under firm pres- 
sure. On the 3d, as the bowels had not acted for the last two days, I discon- 
tinued the opium. On the 5th, diarrhoea set in, with some renewed tenderness of 
the belly ; and the pinched and anxious countenance returned. He had then an 
opiate enema; and resumed the opiate pills as before. Under this treatment he 
at length got quite well ; and left the hospital on the 30th. 
48 



\ 

754 CHRONIC PERITONITIS. 

Chronic peritonitis is sometimes merely the sequel of that acute form of inflam- 
mation of the peritoneum, which I have just been describing. Plastic lymph is 
effused, and becomes organized ; serous fluid is poured out, and is not absorbed 
again ; the products of the original inflammation remain ; a low degree of inflam- 
matory action perhaps remains also, or is re-excited by slight causes ; the mischief 
augments ; and the patient is slowly conducted to the grave. 

There is, however, another, not at all uncommon, and equally formidable 
source of chronic peritonitis ; the presence, I mean, of a multitude of little granules 1 , 
lying within or immediately beneath the membrane, or occupying in countless 
numbers, those folds of the peritoneum which compose the omentum. These 
granules occur principally, if not exclusively, in scrofulous persons. Louis, in- 
deed, who considers them to be tubercles, affirms that they are never met with in 
the peritoneum, without being met with also — and usually in a more advanced 
state and greater abundance — in the lungs; but this rule is not universally true-. 
I have seen more than one instance of well-marked granular disease of the serous 
membrane of the abdomen, without a single tubercle in the pulmonary tissues - . 
Still the observation of Louis holds good in a vast majority of eases : and when 
we have symptoms of chronic peritonitis, which were not preceded by those of 
acute inflammation of the membrane, and when we perceive at the same time 
indications of phthisis, or of any other unequivocal form of scrofula, we shall seldom 
be wrong in connecting the chronic peritonitis with the presence of these miliary 
granulations. Whether they are truly scrofulous tubercles, or whether, as some 
suppose, they are sui generis, or, again, simply minute spherules of coagulable 
lymph, I do not undertake to determine. I have been in the habit of regarding 
them as the cause, and not as the consequence, of the inflammation* with which 
they jfre found associated. 

The symptoms of chronic inflammation of the peritoneum are more obscure, in 
general, than those of the acute disease. And when the disorder is primitive, not 
the relics I mean of more active inflammation, it often begins, and steals on, in a very 
insidious manner. The patient compfains of abdominal pains : sometimes slight, 
amounting to scarcely more than uneasiness, but abiding; sometimes occasional 
only. Usually there is a sensation of fullness and tension in the belly, although 
its bulk may not be sensibly altered. Sometimes there is a sense of pricking felt. 
Dr. Pemberton remarks, that you may detect a sort of deep-seated tension; that 
the skin and muscles lie loosely on the peritoneum, which gives to the hand a 
sensation as of a tight bandage underneath, over which the integuments appear to 
slide. The uneasiness, or the pain, is augmented by pressure; or perhaps is felt 
only when pressure is made. Sometimes the functions of the intestinal canalare 
disturbed : there are loss of appetite ; nausea and vomiting ; an irregular state of the 
bowels, and unnatural evacuations from them. Sometimes, on the contrary, the 
digestive organs perform their office in a tolerably healthy manner. These dif- 
ferences depend apparently upon the circumstance of the inflammation visiting, or 
sparing, the peritoneal covering of the stomaeh and bowels ; and of the parts 
concerned in the secretion of bile. Sooner or later, in most cases, the abdomen 
enlarges, and fluctuation is felt. All along there is some fever, more or less 
distinctly marked ; with progressive emaciation and debility. The face is pale 
and sallow, and wears an expression of languor. 

Very much the same set of symptoms are apt to result from scrofulous disease 
and enlargement of the mesenteric glands: and consecutive slow inflammation of 
the peritoneal membrane. 

Accordingly, after death, we often find those glands swelled, and red, and hard ; 
sometimes forming very large tumours : or we discover the whole surface of the 
membrane thickly bestrewed with innumerable small, round, grayish or white 
granules: sometimes it is covered, here and there, or everywhere, with false 
membranes: the intestines are frequently agglutinated into one mass ; or they are 
adherent to each other, or to the other parts of the peritoneum, in places only. 
The omentum is generally thick, red, and fleshy, as if its component parts had 



ASCITES. 



755 



been matied together; and there is more or less fluid, commonly turbid and flaky, 
in so much of the cavity as happens to be left. 

These are very unpromising forms of disease; and it is seldom that we can do 
more than mitigate the most distressing of the symptoms; or retard, perhaps, the 
march of the disorder. Leeches to the abdomen, in moderate numbers, and 
frequently repeated, and followed by soft warm poultices. Blisters, when the 
pain is not severe, and the tenderness less. Attention to the state of the bowels, 
which should be regulated by mild laxatives rather than by drastic purges. A 
nourishing, but unstimulant diet. These are the measures to which we must 
look for benefit. It has been thought that frictions upon the belly, with oint- 
ments containing iodine, have done good: so that it will be well to make trial of 
such. But do what we may, in nine cases out of ten, our best directed efforts 
will be disappointed. 

When there is much fluid collected in the abdominal cavity in these cases, they 
take their character from this predominant symptom, and are called cases of ascites. 
But this is only one form of ascites — that form which results from chronic inflam- 
mation of the peritoneal membrane. I shall pass, however, by an easy transition-- 
to the other forms of dropsy of the belly. 

There is another form of ascites, not very common, which approaches in its- 
character to inflammation, and which is therefore called active ascites. I mean 
that we sometimes see persons, who were previously in good health, become 
rapidly ascitic, after exposure to cold and wet, and rapidly recover again under 
the remedies that are used to subdue inflammation. Perhaps it may be said that 
these are cases of inflammation; and it may be so. But they want many of the 
ordinary symptoms of peritonitis; and if inflammation be present, it has no worse 
effect than the effusion of serum, which, under depletion or mercury, is speedily 
taken up again. I should rather conceive, however, that these cases are to be 
included in that category of dropsical effusions which I spoke of formerly, as 
resulting from the detention or absorption, in the first place, of an undue quantity 
of watery fluid into the blood, and its subsequent discharge, by a kind of secre- 
tion, either into shut cavities, or through some one of the natural vents of the 
body. The balance of the circulation between the skin and the internal surfaces 
appears to be destroyed on these occasions, by the operation of external cold upon 
the tegumentary membranes. 

But by far the greater number of cases of ascites are cases of passive dropsy- 
which arise slowly from a mechanical obstacle to the free return of the venous 
blood towards the heart. 

Ascites occurs, as you know, in general dropsy, with anasarca of the universal' 
areolar tissue; and this general effusion of fluid depends, in almost every case, 
either upon a peculiar renal disorder, or upon organic disease of the viscera of the 
thorax; of the lungs, or of the heart, or of both ; and, above all, upon such disor- 
der as is attended with dilatation of the right chambers of the heart. 

But I exclude this form of ascites, wherein the dropsy of the belly is only a 
portion of more general disease of the same kind, and limit myself at present to 
that kind of passive ascites which is unattended with dropsy elsewhere ; or which 
at any rate precedes the occurrence of serous accumulation in other parts. 

The symptom which first leads us to suspect ascites, is the progressive en- 
largement of the abdomen. But the abdomen may grow gradually large and 
prominent when there is no disease whatever: in pregnancy, for example; or in 
mere obesity. It is necessary therefore to search for more definite signs of peri- 
toneal dropsy. 

In order to make an accurate diagnosis of ascites, we must know what are the 
morbid conditions with which it is most liable to be confounded. Solid tumours 
and simple corpulency are readily enough distinguished. But there are certain 
kinds of encysted dropsy of the abdomen, of which the recognition is not so easy 
and obvious. Of these what is called ovarian dropsy is the chief. In some of 



756 



ASCITES. 



its symptoms this complaint closely resembles ascites : in some it differs from il 
widely. So also the treatment of the two disorders is alike in some respects ; 
dissimilar in others. For these reasons, and because I am more solicitous to be 
practical than to be methodical, I shall consider these two maladies together; 
turning first to the one, and then to the other, and marking, as I go on, the various 
points of similitude, and contrast, which they mutually offer. 

Recollect that ascites signifies the accumulation of serous liquid in the bag of 
the peritoneum ; whereas ovarian dropsy consists in the collection of fluid in one or 
more cells within the ovary : or in a serous cyst connected with the uterine appen- 
dages. 

One source of distinction between the two is furnished by the condition of the 
abdomen during their early stages. 

In ascites the enlargement is uniform and symmetrical, in reference to the two 
sides of the body. When the patient lies on her back the flanks bulge outwards, 
or swag over, from the weight and lateral pressure of the augmenting fluid. This 
increased breadth of the trunk is not observable in the case of an ovarian tumour; 
nor, I may add, in pregnancy. 

When we are able to trace the early history of ovarian dropsy, we find, in most 
instances, that the abdominal tumour was first perceived on one side; in one or 
the other of the iliac fossae, or somewhere between the ribs and the ilium. But 
when the enlargement of the abdomen is great, the distinction between ascites and 
encysted dropsy, drawn from the shape of the swelling, ceases. The ovarian 
tumour distends the abdomen, if not uniformly, yet nearly or quite as much on 
one side as on the other. 

The next thing we do, when the visible bulk and shape of the abdomen have 
suggested a suspicion of ascites, is to employ the sense of touch. 

Examination by pressure will sometimes suffice to assure us that there is fluid 
in the peritoneum. If you press suddenly with the tips of your fingers, in a 
direction perpendicular to the surface, you will often become aware of a sensation 
which it is difficult to describe in words, yet which is quite decisive, and not to 
be mistaken ; a sensation of the displacement of liquid, and of the impinging of 
your fingers upon some solid substance below. So that, by this manoeuvre, you 
frequently detect, not merely the presence of the liquid, but an enlarged liver, or 
spleen, or (it may be) an ovarian or other tumour; even when simple palpation, 
or handling in the ordinary way, would not enable you to ascertain these enlarge- 
ments. 

Again, percussion of the abdomen is fertile of information in these cases. First, 
by the sense of fluctuation which it causes when liquid is collected within. The 
left hand being laid fiat against one side of the tumid abdomen, if a slight blow be 
struck with the fingers of the right upon the opposite side, the impulse is con- 
veyed by a wave of the liquid to the open flat hand, which feels a little shock 
that is perfectly distinctive. The larger the amount of the accumulated liquid, 
and the thinner and tighter the walls within which it is confined, the more sensible 
and decided is this fluctuation. Even when the quantity is small, not exceeding 
a few ounces, a little practice and management will enable you to detect it. Per- 
cuss with one finger the most depending part of the cavity, and apply at the same 
time a finger of the other hand, very near the part struck ; and if liquid be there, 
you will perceive a limited yet distinct fluctuation. In the same way the presence 
of liquid in a small cyst may sometimes be ascertained. Mueh more when the 
cyst is large. And the cyst, in ovarian dropsy, is often very large ; and the liqud 
it contains is often thin and aqueous ; and then the fluctuation may be quite as 
perfect and perceptible as ever it is in ascites. 

Hence mere fluctuation is not a discriminating symptom between ascites and 
ovarian dropsy. 

But, secondly, percussion is full of instruction in the sounds it elicits. The 
sense of hearing will generally supply what the sense of touch may leave wanting. 
In true ascites the relative place of the liquid and of the intestines is determined 



ASCITES. 



757 



by the posture of the patient. The bowels, which always contain some gas, float 
to the upper part of the liquid, and there give out (when the finger, as a plexime- 
ter, is applied to the corresponding surface, and struck) their peculiar resonance. 
Mediate percussion will thus follow the gravitating fluid, and discover always a 
dull sound in the lowermost and a hollow sound in the uppermost part of the 
abdomen. 

But it is not so in ovarian dropsy. The cyst, in a diseased and enlarging ovary, 
rises in front of the intestines, which, being tied down by the mesentery, cannot 
embrace the tumour so as to reach its anterior aspect, but are in fact pressed back 
by it towards the spine. Hence, if there be any resonance produced by percus- 
sion, it is in one, or the other, or in both, of the flanks; and the umbilical region 
yields a dull sound whatever the position of the patient may be. The same is 
irue of the enlarging womb in pregnancy. 

The simple expedient, then, is quite decisive. In ascites the epigastric and 
umbilical regions are tympanitic on percussion; in ovarian dropsy the latter, a£ 
least, is dulL To be quite sure it is well to make the patient assume different 
postures in succession. If the person affected with ascites turns upon her side, 
the uppermost flank will become resonant; the umbilical region dull: whereas in 
ovarian dropsy, the sounds remain severally where they were under every change 
of position. In ascites, with a little care, you may ascertain the exact level at 
which the contained liquid stands; and measure its rise or fall from day to day. 

This mode of diagnosis is scarcely open, under ordinary circumstances, to fal- 
lacy or exception. Yet there are two or three possible conditions in which it may 
fail; and these it is right that I should briefly mention. 

1. The distension, in true ascites, may be so great, that the mesentery shall wot 
foe broad enough to allow the buoyant intestines to reach the surface, when the 
patient is supine. This impediment to the efficacy of the proposed test I have 
met with in practice. A woman came under my charge in the hospital with 
ascites. Fluctuation of the belly was unequivocal. While she lay on her back, 
the umbilical and epigastric regions were resonant when percussed; the flanks 
were dull. When she turned upon either side, the other side, previously dull, 
gave the hollow sound ; the umbilical and epigastric regions, previously resonant, 
gave the dull flat sound. Under the treatment employed, the accumulated liquid 
was removed, and she left the hospital. 

Some time afterwards, as I was going round the wards, I recognized the same 
woman amGng the patients recently admitted by my colleague, Dr. Hawkins, 
The ascites had returned. The abdomen, enormously distended, projected up- 
wards, as she lay on her back, to an excessive height. I found that fluctuation 
was very distinct, as before: but every part of the belly yielded a dull sound when 
struck by the fingers. At length this patient died : and it was seen, after death, 
that there was nothing to prevent the rising of the intestines. They had floated, 
at the utmost tether of the mesentery, as high as they could, without reaching the 
surface of the prominent belly. 

2. Another occasional source of fallacy I have just now hinted at. The intes- 
tines may be tied down, and so prevented from ascending by their specific light- 
ness, to the upper part of the surrounding liquid. And this may happen, either 
in consequence of the adhesion of the'various coils of the intestines to each other, 
and to the parts behind them : whieh is not an uncommon occurrence :— or the 
intestines, though unadherent, may be swathed, as it were, and bandaged down, 
by a thickened and diseased omentum. This also I have myself seen. A man 
died in the hospital, who had manifest ascites. Yet his whole abdomen, though 
not so much distended as to hinder the intestines, had they been free to rise, from 
reaching its walls, sounded dull on percussion. Inspection of the body explained 
this circumstance. When the peritoneum was opened by an incision carried 
through the fore-part of the abdomen, a quantity of serous liquid gushed out. The 
Hoor of the cavity which it had occupied was "smooth and level; and was found, 
on further examination, to be formed by a thick cake of omentum, strapped tightly 



758 



ASCITES. 



over the subjacent intestines. Of course, the same diseased condition may 02037 
in the female. 

3. On the other hand, I have once known an ovarian cyst to exist, when the 
umbilical region was tympanitic under percussion. The case furnished just that 
kind of exception which serves to prove a rule. This was also a hospital-patient. 
Her history was the history of ovarian dropsy. Some time previously- she had 
discovered a small tumour in one of the iliac regions. It increased without much 
disturbance of her general health, until it became very inconvenient from its bulk. 
She was then tapped in one of the Borough hospitals : and she stated distinctly 
that it was not a clear watery fluid that was evacuated; but a glutinous, mixed, \ 
and grumous matter: such as belongs to ovarian disease. No doubt could be 
entertained that the enlargement of the abdomen resulted from disease of that kind. 
Yet the umbilical region, when percussed, always rendered a hollow sound. 
Upon the death of the patient the mystery was solved. Air hissed forth from the 
opening made by the scalpel through the abdominal parietes : and the source of 
it being traced, an ovarian cyst, of considerable magnitude, was found adhering 
to the peritoneum in front of the belly, and containing no liquid, but some yel- 
lowish shreds only ; the remains, apparently, of some smaller included cysts. 
This ovarian bag had been filled with air, and had given occasion to the equivocal 
sounds. 

These sources of possible mistake or obscurity very seldom occur ; and the 
physical diagnosis, as I have now pointed it out, is very sure and valuable. So 
completely physical, indeed, are these tests, that we recognize ascites by them 
as readily and certainly in the dead, as in the living body. 

Other points of distinction may frequently be derived from the history and 
progress of the two disorders. 

The equable enlargement of the abdomen, on both sides, in ascites ; and its 
unequal prominence on one side in the early stages of ovarian disease; I have 
already mentioned. 

Again, it is observable that in true ascites, there are almost always manifest 
indications of constitutional suffering and disturbance: a sallow complexion ; de- 
bility; emaciation. The morbid accumulation results (as we shall see) from 
disease in some organ, of which the functions cannot be impaired without injury 
to the whole system. 

Ovarian dropsy, on the other hand, may last long, and be extreme m degree, 
while the general health is scarcely affected. The very bulk and weight of the 
swelling, produce, indeed, much 'inconvenience and discomfort; but, in other 
respects, the patient often remains in good health. This appears to be owing to 
the circumstance that the ovary is not directly necessary to the life or well-being 
of the individual, but is merely subservient, for a limited time, to the purpose of 
reproduction. 

Among the symptoms that are common to ascites and ovarian dropsy in their 
advanced stages, are all those which are occasioned by weight and pressure : viz., 
shortness of breath, from the resistance opposed to the descent of the diaphragm ; 
anasarca of the legs and thighs, from pressure upon the inferior cava and its 
branches ; and a peculiarity of carriage and gait, like those of a woman big with 
child, and depending upon the same cause, the necessity of throwing the head 
•and shoulders backwards, to balance the weight of the distended abdomen in front, 

It is necessary to caution you against mistaking a distended bladder for dropsy 
*of the abdomen. An old Frenchman was brought into the Middlesex Hospital, 
afflicted (so his friends said) with dropsy. He had been treated for that com- 
plaint. The abdomen was large, and dull under percussion from the pubes to 
above the umbilicus. In the hypogastric region I could detect an obscure sense 
of fluctuation. I noticed a strong smell of urine about this patient. Being inter- 
rogated, he said that he had formerly had some " stoppage," but that he now 
passed plenty of water; that it even ran from him. It was obvious that his blad- 
■ der was enormously distended, unable to contract upon its contents, and overflow- 



CHRONIC ASCITES. 



759 



ing. With some difficulty a catheter was introduced, and some quarts, I forget 
the exact quantity, of turbid and stinking urine were drawn off. The patient 
sunk at length, and the bladder was found to be much diseased. I have known 
similar mistakes occur in private practice. You will not think the caution I am 
now giving you superfluous, when I tell you, on the authority of Sir Everard 
Home, that John Hunter once actually tapped a distended bladder, in the belief 
that the disorder was ascites. 

Encysted dropsy, in the* abdomen, is not always ovarian dropsy. Omental 
dropsy is described: the omental cavity alone being unfolded, and full of liquid* 
This I have never seen. Cysts containing a considerable quantity of a clear thin 
liquid, and connected with the liver, are common. Probably these are in all cases 
(they certainly are in many) the effects of the growth of hydatids. Dropsy of 
the Fallopian tubes : dropsy of the uterus : large serous cysts in the kidney : con- 
stitute other forms of abdominal encysted dropsy. Such states must be discovered 
by their own particular circumstances. None of them are very common., 



LECTURE LXVIL 

Pathology of Chronic Ascites ; of Ovarian Dropsy. Treatment of these two 
disorders. Internal remedies : Extirpation of the ovarian sac : Paracentesis 
Jlbdominis. 

In my last lecture I pointed out the means we possess of distinguishing ascites 
from ovarian dropsy. Continuing the parallel between these two disorders, I have 
still to consider their pathology ; and to prescribe their treatment. 

I mentioned that chronic ascites is sometimes the sequel of acute inflammation 
of the peritoneum. In such cases, the abdomen is usually uneasy, and tender 
under pressure; or at any rate, more sensible than common: and I believe more 
hot also than common. Whereas when ascites is passive as well as chronic, you 
may make the requisite examination without causing any distress to your patient. 
There is no pain produced by palpation, by pressure, or hy percussion. Even 
when the dropsy has resulted from bygone inflammation, it does occasionally, 
though rarely, happen, that no other traee of such inflammation is discoverable in 
the living patient. The absorbing function of the membrane having, however, 
been spoiled, the collected liquid remains. Such a condition, I believe, I have 
witnessed. The history of sudden and sharp pain, and tenderness of the abdomen, 
with fever, immediately before the dropsical swelling took place, made it probable 
that it was the consequence of inflammatory effusion. But the fever had entirely 
subsided; no tenderness was left; no large veins were visible on the surface of the 
belly, denoting internal obstruction ; and the general health was good. The patient 
had no other dropsy. 

The main exciting cause, however, of true and uncombined ascites, when no 
inflammation is, or has been, at work, is some impediment to the venous circula- 
tion in the abdomen. Whereabouts, and of what kind, is this impediment ? That 
is the question which, in each particular instance, we ask ourselves. 

The old doctrine respecting the causes of ascites, vaguely referred the collection 
of liquid to obstruction; and to organic diseases of the abdominal viscera; and 
above all, to hepatic disease. But as we are now better instructed, and know that 
organic diseases produce the dropsy, ultimately, by retarding the flow of blood 
through the system of the vena portre, we see that the truth was only half perceived 
by the ancient pathologists. We can now understand why some organic diseases 
of the abdomen lead to dropsy of the peritoneum, and others (even of the same 
viscus) do not. And we have no difficulty in comprehending why, of all the 
abdominal viscera, the liver is the one whose diseases are the most frequently 



760 



CHRONIC ASCITES. 



connected with ascites : that gland being traversed by the converging branches of 
the venous trunk, through which passes by far the greater part of the serosity 
absorbed from the surface of the vast membrane that enwraps most of the abdomi- 
nal organs, and lines the cavity containing them. It is plain that an accumulation 
of serum in the peritoneal sac may arise from a mechanical obstruction in the 
trunk of the vena portes, or in some of the principal branches that unite to form 
that vein ; or from certain diseases of Jhe liver itself. But we know that disease 
of the liver is. of very common occurrence, and oftentimes very obvious* while 
there is no ascites. And a further question arises — With what kinds of disease of 
the liver is hepatic ascites most apt to be associated? 

In truth, there is one special form of liver-disease which, though not the sole, is 
the grand cause, of passive and simple ascites. It has long been noticed that mere 
enlargement is not the most common condition of the liver met with in hepatic 
dropsy ; but rather the small, hard, contracted viseus. Mere increase in the size 
of the organ may interfere but little with the portal circulation ; whereas a shrink- 
ing and diminution of its bulk must needs de so. In point of fact, that particular 
state of the liver which the French have termed cirrhose, and which is familiar to- 
morbid anatomists in this country as the Itobnail liver, is the great source of 
passive ascites. 

The true character of this remarkable condition of the liver is of modern disco- 
very. The credit of correcting the erroneous opinions which had been entertained 
respecting it is due, I believe, to Mr. Kiernan. The change undergone by the 
organ has also been clearly described by Dr. Carswell ; whose delineations of 
its physical appearance are now before you. The change results from chronic 
inflammation, and chronic thickening (miscalled hypertrophy), of Glisson's cap- 
sule. Since Mr. Kiernan's ^admirable exposition of the minute anatomy of the 
liver has been given to the world, few can be ignorant that the areolar tissue* 
termed the capsule of Glisson, accompanies the portal vein, the hepatic artery, 
and the biliary ducts ; and forms a sheath around these vessels in their course 
through the liver : while the hepatic vein and its branches are lodged in the pro- 
per substance of the gland without any such investing membrane. It follows thafc 
a general thickening of this tissue must produce a general pressure upon the 
portal veins, and hinder the return of the venous blood from the intestines* 
Hence, as in analogous cases, congestion of the capillaries, arrested absorption* 
mechanical transudation of serous liquid. The pressure affects also the nutrient 
vessel, the artery of the liver; so that, in most instances, there are atrophy and 
shrinking of the organ. And sometimes, but not always, from pressure upon the 
biliary vessels, there is jaundice also. By degrees, the areolar tissue itself begins 
to shrink ; and the spaces in which it ramifies on the surface of the liver are 
pulled inwards; the lobules appear to be prominent; and the surface becomes 
irregular and Snobby, and studded with little roundish eminences like the heads 
of nails. The constricted lobules are very conspicuous in the cut surface also of 
the liver. 

In the living body the presence of this hepatic disease is, for the most part, a 
matter of inference only. It is rendered probable by its ascertained frequency in 
connection with ascites, and by the absenee of any other obvious cause for the 
dropsy. But sometimes the irregular surface can be felt through the walls of the 
abdomen. 

The nature of this morbid change affords a reason for the intractable and un- 
promising character of ascites in general. The obstructed blood seeks indeed 
new channels; but the compensation they furnish is rarely sufficient. The super- 
ficial veins become obvious, numerous, large; and wander with many inoscula- 
tions over the surface of the belly. Large veins, significant of the same compensat- 
ing effort, have been met with also in the adhesions which previous inflammation 
had left between the liver and the diaphragm. 

Among the causes to which the thickening of the capsule of Glisson may be 
ascribed, habitual intemperance holds the chief place. 



OVARIAN DROPSY. 



761 



But this condition of Glisson's capsule, though it is the principal, and by far 
the most frequent, is not the only cause of obstruction to the current of the blood 
in the portal vessels, and of consequent ascites. In those specific forms of liver 
disease in which separate tumours are scattered through its substance, one of these 
tumours maybe so placed as to press upon the trunk of the vein. So, obviously, 
may abdominal tumours of any kind; enlarged mesenteric glands; cancer of the 
pylorus ; cancer of the head of 'the pancreas ; and the like. 

Ascites is found to be not unfrequently associated with disease and enlargement 
of the spleen also; but in most instances of this kind, the enlargement of the 
spleen and the peritoneal dropsy are not connected as cause and effect ; but are 
both consequences of portal obstruction. 

When, after death preceded by ascites, the cavity of the abdomen is laid open, 
its contents present a bleached and sodden appearance. It has been made a ques- 
tion whether this be the result of the long-continued immersion of the living tissues 
in the accumulated water; or of their short maceration after death. The question 
has no practical importance. 

Dropsy of the ovary, in its ordinary form, consists (I believe) in disease and 
enlargement of one, or more, of the Graafian vesicles ; or of the ova which they 
inclose. 

The actual condition of the dropsical ovary is subject to much variety. Some- 
times there is but one cyst; and this may be no bigger than a pea; or it may be 
large enough to contain many gallons. Its walls may be as thin and flexible as 
those of the healthy urinary bladder; or they may be firm, and half an inch or 
more in thickness. It may spring from a small pedicle, and lie free and unat- 
tached in the cavity of the peritoneum; or it may adhere, partially or at all points, 
to the contiguous parts; or it may be tied down by bands of coagulable lymph. 
Its inner surface may be smooth and even, or knobby and irregular. Lastly, the 
fluid contained in the cyst may be thin, or consistent; limpid, or glutinous; 
opaque, or transparent; and of various tints ; so that, in different cases, it may be 
colourless, green, purple, red ; and more or less resemble in appearance pure 
water, white of egg, jelly, glue, birdlime, or treacle. Most commonly, however, 
when the cyst is single, its contents are thin and aqueous. 

Again, the dropsical ovary may be multilocular, composed of many cysts, 
which are usually distinct, but which sometimes communicate together; and 
these cysts, in the same ovary, while they vary much in size, may differ also 
from each other in any or all the particulars just enumerated as being incidental 
to a solitary cyst. 

Commonly one of the cysts is much more capacious than the rest; and some 
part of its inner surface is frequently embossed, as it were, by the projecting out- 
line of a group of small nodules, which seem to lie within the parietes of the 
larger cyst, but which, in truth, are cysts of similar origin with it, but of more 
stunted growth. 

The external surface also of the multilocular ovary is generally lobulated; and 
its inequalities may often be discovered by a careful examination of the abdomen 
in the living subject. 

Sometimes the tumour is solid throughout; in which case the term dropsy is 
altogether misapplied. 

These differences are not without occasional importance, in reference to some 
points in the treatment of the disease. 

The progress of ovarian dropsy is no less wanting in uniformity. Sometimes 
it is very rapid ; sometimes it is very slow. It may destroy life in a few months; 
it may continue, a mere burden, with scarcely any fatal tendency, for many years. 
Not unfrequently, after a period of active increase in the tumour, the morbid pro- 
cess, without any obvious cause, suddenly stops: and the pause maybe final; or, 
after an uncertain interval, the disease may resume its former activity. 

Under all circumstances the malady is a serious one : for its possible grievances 



162 



OVARIAN DROPSY. 



are many ; and its issue is precarious and unpromising. Although, in some cases, 
the general health for a long time is but slightly or not at all impaired, in others 
the disease runs a short course; the tumour increasing rapidly and proving ulti- 
mately fatal by its bulk and pressure; or embittering and abridging the unhappy 
patient's existence by some accident of growth or position. Even when of no 
vast magnitude, it may be so situated as to impede or prevent the expulsion of 
the feces from the bowel, of the urine from the bladder, or of the fcetus from the 
gravid uterus. 

The single cysts, having thin parietes, and containing a serous liquid, are not 
always produced by disease and distension of a Graafian vesicle; for they some- 
times have no connection with the ovary, but spring from some other part of the 
uterine appendages. 

Neither, perhaps, can it be demonstrated that the complaint originated within 
the Graafian vesicles, when it exists in its more complicated form ; when the 
cysts are many, and their contents various. But the shape of the cysts, which 
are more or less spherical, their number, their isolation in most cases, and the 
diversity in the matters by which they are filled, render this view of their origin 
at least a probable one. 

This form of the disorder has been considered as belonging to the category of 
malignant diseases; but, in my judgment, without sufficient reason. It is true 
that the tumour does sometimes involve one or more of those morbid conditions, 
which have been denominated seirrhus, fungus hasmatodes, cerebriform disease, 
or melanosis, and which all, or nearly all, appear to be varying results of the 
same morbid process, and to be referable to the genus carcinoma : but whenever 
this is observed to be the case, other structures also are found to be infested with 
analogous changes. The so-called malignant disease occupies the ovary in com- 
mon with other parts ; and this is one of its most constant characters, namely, 
that proceeding from some vice in the constitution, or disseminated from some 
local germ, it pervades different organs of the body at the same time, or in suc- 
cession ; whereas, in by far the majority of instances of ovarian dropsy, these 
peculiar products are met with neither in the diseased gland, nor in any other 
place. It has already been remarked that many women, labouring under ovarian 
dropsy, enjoy, nevertheless, in all other respects, very good health, even for many 
years. The victims of malignant disease are not so fortunate. They either are 
soon cut off, or if they linger, they seldom fail to exhibit, in their complexion and 
general condition, notable indications of the mischief which is in progress, and 
gradually undermining the powers of life. 

If it be admitted, as a reasonable conjecture, that the Graafian vesicles, or the 
ova they contain, are the seat of the primary changes, we may push our specula- 
tions a little further. These ova are destined, under the peculiar stimulus of 
impregnation, to build up the fabric of the body in all its parts and qualities. And 
we may suppose that, in consequence of some unnatural and morbid stimulus, 
perverted and erring action may be set up, and strange products result. It is not 
uncommon to find fat, hair, cholesterine, teeth, and other bones, in the diseased 
ovaria, even of virgins. 

This view of the matter is strengthened by the fact, that dropsy of the ovary, 
of the ordinary kind, has not been known to commence before the age of puberty ; 
nor often after the capability of child-bearing had ceased; but only, or chiefly, 
during that period in which the organ, if healthy, is susceptible of its proper and 
temporary function. Virgins, and barren and fruitful wives, are alike subject to 
the disease; but in what relative proportions, statistical inquiry has not yet (so 
far as I know) determined. Where it accompanies, it may also account for, 
sterility. 

The catamenia during the progress of the malady sometimes appear with more or 
less of regularity and quantity; sometimes are entirely suspended. This function 
is so often interrupted under other circumstances, that its derangements shed but 
little light upon cases that are otherwise obscure. When the discharge continues 



TREATMENT OF OVARIAN DROPSY. 



763 



to recur, we may presume that one, at least, of the ovaries is in a tolerably healthy 
state : when both are sensibly diseased, the catamenia may be expected to be 
wanting. 

The treatment of these two forms of abdominal dropsy must, up to a certain 
point, at which the operation of tapping becomes expedient, be considered sepa- 
rately. Of both it may be said, that their cure is seldom accomplished ; yet, for 
reasons already assigned, ascites has, upon the whole, a more certain progress 
towards the destruction of life- than ovarian disease: while, perhaps, it is oftener 
cured. 

In passive ascites, when the distension of the peritoneum has crept on without 
pain, fever, or other marks of inflammatory action, our first and best hope of 
evacuating the collected liquid will rest upon diuretics. Hepatic ascites and renal 
disease may be sometimes found in conjunction, but according to my experience, 
they seldom are so : and except that both may probably owe their occasional 
origin to habits of intemperance, there appears no reason why they should be. 
Diuretics may be administered, therefore, without scruple. The hydragogue 
purgatives are to be employed, also, when diuretics fail to act, or to reduce the 
swelling; and when the disease is not already complicated with diarrhoea. And 
inferring with more or less certainty the existence of hepatic disease — sometimes 
from palpation of the enlarged or altered liver, sometimes from the coincidence of 
jaundice, but most of all from the result of accumulated experience respecting the 
morbid anatomy of such cases — we give the patient the chance of the remedial 
influence of mercury. The disorder being chronic, the introduction of that drug 
should be gradual. The iodide of potassium is held by some physicians to be 
especially serviceable in hepatic ascites. Compounds of mercury and iodine may 
be applied, by inunction, to the surface; of the abdomen, and to the right hypo- 
chondrium in particular. In Germany, the muriate of ammonia is in much repute 
as a therapeutic, agent. This diuretic salt, though seldom administered internally 
in this country, is believed by some practical men who have employed it, to ex- 
ercise the same beneficial influence upon the functions of the liver, as is com- 
monly attributed to preparations of mercury ; while it is less productive of distress 
or inconvenience. My own experience upon this point is too limited to justify 
me in expressing any confident opinion about it; but in some recent instances I 
certainly have noticed a remarkable improvement in the character of the biliary 
excretion, after the daily exhibition of sal-ammoniac combined with the extract of 
taraxacum. 

You will generally be obliged to try, in their turn, all the diuretics within your 
reach, and frequently to no purpose. Our efforts to remove by medicine the 
accumulated liquid, or to cure the morbid condition on which the accumulation 
depends, are too often made in vain. The distension of the peritoneum continues 
to augment; the distress arising therefrom becomes urgent and extreme; and at 
length, to afford temporary ease to the patient, and in the faint hope also of giving 
him permanent relief, we resort to the mechanical expedient of paracentesis. 

When we have the opportunity of treating ovarian dropsy from its commence- 
ment, we sometimes find that the enlarging ovary is painful, or tender. This is 
an indication for antiphlogistic measures. But from such remedies, or from any 
remedies, little more than temporary relief is to be expected. My position as 
physician to a hospital, has brought under my notice several cases of ovarian 
swelling, at a very early period of its development; when all that could be de- 
tected by careful examination of the abdomen was a small tumour, not larger, 
perhaps, than an egg, and occupying the situation of the ovary; to which the 
attention of the patient had been drawn by some pain or uneasy feeling in that 
part. I have treated such cases assiduously, with the remedies of chronic inflam- 
mation, frequent topical bleedings, and the use of mercury till the gums were 
affected; with the remedies of ordinary dropsy, diuretics and drastic purgatives; 
and with remedies accounted specific, the liquor potassae, the various preparations 



764 



TREATMENT OF OVARIAN DROPSY. 



of iodine ; and I mast honestly confess to you that I am unable to reckon one 
single instance of success. Yet these are the measures that we are bound to try. 
They have succeeded — as we are assured by competent and credible witnesses; 
they may therefore succeed again. The amount of my own experience, however, 
tends to the persuasion that medicine has, in general, very small influence over 
the progress of this disorder. The cases that do well, do well we scarcely know 
how or why; the cases that prove fatal run their course in spite of us. 

Sometimes, as has been stated, these ovarian tumours reach a certain magni- 
tude, and then (wherefore we cannot tell), enlarge no more; but remain a mere 
inconvenience and deformity, for many years. Occasionally, either spontaneously, 
or in consequence of some accidental violence, they burst into the cavity of the 
peritoneum, whence the effused fluid may be absorbed; but more commonly it 
causes fatal inflammation. Or the bursting tumour may empty itself harmlessly 
(adhesion having previously taken place), through some channel of communica- 
tion with the bowels or with the bladder ; or externally through the parietes of 
the abdomen. 

Tumours, supposed to be ovarian, do sometimes disappear entirely. It may, 
however, be doubted whether all, or even many, of the enlargements which have 
had this fortunate issue, were really connected with the ovary. One source of 
mistake I have myself more than once encountered, and I believe it to be not 
uncommon. A brief statement of the circumstances under which I first observed 
the fallacious symptom, will show you at once what I mean. Some years ago I 
was sent for by a lady, who for many days had been labouring under an ordinary 
attack of continued fever. While examining the abdomen by pressure, I disco- 
vered, on the right side, between the ilium and umbilicus, a round, hard, painless 
tumour, as big as a swan's egg. The patient was aware of it ; and thought it had 
existed for some time. At the next visit it was gone. In the interim, very 
abundant discharges from the bowels had followed the administration of purga- 
tive medicine. The tumour had obviously been formed by the accumulation of 
fecal matters in the caecum. 

Similar collections take place, less frequently, on the left side, just above the 
sigmoid flexure. 

The parts concerned in this disorder are not essential to life, or to the enjoy- 
ment of health. On some of the lower animals, the operation of spaying is as 
customary in the one sex, and is performed with as little risk, as that of castration 
in the other. The ovaries have in several instances been extracted from the living 
human body, without any ill consequences. These facts, and the intractable 
character of the disease, have naturally suggested the expediency of extirpating 
the tumour in cases of ovarian dropsy. 

But although the ovary, when healthy, or when not much enlarged, may be 
removed without much difficulty or hazard, the operation becomes always peri- 
lous, and often impracticable, when the altered gland has attained any considera- 
ble magnitude. Yet these are the very cases for which the remedy is needed. A 
large ovarian tumour is usually multilocular, with firm parietes, and thick internal 
septa ; and is therefore incapable of collapsing much when punctured. To extir- 
pate such a tumour, the abdomen must be (as it frequently has been) laid open 
from the sternum to the pubes. Most commonly, also, a large ovarian swelling 
is adherent to the contiguous parts ; a circumstance which either makes the pro- 
posed removal of the tumour impossible, or, if the connections admit of being 
broken down, augments in a fearful manner the jeopardy of the patient. It is not 
surprising, therefore, that the results of experience have been so discouraging as 
well nigh, in most minds, to prohibit such attempts in future. The operation has, 
indeed, in several authentic cases, been quite successful. In other instances, the 
surgeon, after exposing the adherent mass, has been fain to replace the effused 
bowels, and to sew up the abdomen, as speedily as possible ; and the patient, 
having suffered all this in vain, has sometimes been fortunate enough to escape 
with life ; but not always. In others, the adhering tumour has been separated, 



TREATMENT OF OVARIAN DROPSY. 765 

• 

and the object achieved ; and the woman has lived thereafter for some hours. 
Three times, at least (one of the cases is recorded by Mr. Lizars, another by Mr. 
King, the third fell under the cognizance of Dr. Richard Bright), the abdominal 
muscles and the peritoneum have been slit open, for the purpose of extracting a 
diseased ovary, — when no disease existed. 

But of late, a modification of the process of excision — whereby it is adapted 
to certain forms or conditions of the disease — has been proposed and practised ; 
and holds out somewhat more of promise. 

It consists in making, not a long, but a small incision through the walls of the 
abdomen, and through the peritoneum, so as to bring the surface of the diseased 
ovary into view. The cyst is then secured, by means of a tenaculum, or of a 
ligature, from receding inwards, and punctured, and its contents are suffered to 
escape. When the sac has emptied itself, it is withdrawn through the external 
orifice by gentle traction, until its stalk, or place of attachment to the broad liga- 
ment, comes near the wound. A thread is tied round this stalk, the cyst is cut 
off, the uterine appendages are put back into the cavity of the abdomen, and the 
lips of the wound are brought together. 

Although this method does not appear to have been actually performed till very 
recently, it had been suggested as long ago, at least, as the time of Dr. William 
Hunter, who, in a paper on the disease, has these remarks. " If it be proposed, 
indeed, to make such a wound in the belly as will admit only two fingers or so, 
and then to tap the bag, and draw it out, so as to bring its root or peduncle close 
to the wound of the belly, that the surgeon may cut it without introducing his 
hand, surely in a case otherwise so desperate, it might be advisable to do it, 
could we beforehand know that the circumstances would admit of that treatment." 

In these few words, Dr. William Hunter not only describes the mode of exci- 
sion, but alludes to circumstances that may render it inadmissible, as well as to 
the uncertainty that may arise about the existence of those circumstances. What 
the circumstances are is sufficiently obvious. 

However, this suggestion has been carried into successful practice by Mr. West, 
Mr. King, and others. To an interesting paper on the subject, published by Mr. 
Gorham, in the Lancet, is appended a summary account of ten cases ; by which 
account it appears, that five of the ten patients were cured by the operation ; two 
recovered from the attempt to extract, which was unsuccessful ; two died very 
soon after the operation, and evidently in consequence of it. The remaining 
patient, whose case has already been adverted to, recovered also from the inci- 
sion ; but there was no diseased ovary to amputate : so fallacious, sometimes, is 
the diagnosis. 

This mode of operating merits careful consideration, and further trial. Its re- 
commendations are — 

1. That the first steps — the incision and the puncture — are the same in kind 
as the first steps in ordinary paracentesis, and not much more severe or danger- 
ous ; the only difference being that the incision requires to be somewhat larger in 
the one case than in the other. 

% 2. That, when successful, it affords a complete and permanent cure, which 
can hardly be hoped for from any other plan. 
The objections to its general use are — 

1. That the single sacs, with thin and flexible walls, do not, commonly, reach 
a very large size. When small, or of moderate dimensions, they produce so little 
distress or inconvenience, that an operation, which must always be uncertain and 
tentative, ought not to be recommended. 

2. That the multilocular tumours, with solid walls and partitions, can scarcely 
be so drawn through the opening made into the abdomen. 

3. And above all, that adhesion of the tumour to the neighbouring parts would 
interfere with and prevent the success of the operation. 

In most, however, of the five cases of cure referred to by Mr. Gorham, the 
sacs thus removed were large. From one of them 12 pints of fluid were let 



766 



TREATMENT OF OVARIAN DROPSY. 



out ; from another, 27 pints; from a third, upwards of 20 ; and from a fourth, 24 
pints. 

It is difficult to guess beforehand whether the tumour be attached to the parts 
surrounding it or no. If it be readily movable by the fingers applied to the sur- 
face of the belly, so'as to admit of being pushed hither and thither without pain 
or distress to the patient, it is probably unadherent. , In one of the same five 
cases, the patient being in labour, Mr. West found that the tumour lay between 
the uterus and the brim of the pelvis. By gentle pressure, per vaginam, it was 
made to recede into the cavity of the abdomen. This afforded a presumption 
that it was free from adhesion; accordingly the sac was afterwards easily excised. 
The tumour is attached anteriorly to the peritoneum lining the front of the abdo- 
men more frequently than to any other part. This Mr. Gorham attributes to par- 
tial inflammation produced by the puncture in the operation of tapping ; hence 
the presumption that the cyst is loose is, cxteris paribus, the stronger, when para- 
centesis has never been performed. 

If this mode of excision should be thought advisable, it ought to be attempted 
while the tumour is yet of moderate bulk, before the peritoneum has been much 
stretched, and while the chance of adhesion is the least. When any distinct his- 
tory of bygone peritonitis can be traced, the existence of adhesions may be confi- 
dently reckoned upon.* 

To the simpler operation of tapping, the contrary precept applies. Neither 
in ascites, nor in ovarian dropsy, should paracentesis be resorted to, until it seems 
absolutely indispensable. To this rule there are, in my opinion, very few excep- 
tions. 

The operation itself, though commonly esteemed a trivial one, is not without 
its dangers. The instances are not few in which it has been followed by fatal 
peritonitis, excited either by the mere passage of the lancet or trocar through a 
previously unhealthy membrane, or, (in the case of ovarian dropsy,) by the escape 
of some portion of the contents of the cyst into the cavity of the abdomen. For- 
merly, the rapid evacuation of a large quantity of liquid from the belly was often 
attended by terrifying effects; fainting, convulsions, almost instant death. This 
made the ancient physicians afraid of the operation: and when they could no 
longer avoid it, they let the accumulated fluid out by little and little, and at short 
intervals. 

The cause of these alarming symptoms is now well understood, and easily 
obviated. They were owing, doubtless, to the sudden removal of the pressure to 
which the viscera and large blood-vessels had been for some time submitted and 
accustomed. For this explanation of the fact we are indebted to the sagacity of 
our celebrated countryman, Dr. Mead, who was the first to suggest that external 
compression should be substituted, in lieu of the tension taken off by the opera- 

* Since this lecture was first printed, an interesting paper by Mr. Phillips upon the ques- 
tion of extirpating ovarian cysts has been published in the 27th volume of the Medico- 
Chirurgical Transactions. 

Mr. Phillips exhibits, in a tabular form, "the results of 81 operations, performed for the 
purpose of extracting ovarian tumours. In 61 cases the tumour was extracted ; in 15 cases 
adhesions, or other circumstances, prevented its removal; in 5 instances no tumour was 
found. Of the cases in which the operation was completed, the tumour being extracted, 35 
terminated favourably; the patient recovered. In 26 instances the termination was unfa- 
vourable; the patient died. Of the five cases in which no tumour was discovered all 
recovered. 

" Of the 15 cases in which adhesions or other circumstances prevented the extraction of 
the tumour, 9 recovered, 6 died." 

In two other tables Mr. Phillips collects together: — 

I. Cases in which a large incision was made, 55 in all: and among these cases there were 
26 deaths, 23 cures, and 6 recoveries which were not cures. 

II. Cases in which the incision was small (usually under six inches), amounting In all to 
27. Among these there were 7 deaths, 13 cures, and 7 recoveries from the unsuccessful 
operation. 



TREATMENT OF OVARIAN DROPSY. 



767 



tion. The complete success of that expedient fully justified his ingenious opinion. 
We now drain the cavity of its liquid contents without scruple or delay. A sheet, 
or broad roller, is thrown round the patient's body, and tightened as the fluid 
escapes, so as to maintain an equable pressure, which is continued for a while, 
and at length gradually withdrawn. 

Other casualties occasionally happen; the trocar has sometimes pierced the 
intestine. In one instance which I myself witnessed, clear serum issued for some 
time through the canula, but at length pure blood ; not less than a pint. The 
patient sank ; and no opportunity was given to investigate the cause of the bleed- 
ing. In another strange but well-authenticated case, the almost incredible quan- 
tity, twenty-six pints, of blood flowed out at the orifice made by the trocar, and 
afterwards separated into clot and serum. To the wonder of those who saw the 
incident, this patient recovered from the tapping ; and the source of the hemorrhage 
is still a matter of conjecture. 

And apart from these mischances — which, after all, are not of frequent occur- 
rence — you must bear in mind that paracentesis can seldom be contemplated as a 
mode of cure, but simply of temporary relief from distress. A few instances have 
happened where the liquid has been drawn of, and has not again collected : but 
such cases are very few. So, also, according to my experience, are those, much 
talked of by authors, in which the kidneys resume their activity upon the removal 
of the dropsical fluid. Ordinarily, the liquid reaccumulates, often with more 
rapidity than before ; and again, and again, the pain and the hazard of the opera- 
tion must be repeated: wherefore, in my judgment, paracentesis in abdominal 
dropsy ought seldom to be performed, unless the quantity of liquid is so great as 
to occasion painful distension ; or causes great distress of breathing by its upward 
pressure against the diaphragm ; or gives rise to some positive suffering or urgent 
inconvenience, which the evacuation of the water may be expected to remedy. 

Acupuncture of the dropsical abdomen has of late been recommended ; and 
cures, thus effected, have been announced. It is said, or supposed, that the in- 
closed liquid, oozing gradually into the areolar tissue of the integuments of the 
abdomen, is thence removed, gradually, by absorption. Of this method of treat- 
ment I have no practical knowledge. 

It is seldom that tapping is many times performed upon the same person, when 
the complaint is mere passive ascites. The dropsy returns indeed, and again the 
operation is required; meanwhile, in most cases, the health and strength rapidly 
deteriorate, and the patient sinks. 

The same speedy declension and early death occur sometimes in ovarian dropsy 
also ; yet the operation commonly bears to be repeated more often than in ascites, 
without serious detriment to the general health. Sometimes the liquid re-accumu- 
lates in the cyst very quickly, sometimes slowly; in a very few instances not at 
all. I have had under my own care a patient who had been tapped for this disease 
thirty-eight or thirty-nine times. Extraordinary examples of a similar kind are 
on record ; one or two I may mention as specimens. 

Dr. Mead narrates the case of a lady, who " for the information of posterity, 
ordered by her will that the following English inscription should be engraved ok 
her monument, in Bunhill Fields: — 

Here lies Dame Mary Page, 
Relict of Sir Gregory Page, Bart. 
She departed this life, March 4, 1728, 
In the 56th year of her age. 
In 67 months she was tapped 66 times : 
Had taken away' 240 gallons of water, 
without ever repining at her case, 
or ever fearing the operation." 

Among authenticated instances, the most remarkable that I have met with is 
detailed in the Philosophical Transactions for 1784, by Mr. Martineau, who was 
at that time surgeon to the Norfolk and Norwich Hospital. An abstract of the 



768 



ACUTE GASTRITIS. 



case is given in the printed catalogue of the Hunterian Museum, where the cyst 
is preserved : it belonged to the left ovary of Sarah Kippus, a widow, fifty-five 
years old. " The complaint began after a miscarriage, at the age of twenty-seven. 
From the year 1757, to August, 1783, when she died, she had been tapped eighty 
times, and had, in all, had taken from her 6631 pints of fluid, or upwards of 
thirteen hogsheads. 108 pints was the largest quantity ever taken away at any 
one time. But after death Mr. Martineau could not make the sac contain more 
than fifty pints." 

Upon the whole, it may be stated of this operation, as applied to ovarian dropsy, 
1. That when it is essential to the comfort and continued existence of the 

patient, it brings sensible relief to her distress, and often materially prolongs her 

life. 

But, 2. That when it is performed under less pressing circumstances, it tends 
to shorten the patient's days. Dr. Bright is of opinion that the number is small 
of those who survive the first tapping more than four years. A respectable woman 
having very large ovarian dropsy, entered the Middlesex Hospital, under my care, 
for the express purpose of being tapped. The tumour incommoded her by its 
bulk and weight, but in no other way ; and she had carried it for thirteen years. 
I felt that I should not be justified in sanctioning the operation in such a case. The 
patient was made to understand that the performance of it would not be altogether 
free from immediate danger; and that if she went through it safely, the swelling 
would return, and the same kind of remedy again become equally necessary. She 
was instructed how to suspend the heavy overhanging abdomen by a sling passing 
over her shoulders. There appeared no reason why she should not continue in 
good health for another period of thirteen years. 

I am aware of another instance, in which a woman, similarly burdened, but 
otherwise in comfortable health, has lived, not without enjoying life, between 
twenty and thirty years. Had she been tapped when the mere enlargement might 
have seemed to justify the operation, she would probably have been for twenty 
years in her grave. 



LECTURE LXVIII. 

Jicute Gastritis: symptoms ; anatomical characters; treatment. Chronic In- 
flammation of the Stomach ; thickening of the Mucous Membrane ; Ulcer- 
ation ; symptoms and treatment of the disorder. Cancer of the stomach. 

Acute inflammation, when it affects the peritoneum, usually spreads with rapi- 
dity over the whole surface of the membrane. This is characteristic of inflam- 
mation of the serous membranes generally. But it is not so with the other 
tissues that compose the alimentary canal. Inflammation of the mucous mem- 
brane may be, and often is, very limited in extent: and the different portions of 
the intestinal tube, as they differ in function, so also they differ*somewhat in their 
diseases, and still more in the symptoms by which those diseases are revealed. 
Not being fettered by any artificial system of arrangement, I shall take the course 
which promises to be practically most useful, and consider separately the maladies 
of the several parts of the alimentary canal in the abdomen, extending my remarks 
occasionally to the whole of the tube, when speaking of disorders that are com- 
mon to all portions of it. 

Let me, then, in the first place, draw your attention to the organic diseases, and 
the morbid conditions, of the stomach. 

It is remarkable, all things considered, how seldom the stomach is affected with 
acute inflammation. , Scarcely ever do we find either the organ as a whole, or 
any one of its tissues separately, the subject of spontaneous acute inflammation. 



ACUTE GASTRITIS. 



769 



What is described in books as gastritis, means inflammation of the mucous mem- 
brane of the stomach : and almost all that we know, for certain, of this disease, 
we derive from observation of the effects of strongly irritant substances upon that 
membrane. Idiopathic gastritis, in an acute form, I never saw. Acute gastritis, 
from the contact of corrosive or acrid poisons, I have frequently seen: and a 
highly interesting affection it then becomes. This is a subject that cannot be 
thoroughly discussed in this course of lectures : neither may it be altogether 
omitted. 

When an irritant poison has been received into the stomach and excites inflam- 
mation there — or when acute inflammation arises from any cause — the symptoms 
which mark that inflammation are pain, usually of a burning character, in the 
epigastrium; with frequent vomiting, especially upon the entrance of any thing 
into the stomach ; and often with hiccup, and with tension of the upper part of 
the abdomen. To these local symptoms are added fever of a low type; and a 
small and weak pulse. At first, indeed, the pulse, although small, is generally 
sharp and hard; but it soon becomes thready and feeble. The muscular power 
undergoes a corresponding depression ; the patient is pale and faint, with collapsed 
features, cold extremities, and a damp skin. 

In all this we see a strong tendency to death by asthenia. It is clear that the 
subdued state of the circulation is dependent upon the inflammation, for it is often 
relieved by the remedies of inflammation. In acute gastritis, as well as in peri- 
tonitis, you will find that the pulse expands, becomes more distinct and full, under 
early bleeding: sometimes even while the blood is flowing. 

Upon this remarkable sympathy between the heart and the stomach I have 
frequently had occasion to insist. You are aware that a smart blow upon the 
epigastrium may put a sudden stop to the movements of the heart, and induce 
mortal syncope, without leaving any local trace of its operation. On the other 
hand, a person in a state of extreme exhaustion and faintness, will sometimes re- 
vive at once, upon swallowing into the stomach an ounce or two of brandy, and 
recover his pulse and colour much too speedily, to allow of our ascribing these 
effects to the absorption of the alcohol into the blood. Dr. Alison suggests that the 
depression of the circulation may be attributable to the peculiar sickening pain 
which accompanies inflammation or sudden injury of the stomach. It appears, 
however, more probable (as has been intimated to me by an obliging correspond- 
ent) that the remarkable sympathy in question is governed by the nerves of orga- 
nic life. The great solar plexus of the ganglionic system lies upon the spinal 
column immediately behind the stomach. The heart is largely supplied with 
nervous filaments from the same system. Hence we might almost expect that 
any sudden stimulus applied to this important plexus would excite, and that any 
sudden depressing influence would subdue, the natural action of the heart. 
Upon the carae principle may be explained the facts that deadly faintness and 
nausea are apt to result from injury of the testes, which are also abundantly en- 
dowed with influence from the nerves of organic life. Be this as it may, it is 
important for you to know that the mode of dying in these cases is precisely what 
Bichat describes as death beginning at the heart. 

The pain that accompanies gastritis is augmented by pressure upon the epigas- 
trium. It is increased also by the full descent of the diaphragm, and the breath- 
ing is consequently short and constrained. In the most exquisite cases of gas- 
tritis, produced by chemical or mechanical irritants applied to the interior of the 
stomach, the inflammation probably reaches and involves, more or less, the peri- 
toneum. The patients speak of the pain as a pricking and burning sensation ; 
it is attended with great anxiety and restlessness. The sufferer is tormented with 
extreme thirst, while all that he drinks, even cold water, is almost instantly re- 
jected by vomiting. „ 

Hiccup does not always accompany acute gastritis. It sometimes occurs early ; 
but more generally it comes on late in the disease, when the patient is sunk and 
much debilitated. 
49 



770 



GASTRITIS* 



The bowels, in this complaint, are sometimes bound: sometimes, on the con- 
trary — ^especially when the inflammation has been caused by corrosive poison- 
dysenteric diarrhoea ensues, with much griping and tenesmus. 

Such, then, are the symptoms that indicate the existence of acute gastritis ; bat 
you ought to be aware that they occur in varying combinations, and with different 
degrees of severity ; and consequently that the course of the disease is not uni- 
formly the same in all cases. When the symptoms are the most violent, and the 
progress of the complaint is the most rapid, the peritoneal coat of the stomach is 
usually, I believe, more or less implicated. 

Intense inflammation of the stomach may be expected to be rapid in its pro- 
gress. It may destroy life within twenty-four, or even twelve hours. When it 
is fatal, it generally is so within a few days ; and death takes place by fainting ; 
with a remission of the pain, sometimes very sudden, and sometimes occurring 
only just before dissolution. But as idiopathic gastritis is rare, fatal idiopathic 
gastritis is, of course, still more so. Louis states, that during six years' expe- 
rience at La Charite, in which period he noted the details of 6,000 cases of disease, 
and of 500 dissections, he did not meet with a single instance of fatal idiopathic 
gastritis. The subject derives almost all its importance, therefore, from its con- 
nection with poisoning; and the many interesting points of inquiry which arise 
out of that connection will be brought before you by the Professor of Forensic 
Medicine. This consideration is a great satisfaction and relief to me ; because I 
iind that the limits of my own course will not permit me to go into any detail in 
this matter. 

The morbid appearances to be looked for after death by acute gastritis, are red- 
ness of the mucous membrane, softening, sloughing, and even (after the action of 
strongly corrosive poisons), perforation of all the coats of the stomach. 

I wish particularly to caution you against being misled by mere redness of the 
interior of the stomach ; or of the inner surface of the alimentary canal in general ; 
or of any mucous membrane; and indeed I may add, of any serous membrane 
also. Redness and inflammation have been' made, too often, convertible terms. 
Persons finding the inner surface of the stomach red, have hastily concluded, 
from that circumstance, that suspicions of poisoning, which had arisen, were well 
founded. We are indebted to Dr. Yelloly, in the first instance, and to M. Billard 
and some other Frenchmen, in the second, for correcting this error — an error 
which not only was of importance in questions of imputed poisoning, but has run 
through and vitiated almost the whole of pathology, both lately and heretofore. 
Mistaking mere redness for evidence of inflammation, Cullen divided gastritis into 
two species — one of which he called gastritis erythematica ; and he inferred from 
the observation of cases in which redness of the membrane had been met with 
after death, that this peculiar kind of inflammation of the mucous coat of the 
stomach might take place, without fever, pain, or vomiting, or any other symptom 
indicative of gastritis : whereas it is almost certain that, in the cases to which he 
refers, there really was no inflammation at all. So also Morgagni, puzzled by 
intestinal vascularity, was disposed to attribute the absence of pain, in what he 
believed to have been inflammation of the bowels, to a paralytic affection, which 
blunted the sensibility of the parts ; and Haller conceived, from so constantly 
meeting with this vascularity in his inspections of the body, that inflammation of 
the bowels was almost always present in fevers of all kinds ; and was frequent in 
every other complaint. And the same doctrine has been strenously inculcated of 
late years, as I dare say you know, by Broussais, in France, and adoptee! by a 
vast host of his disciples. Finding the lining membrane of the stomach and intes- 
tines red and vascular in most of the bodies of patients who had died of fever, 
Broussais concluded that fever depends, in all cases, upon inflammation of the 
gastro-enteric mucous membrane. You will perceive that this doctrine must 
exercise a vast influence upon the practice of those who entertain it. If inflam- 
mation constitute an essential part of any disorder, it follows that the remedies of 
inflammation will be adapted to that disorder; and thus, even so slight a mistake 



GASTHITIS. 



771 



as that may appear to be, against which I am now cautioning you, of regarding 
every surface which is red as being inflamed also, may lead to very mischievous 
views in respect to treatment. 

The redness that is independent of inflammation may be of various kinds ; but 
the principal cause of it is venous congestion. " The appearances of vascular full- 
ness (says Dr. Yelloly) in the villous coat of the stomach, whether florid or dark- 
coloured, in distinct vessels, or in extravasations of different sizes, are not to be 
regarded as unequivocal marks of disease; inasmuch as they occur in every variety 
of degree and character, under every circumstance of previous indisposition, and 
in situations where the most healthy aspect of the organ may be expected." To 
the truth of this statement I can bear witness, having at one time of my life care- 
fully examined, with a view to this matter, a great number of stomachs in succes- 
sion, in the dead house of a large hospital. " The vascularity (according to Dr. 
Yelloly) is entirely venous, and depends on a power capable of being exercised 
on the artery itself at the close of life, which carries on the blood to the veins, 
after the further supply of fresh blood from the heart is stopped. The branched 
or stellated form of vessels, under which the vascularity usually appears, is capable 
of being imitated, either by injecting the veins with fine injection, or by forcing 
back with the finger, or the back of a scalpel, the blood from the larger branches 
of veins into the smaller." 44 And this vascularity soon becomes diffused redness, 
by transudation of the blood through the coats of the containing vessels, just as 
happens with the bile in the gall-bladder." 

Redness, from mere repletion of the smaller veins, is usually extensive and un- 
defined ; exeept that, being influenced by the force of gravity, it settles into the 
most depending parts of the organ, which are either its exclusive seat, or at any 
rate are of a deeper colour than the parts more elevated. It is attended with an 
empty state of the arteries, and with a full state of the larger veins. Hence the 
condition of the venous and arterial trunks, and especially of the vena portse, 
should, in doubtful cases, be ascertained before the main blood-vessels are laid 
open and drained of their contents. 

The redness that belongs to inflammation is generally circumscribed, and of 
limited extent ; it occupies indiscriminately the upper or the lower side of the tube 
(for these remarks apply alike to the stomach and to the intestines) ; it is attended 
with some fullness of the corresponding arterial trunks ; and it may or may not be 
coincident with comparative emptiness of the venous system within the abdomen. 
Much will depend, in this respect, upon the mode of dying, as I have fully ex- 
plained to you on a former occasion. 

You will please to remember, then, in all your future investigations into morbid 
anatomy, that it is generally difficult, and often impossible, to determine, from the 
aspect of the vessels of a dead part, from its redness, that inflammation had been 
present in that part during life, unless the unequivocal products or effects of inflam- 
matory action are present also. 

A much more certain evidence of inflammation of the mucous membrane of the 
stomach and intestines, is its softening. This can be attributed to nothing else, 
except it be to decomposition : and it is well known that this membrane is slow 
and late in passing into the state of putrefaction after death. To certain questions 
respecting perforations of the stomach I shall by and by return. 

I say that gastritis is most commonly the effect of poisons applied to the mucous 
surface of the stomach : but I must include under that head certain substances, 
which, to most people, are not poisonous or injurious at all, and which only 
become so to some persons under particular circumstances. Thus, large draughts 
'of cold drink, taken when the body is hot, and rapidly parting with its heat, and 
especially large draughts of cold sour liquors, as cider or stale beer, are apt to 
give rise to acute gastritis. Another occasional cause of gastritis is the ingestion 
of very large quantities of food at one time, especially during convalescence from 
any serious disorder. It is an exceedingly curious fact, too, but one which I 
merely mention without dwelling upon, that certain poisons introduced into the 



772 CHRONIC INFLAMMATION 

body through some other channel, will cause inflammation of the mucous mem- 
brane of the stomach, with which they have not been in contact. Corrosive 
sublimate, and arsenic, excite inflammation, with ulceration or sloughing of the 
mucous membrane, even when they are merely rubbed, in a. certain quantity, 
upon the skin ; or when they are inserted into the rectum. 

The treatment of acute gastritis is simple. The chief nicety respects the em- 
ployment of blood-letting. Early in the disease, if the pain be severe, you must 
try the effect of venesection, notwithstanding the smallness and feebleness of the 
pulse. How much blood you are to abstract cannot be told beforehand. Take 
away a small teacupful, keeping, meanwhile, your finger on the wrist. If the 
beat of the artery does not grow weaker, and still more if it becomes fuller and 
stronger, go on with the bleeding, and take another cupful, and another, according 
to the circumstances of the case and to the effects produced. Apply leeches to the 
epigastrium, and cover the bleeding bites with a soft, light poultice. Keep the 
patient as strictly as you can, in the horizontal posture: in other words, see that 
the depressing influence of the disease upon the action of the heart is riot aided 
and augmented by the position of the*body. If cold water is retained, that is the 
best medicine which you can give by the mouth ; purgatives so administered 
would be almost sure to be rejected ; and if not rejected, they would be likely to 
increase the existing inflammation of the organ. Enemata are, however, extremely 
useful : of warm water, if the bowels are not much confined ; of purgative mate- 
rials if they are. After the intestines have been thus cleared — or when they are 
loose and irritable — opiate injections (thirty or forty drops of laudanum, with 
three or four ounces of starch or gruel) do much good. They often have a very 
tranquilizing effect upon the irritable stomach, and check the vomiting. These 
measures are to be pursued until the inflammation has subsided. 

When any corrosive substance has been swallowed, I scarcely need say that 
pains should be taken to remove it as speedily as possible from the stomach; or 
to administer such remedies as are known to -be capable of decomposing the poi- 
son, or of affording a specific antidote to it. Not that the stomach-pump should 
be employed in such cases, as it too often is. These, however, are points that 
must be fully treated of in the lectures on forensic medicine, and therefore I shall 
dwell upon them no longer here. 

Chronic inflammation of the stomach is probably a very common disorder. 
It does not put life in Immediate jeopardy; and it is often recovered from. It 
deranges, however, the functions, and perverts the feelings of the stomach: it 
gives rise to the manifold and multiform symptoms of dyspepsia. But dyspepsia, 
with its manifold and multiform symptoms, may be, and often is, entirely inde- 
pendent of inflammation. You see, then, why the effects of chronic gastritis are 
various ; and why the symptoms that are supposed to denote its presence are apt 
to be obscure, uncertain, and equivocal. I intend, before I quit the subject of 
the stomach, to investigate the principal circumstances that mark its functional 
disorders, and to describe the means which we sometimes find effectual for their 
relief. I shall therefore restrict myself at present to a few points which seem to 
have been fairly ascertained respecting chronic gastritis. 

We know that chronic inflammation had been going on in the stomach when, 
after death, we see that its coats are thickened; or when we perceive that a por- 
tion of one or more of them has been removed by ulceration. 

It is not at all uncommon to find the mucous membrane of the stomach, over a 
larger or smaller space, thick, granular, uneven, and of an unnatural colour. 
Gray, or slate-coloured, it often is. This slate colour is much dwelt upon by the 
French writers, as being a sure and unequivocal impress of chronic inflammation. 
The colour proceeds, I believe, from the operation of the gastric acids upon the 
blood, Which under habitual congestion or slow inflammation, is detained in the 
vessels of the altered part. The ulcers that result from chronic inflammatory 
action* are usually small, varying from the size of a split pea to that of a shilling 5 



OF THE STOMACH. 



773 



sometimes with no surrounding vascularity or thickening at all, but looking 
exactly as though a piece of the mucous membrane had been struck out by a 
stamp; sometimes with rounded and elevated edges only ; and sometimes they 
occupy patches of thickening and induration of the parietes of the stomach. There 
may be one solitary ulcer; or a few ; or many. It is seldom, however, that they 
are numerous. 

Ulcerative disease of the stomach may prove fatal in various ways. The ulcer 
may penetrate as faras the peritoneum, and excite inflammation of that membrane, 
whereby the stomach becomes adherent to the neighbouring parts. In these cases, 
prior or subsequently to adhesion, death may at length ensue, from gradual ex- 
haustion and protracted suffering. 

If an ulcer happen to lie over the track of a large blood-vessel in the stomach, 
it may eat its way into that vessel, and give rise to fatal hemorrhage. 

Or the ulcer may perforate the walls of the stomach, without any previous 
adhesion, and suffer the food, or the secretions of the stomach, to pass into the 
peritoneal cavity, where intense inflammation is lighted up, and the patient soon 
perishes. 

Or the ulcers may at length heal. Of this we are certain, because we some- 
times find cicatrices marking the spots which the ulcers had occupied. 

The symptoms of chronic gastritis are pain or uneasiness in the epigastrium, 
increased by pressure ; increased also on the introduction of food, or perhaps felt 
only while digestion is in progress ; flatulence and eructation ; vomiting of mu- 
cus, and of the meals ; loss of sleep ; languor and debility. 

Not that even these symptoms are constant in all cases. Sometimes there is 
no actual pain, but a sense of heat or of acidity. The vomiting, too, in the outset, 
is occasional only ; and is then attributable, often, to some error or imprudence in 
respect to diet. And sometimes the complaint, may run nearly its whole course, 
up to one of the fatal terminations just now mentioned, with scarcely any other 
sign of its existence than uneasiness after meals, which subsides in two or three 
hours entirely. With the local symptoms I have been describing there are often 
conjoined some acceleration and hardness of the pulse : more or less thirst: a dry 
skin: scanty and deep-coloured urine: a red tongue; red especially at its tips 
and edges; patchy and fissured perhaps; or smooth and glossy, like a slice of 
raw meat. The throat is also frequently tender ; and the pharynx and palate 
unnaturally vascular. 

In attempting to relieve or cure chronic gastritis we have to guard against 
applying any thing to the inflamed surface which may be likely to add to the 
existing mischief, or which has been found, upon trial, to give pain. We employ 
at the same time the ordinary remedies of chronic inflammation. Leeches may 
be put upon the epigastrium, and repeated day by day, or every other day, in 
small numbers, so long as there is much tenderness on pressure. When the ten- 
derness is less, counter-irritation is very useful : repeated blisters ; or friction with 
the tartar emetic ointment over the region of the stomach. But, after all, the main 
dependence must be placed in the due regulation of the food, which should be 
mild and unstimulating in quality, and sparing in quantity. The well-known 
farinaceous substances which figure in the bill of fare of a sick chamber : arrow- 
root; sago ; tapioca ; gruel ; milk also ; and jellies. And even these bland articles 
of nourishment must be given in moderation, so as never to distend the stomach 
or to stretch its coats by their bulk, or to overtask its power of digestion. It is 
difficult, in such eases, to give precise rules for the management of the diet, which 
must be left to the common sense of the practitioner. 

With respect to internal medicines, they must be such as appear to be called 
for by particular symptoms. Of these, which are in fact the symptoms of dys- 
pepsia, I postpone the further consideration. Appropriate means must be used 
for the regulation of the bowels : mild laxatives by the mouth ; emollient or pur- 
gative enemata by the rectum. 

When I say that a good deal must be left, in these cases of chronic disease of 



774 



CHRONIC INFLAMMATION 



the stomach, to the judgment and good sense of the practitioner, I am forcibly- 
reminded of a most striking andinstructive case, beautifully told by the celebrated 
Dr. Wm. Hunter, in the sixth volume of the Medical Observations and Inquiries. 
The perusal of that history has afforded me hints upon which I have often aeted 
with great advantage to my patients, and with some credit to myself. As I doubt 
whether many of you would find immediate opportunity or leisure for [referring 
to the narrative, and as I should spoil it by attempting to give you an abstract of 
it, I am tempted to read it here in Dr. Hunter's own words. 

" Many years ago (he says) a gentleman came to me from the eastern part of 
the city, with his son, about eight or nine years old, to ask my advice for him. 
The complaint was great pain in the stomach, frequent and violent vomitings, 
great weakness, and wasting of flesh. I think I hardly ever saw a human crea- 
ture more emaciated, or with a look more expressive of being near the end of alt 
the miseries of life. The disorder was of some months' standing, and from 
the beginning to that time had been daily growing more desperate. He was at 
school when first taken ill, and concealed his disorder for some time : but growing 
much worse he was compelled to complain, and was brought home to be more 
carefully attended. From his sickly look, his total loss of appetite, besides what 
he said of the pain which he suffered, but especially from his vomiting up almost 
everything which he swallowed, it was evident that his disorder was very serious. 

" Three of the most eminent physicians of that time attended him in succes- 
sion : and tried a variety of medicines without the least good effect. They had 
all, as the father told me, after sufficient trial, given the patient up, having nothing 
further to propose. The last prescription was a pill of solid opium; for in the 
fluid state, though at first the opiate had stayed some time upon his stomach, and 
brought a temporary relief, it failed at length, and like food, drink, and every 
medicine which had been given, was presently brought up again by vomiting. 
The opiate pill was therefore given in hopes that it would elude the expulsive 
efforts of the stomach. It did so for a time; but after a little use, that likewise 
brought on vomiting. Then it was that his physician was consulted for the last 
time, who said that he had nothing further to propose. 

" Though at first the boy professed that he could assign no cause for his com- 
plaint, being strictly interrogated. by his father, if he had ever swallowed any thing 
that could hurt his stomach, or received any injury by a blow, or otherwise, he 
confessed that the usher in the school had grasped him by the waistcoat at the 
pit of the stomach, in a peevish fit, and shaken him rudely, for not having come 
up to the usher's expectation in a school-exercise. That though it was not very 
painful at the time, the disorder came on soon after. This account disposed the 
father to suspect that the rude grasp and shake had hurt the stomach. With that 
idea he brought him to me, as an anatomist, that an accurate examination might 
if possible discover the cause or nature of the disorder. 

" He was stripped before the fire, and examined with attention in various situa- 
tions and postures; but no fullness, hardness, or tumour whatever could be dis- 
covered ; on the contrary, he appeared everywhere like a skeleton covered with 
a mere skin ; and the abdomen was as flat, or rather as much drawn inwards, as 
if it had not contained half the usual quantity of bowels. 

" Having received all the information that I could expect, and reflected some 
little time upon the case, I wished to speak with the father alone, in another 
room; and to give my patient some employment as well as refreshment, asked 
him to take a little milk in the mean time. But his father begged that taking 
any thing into his stomach might be put off till he got home, because he was cer- 
tain that it would make him sick ; 'just before we set out (said he) I gave him a 
little mijk ; but he was sick, and brought it all up in the coach, before we had got 
many paces from the house.' 

" In the adjacent room I said to the father, This case, sir, appears to me so 
desperate, that I could not tell you my thoughts before your son. I think it most 
probable, no doubt, that he will sink under it; I believe that no human sagacity 



OP THE STOMACH. 



775 



or experience could pretend to ascertain the cause of his complaint: and without 
supposing a particular or specific cause, there is hardly any thing to be aimed at 
in the way of a cure. Yet, dreadful as this language must be to your ear, I think 
you are not to be without hope. As we do not know the cause, it may happen to 
be of a temporary nature, and may of itself take a favourable turn ; we see such 
wonderful changes every day, in cases that appear the most desperate, and espe- 
cially in young people. In them the resources of nature are astonishing. 

M Then he asked me if I could communicate any rules or directions, for giving 
him a better chance of getting that cure from nature, which he saw he must de- 
spair of from art. 

"I told him that there were two things which I would recommend. The first 
was not so important indeed, yet I thought it might be useful, and certainly could 
do no harm. It was to have his son well rubbed, for half an hour together, with 
warm oil and a warm hand, before a fire, over and all around his stomach, every 
morning and evening. The oil, perhaps, would do little more than make the 
friction harmless, as well as easy ; and the friction would both soothe pain, and 
be a healthful exercise to a weak body. 

" The second thing that I had to propose,, I imagined to be of the utmost con- 
sequence. It was something which I had particularly attended to in the disorders 
of the stomach, especially vomitings. It was, carefully to avoid offending a very 
weak stomach, either with the quantity, or quality, of what is taken down ; and 
yet to get enough retained for supporting life. I need not tell you, sir, said I, 
that your son cannot live long, without taking some nourishment; he must be 
supported to allow of any chance in his favour. You think that for some time 
he has kept nothing of what he has swallowed ; but a small part must have 
remained, else he could not have lived till now. Do you not think, then, that it 
would have been better for him if he had only taken the very small quantity 
which remained with him, and was converted to nourishment? It would have 
answered the end of supporting life as well, and perhaps have saved him such 
constant distress of being sick, and of vomiting. The nourishment which he 
takes should not only be in very small quantity at a time, but in quality the most 
inoffensive to a weak stomach that can be found. Milk is that kind of nourish- 
ment. It is what Providence has contrived for supporting animals in the most 
tender stage of life. Take your son home, and as soon as he has rested a little, 
give him one spoonful of milk. If he keeps it some time, without sickness or 
-vomiting, repeat the meal, and so on. If he vomits it, after a little rest, try him 
with a smaller quantity, viz., with a dessert, or even a teaspoonful. If he can 
but bear the smallest quantity, you will be sure of being able to give him nourish* 
ment. Let it be the sole business of one person to feed him. If you succeed in 
the beginning, persevere with great caution, and proceed very gradually to a 
greater quantity, and to other fluid food, especially to what his own fancy may 
invite him ; such as smooth gruel, or panada, milk boiled with a little flour of 
wheat or rice; thin chocolate and milk; any broth without fat, or with a little- 
jelly or rice or barley in it, &c. <&c. 

" We then went in to our patient again ; and that he might be encouraged with 
hope, and act his part with resolution, I repeated the directions with an air of 
being confident of success. The plan was simple, and perfectly understood. 
They left me. 

" I heard nothing of the case till, I believe, between two and three months after. 
His father came to me with a most joyful countenance, and with kind expressions 
of gratitude told me, that the plan had been pursued with scrupulous exactness, 
and with astonishing success ; that his son had never vomited since I had seen 
him; that he was daily gaining flesh, and strength, and colour, and spirits, and 
now grown very importunate to have more substantial food. I recommended a 
change to be made by degrees. He recovered completely ; and many years ago 
he was a healthy and a very strong young man."* 

* [Acute gastritis is a disease of by no means unfrequent occurrence during infancy, and: 



776 



CARCINOMA OF THE STOMACH. 



The stomach is very frequently the seat of specific malignant disease ; of can- 
cer, in its various forms and denominations. The fatal nature of this complaint; 
the obscurity in which it is sometimes wrapped ; the possibility of overlooking it 

then frequently causes a softening of the mucous membrane of the stomach, to which much 
attention has of late years been directed by the observations of Cruveilhier, Louis, Laisne, 
Billard, and others ; by several of whom it is described as a specific disease. It is to this 
particular lesion that we wish to direct attention in the present note, referring the reader 
for information on the subject of the inflammatory affections of the stomach generally, thai 
occur during the early period of life, to the Editor's Treatise on the Diseases of Children. 

The symptoms of the particular form of acute gastritis, to which we have reference, 
are very accurately described by Billard. The disease commences with the phenomena 
of a violent inflammation of the stomach; as tension of the epigastrium, which is painfa! 
to the touch; frequent vomiting, not only of the milk and drinks taken, but also of a 
green or yellow fluid ; the vomiting occurring every moment, without any reference to 
the period when the child has taken food or drink. There is, sometimes, diarrhoea, varying 
in different subjects, and returning after having ceased for a day or two ; the matters dis- 
charged from the bowels being often green, and similar to those brought up from the sto- 
mach by vomiting. The extremities are cold; the pulse is generally irregular; the. counte- 
nance has a permanent expression of suffering, the face remaining furrowed, as if the 
infant were crying; the cry is expressive of pain ; the respiration is interrupted, and the 
general agitation so great that the existence of a cerebral affection might be suspected. ' 
At the end of six, eight, or fifteen days, the patient sinks exhausted from the want of sleep, 
constant vomiting, and pain : in very young infants the disease is attended with little or no 
fever. 

Dr. Iselin, of Muhlheim, who had an opportunity of studying the disease during its extensive 
prevalence as an epidemic at Gottingen, gives the following description of its phenomena: 

Previous to the attack, the child is often, for several days, unusually restless and fretfu! 
• — finally, a decided febrile attack occurs, attended with a quick pulse, hot and dry skin, 
intense thirst, sleeplessness, and constant vomiting, increased upon food or drink being 
taken into the stomach. To these symptoms is speedily added a copious diarrhoea — the 
dejections being, at first, of a grayish colour, and of some degree of consistence, but sub- 
sequently of a yellowish or greenish serum, decidedly acid. The evacuations are usually 
preceded by contortions of the countenance indicative of pain, which are likewise induced 
by pressure on the abdomen. The latter is always much, often enormously distended, and 
its temperature, especially at the epigastrium, is often considerably elevated, while the ex- 
tremities are cool, or even decidedly cold. The patient exhibits great prostration oi'strength ? 
and a profuse partial perspiration soon breaks out, particularly about the head. 

The disease varies in its duration — proving fatal, in some cases, within twenty-four 
hours, and in others, not until after a continuance of several days, or even weeks. 

In the more violent cases, its onset is very sudden — and it is attended with frequent 
fainting, and an irregular and very quick pulse — the eyes and features are sunken — the 
body is bathed in a profuse perspiration. Convulsions, more or less severe, often attended 
with strabismus, sooner or later, occur; the face becomes of a bluish tint; the diarrhoea 
or vomiting, or both, soon become suspended; the accessions of fainting and convulsions 
become more frequent, and during one of these, death usually takes place. 

The intumescence and augmented heat of the abdomen, particularly of the epigastric 
region, and the coldness of the extremities, are, according to Dr. Iselin, to be considered as 
among the most constant and characteristic symptoms of the disease. The agonized ex- 
pression of countenance, and sunken appearance of the eyes, are likewise almost invaria- 
bly present, even from its earliest stages. 

The age at which this form of gastritis usually occurs is within the first year; it is not,, 
however, necessarily restricted to this period of life. 

The most constant lesion discovered after death, is a softening of the mucous membrane 
of the stomach, and often of the small and great intestines; the membrane being reduced 
to a disorganized and gelatinous pulp; or, the softening may extend to all the tissues of 
the stomach, rendering them liable to be perforated by the slightest force. In the stomach 
these softenings occur especially, according to Baron, Billard, and Iselin, at the great 
curvature, seldom extending beyond the most depending parts. Distinct traces of inflam- 
mation are occasionally observed, surrounding the softened parts, and patches of inflam- 
mation often exist, also, in different portions of the intestinal canal, especially in the small 
intestines. The parietes of the stomach frequently present a serous infiltration. 

Carswell, Burns, Gairdner, Carwell, Hope and other pathologists, deny the connection 
in these cases, of the softening of the gastro-ihtestinal mucous membrane, and inflamma- 
tion, and maintain that, in general, it is to be viewed as a cadaveric phenomenon, resulting 
from the action of the gastric juice upon the tissues of the stomach; others, with Jeeger, 
Zeller and Camerer, refer it to a paralysis of the nerves of the stomach, with increased 



CARCINOMA OF THE STOMACH. 



777 



altogether, or of confounding it with disease of a more innocent character, com- 
bine to invest it with peculiar interest. 

Carcinoma of the stomach has sometimes no symptoms at all, or none which 
the most sagacious practitioner would refer to the organ affected. Not long since 
I saw, in consultation, an elderly clergyman, who complained of pains in his back, 
which were brought on or aggravated by certain movements of the body. His 
bowels were costive; and purgatives always relieved his pains. He was passing 
lithic acid gravel. The pains were felt in or near the renal region. Several years 
before he had suffered in a similar manner; and had then been cured by being 
cupped in the loins. What was the matter here ? Was it lumbago ? Was there 
a calculus in one of his kidneys 1 These were the best guesses that I could make. 
The eminent physician whom I met, and a surgeon of no less eminence, who had 
seen the patient previously, had not been able to obtain any more exact diagnosis. 
Upon this gentleman's death, which occurred not long afterwards, his disorder was 
discovered to have been cancer of the stomach. Excepting slight sickness a 
day or two before he died, there had been no symptom to direct attention to that 
part. 

A young woman came into the Middlesex Hospital, under one of my colleagues, 

acidity of the gastric juices, by which the tissues of the organ are dissolved during the life- 
time of the patient. A somewhat similar opinion is entertained by Laisne, Chaussier, 
Desbarreaux, Bernard, and others. Without denying that the softening observed after 
death in the stomachs of children may be, in many cases, strictly a cadaveric phenome- 
non, and that, in other cases, it may result, during the lifetime of the patient, from other 
causes than inflammation, we are, nevertheless, well convinced from the result of repeated 
and cautious observations, that the gelatinous softening so frequently met with in the sto- 
mach of those infants who die after exhibiting all the symptoms of acute gastritis, is invari- 
ably the effect of an intense inflammation commencing in the mucous tissue of the organ. 

Softening of theparietes of the stomach, as well as of the intestines, unquestionably often 
takes place previously to the death of the patient, in cases where it cannot be supposed to be 
the result of inflammation. Thus, we not unfrequently observe in infants brought up by the 
hand, or improperly fed subsequently to weaning, a loss of appetite, peevishness, great 
restlessness, and want of sleep; the tongue becomes coated with a layer of white or yel- 
lowish mucus; and in some instances aphthae appear upon the parietes of the mouth, and 
the breath has usually a decidedly acid odour. There are a constant diarrhoea, and intense" 
thirst. The diarrhoea, after a time, frequently diminishes or entirely ceases — but soon 
returns again with increased violence — the discharges being a thin serous fluid of a yel- 
low or greenish hue, and having a very strong acid smell; great emaciation and.exhaustion 
soon ensue; the face and extremities become cold; the pulse small and irregular; the 
respiration quick and short. The child utters continually a low piteous moan, or lies 
upon his back with the eyes fixed, glassy, and half closed. No pain or tenderness is in- 
dicated upon gentle pressure of the abdomen; the latter is, however, often greatly swollen 
and tympanitic. The child becomes more and more exhausted, and, finally, expires quietly 
and without convulsions. 

This train of symptoms, with slight variations, mark that form of disease described by 
Camerer, Pommer, Hergt, Romberg, Droste and others, as gastro-malacia, and in which 
the stomach, and often the intestines likewise, present a gelatinous softening of their pari- 
etes, to a greater or less extent, but without the slightest indication of inflammation : the 
softening appearing to depend upon a diminished cohesion of the tissues — the result pro- 
bably of disordered or suspended nutrition. 

Acute gastritis as it occurs in the infant, is under all circumstances, and throughout 
all its stages difficult to manage, and but little under the control of remedies. At its very 
onset leeches to the epigastrium, followed by warm fomentations or soft emollient poultices 
assiduously applied will be found advantageous. Internally, minute doses of calomel will 
often remain upon the stomach and allay the excessive irritability of that organ; we have 
occasionally combined the calomel with the acetate of lead ; one-fourth of a grain of the 
first with half a grain to a grain of the second, will, in a large number of instances, very 
speedily control the vomiting and purging, and afford us time to reduce the local inflam- 
mation by leeches to the epigastrium, followed by blisters, kept on for one or two hours, 
and then replaced by an emollient poultice. The thirst of the child should be allayed by 
small quantities of some bland mucilaginous fluid, given cold, and repeated at short inter- 
vals. Slightly astringent and bitter infusions are recommended by some practitioners during 
the period of convalescence, and we think that we have seen very decided benefit result at 
this period from the proto-carbonate of iron in moderate doses. — C] 



778 



CARCINOMA OF THE STOMACH. 



with a pulsating tumour in her epigastrium. It was thought, at first, to be an 
aneurism, and the case attracted, on that account, a good deal of notice. But the 
tumour subsided very much after free purgation. This led some to suppose that 
it was formed by accumulated feces in the transverse colon. There was no sick- 
ness ; nor indeed any one symptom referable to the stomach. She died. The 
tumour was cancerous ; and in the stomach. Lying in front of the abdominal 
aorta, it had been lifted by its pulsations. 

Cases to the same effect are related by Dr. Seymour in the Medico- Chirurgical 
Transactions ; and by M. Andral in his Clinique Medicate. 

But even when the stomach is the organ pointed out, by the symptoms, as the 
probable seat of the malady, those symptoms fail, often, to indicate with any cer- 
tainty its nature. The effects of the carcinomatous disease exhibit no uniformity. 
The ingestion of food is apt to produce great distress ; but differently in different 
cases : sometimes as soon as the food is swallowed ; sometimes not for an hour 
or two afterwards. Some cases are attended with much pain ; some with none 
at all. One patient vomits continually ; another has little or no vomiting from 
first to last. 

Can these differences be in any way accounted for? Partly they may. By 
analyzing case after case, we approximate to a knowledge of their causes. But 
this knowledge is yet far from being complete. 

One circumstance that has a considerable influence upon the symptoms, is the 
situation of the disease. In respect to this point there are certain general rules 
which are for the most part true. Still we can speak of them only as applicable 
on the average; they are not absolute or infallible. 

The rules I mean are these : 

1st. That there is more suffering, caeteris paribus, when the cancerous disease 
is situated at, or very near, either extremity or orifice of the stomach, than when 
it occupies the intermediate parts ; whether in the greater, or in the lesser curva- 
ture. 

2d. That when the cardia, and its immediate neighbourhood, is the part solely 
or principally diseased, the food and drink find a hinderance in passing into the 
stomach ; but being once there, the distress is over. The symptoms are very like 
those of stricture of the oesophagus. The morsel reaches the bottom of that tube, 
and there causes uneasiness, till at length it is brought up again through the mouth, 
or passes gradually in the natural direction. 

3d. That when, on the other hand, the disease is limited to the pyloric end of 
the stomach, the food enters that bag readily enough, and remains there for a cer- 
tain time ; then uneasy sensations arise, and the imperfectly digested meal is apt 
to be rejected by vomiting. 

It is the difficulty of passing the doorway in these cases, that gives rise to the 
principal suffering ; the difficulty of getting into, or the difficulty of getting out of 
the stomach. But when the disease is confined to the intermediate space, no such 
difficulty occurs ; and therefore little or no pain. 

You must expect, I say, to meet with individual variations from these rules. A 
remarkable example of such variation was presented by one of my hospital pa- 
tients, in the year 1837. I have the notes of that case before me, which I will 
read short. 

Simon Ailes, aged thirty-six, admitted March 14. His main complaint was of 
pain in the epigastrium, always present, but augmented in frequent paroxysms, to 
an extreme degree of severity. At first, pressure gave him some relief. The 
pain was most violent an hour or two after he ate. He was troubled also with 
flatulence, and with sour eructations. Occasionally a clear tasteless fluid, looking 
like water, rose into his mouth. His bowels were costive. 

At this time his countenance was natural and placid ; but it gradually assumed 
that pinched and anxious expression, and that peculiar yellowish hue, which are 
so significant of organic visceral disease. He wasted fast. At length the epi- 
gastrium became tender as well as painful: but no tumour, except the left edge 



CARCINOMA OF THE STOMACH. 



779 



of the liver, could be felt there. He died on the 11th of May, about eight months 
from the commencement of the pain. A week before his death he vomited some 
dark, grumous, offensive fluid, evidently containing blood. With this exception 
he had no vomiting. 

Many remedies were tried, which 1 do not specify, for none of them gave him 
any sensible or continued relief. 

In the smaller curvature of the stomach we found a ragged, sloughy surface, as 
big as the palm of one's hand, and extending to within half an inch from the 
pylorus. A section of this diseased portion exhibited the characters of true scir- 
rhus : a white and hard mass, nearly half an inch across at its thickest part. The 
mucous membrane of the duodenum was congested, and dark-coloured. The 
rest of the intestines were healthy except the rectum, which was surrounded, 
towards the anus, by scirrhus and thickened areolar tissue, intermixed in laminae. 
The gut itself was not affected. 

The diseased stomach was removed, and examined by Mr. Kiernan, who 
found, upon careful dissection, that the trunk of the gastric branch of the par 
vagum run directly into, and was lost in, the scirrhous mass. This sufficiently 
accounted for the dreadful sufferings of the patient. ^ 

And I am here reminded that, with regard to the structural alteration itself, 
there are some circumstances well worth attending to. 

Andral places all these organic affections of the stomach in the class of chronic 
gastritis. But it is clear that he is wrong: and you will perceive at once that it 
is of immense importance to recognize the specific disease from the mere result 
of common inflammation. 

But though cancer is not, in any case, a mere product of common inflamma- 
tion, neither is all that is called cancer really such. Specimens of morbid tex- 
ture, misnamed scirrhus of the pylorus, are not uncommon in anatomical museums, 
I show you some from our own; not so denominated, however. The correct 
labeling would be hypertrophy. You may perceive that the areolar and the mus- 
cular tissues near the pylorus, are very much thickened. A section of the thickened 
parts presents an appearance somewhat like horn ; and is crossed by whitish lines 
that run nearly parallel to each other. The morbid structure is quite definite and uni- 
form ; and very dissimilar, in that respect, to the irregular masses of scirrhus, and 
to the amorphous deposits of encephaloid cancer. Neither does it at all resem- 
ble that of the colloid variety of carcinoma. Changes of this kind are liable to 
occur in the muscular tissue of this, as of other organs, whenever a permanent 
obstacle is opposed to the onward progress of the contents of the hollow viscus, 
The impediment may have been originally produced by inflammatory thickening 
of the textures composing the pylorus; and then the hypertrophy may, in a cer- 
tain sense, be accounted a consequence of inflammation. To that extent alone is 
M. Andral right. He has unquestionably pushed his theory on this subject too 
far. Whatever narrows the pyloric orifice leads to increased effort of the propel- 
ling muscle, and to augmentation of its bulk and power. Now cancer itself, situ- 
ated at, or close upon, the pylorus, may impede the exit of the digested aliment ; 
and then it causes a gradual hypertrophy of the.muscular coat. In these cases 
there is a mixture of the two changes ; of the cancerous growth, with the mus- 
cular hypertrophy : and this is one reason why they have been confounded to- 
gether. Here are several preparations, exhibiting true cancer of the stomach. At 
the bottom of each bottle may be seen a sort of whitish powder, or sediment, 
consisting of some of the matters peculiar to cancer. This fact has been pointed 
out to me by Mr. Kiernan in the numerous specimens contained in his private 
collection. But there is no such deposit when the hypertrophy is not combined 
with malignant disease. 

It has long been thought and asserted, that cancer of the stomach is not so apt 
to be attended, as cancer of other parts, with a disposition to present itself in 
various organs of the body at the same time, or in succession. Now I believe— 
and I am glad to add the weight of Mr. Kiernan's authority to my statement-- 



780 



CARCINOMA OF THE STOMACH. 



that this is not really so. Cancer is a constitutional affection : or, if local and 
solitary in the outset, is prone to disseminate itself. The error has arisen out of 
that confounding of one morbid condition with another, against which I have 
been warning you. Instances are not at all uncommon of thickening of the areolar 
and mucous tissues about the pylorus, producing first a mechanical impediment 
to the passage of the food, then more energetic muscular efforts towards its ex- 
pulsion from the stomach, and at last hypertrophy of the muscular tunic. In 
these cases, you do not find cancer in other organs : because, in fact, there is no 
cancer in the stomach. 

You may say that as both forms of disease are alike fatal, it signifies nothing 
whether there be really cancer or not. But it is always satisfactory to clear away 
an apparent anomaly, and to show that it has no real existence. Besides, you 
know with how much anxiety the relatives of the dead inquire concerning these 
matters. That cancer U runs in families" is well understood even by the public : 
and the distinctions I have been pointing out are surely worth learning, if they do 
no more than enable us to comfort the minds of survivors, and to relieve them 
from the apprehension that they also may be doomed or likely to become the 
victims of cancer. 

Notwithstanding what I have now been saying, it must be allowed that genuine 
cancer of the stomach is accompanied less frequently than some other modes of 
carcinomatous disease, by cancer elsewhere. In fact cancer of the stomach is 
most often of the scirrhous variety, which until it softens is not so readily dis- 
seminated as the others, and which is apt to prove fatal before it softens. 

When primary cancer of the stomach is of the encephaloid kind, or when, being 
scirrhous, it begins to grow soft, — you would expect, after what was stated respect- 
ing suppurative phlebitis, that its secondary manifestation should occur chiefly in 
the liver. And it is so: the reason being that the veins of the stomach commu- 
nicate with the general system not directly, but through the hepatic capillary 
system. 

But to return to the symptoms of carcinoma of the stomach. In some cases, I 
say, the food is rejected by vomiting: in some cases it is not. Now it has been 
argued that this difference depends upen the condition of the pyloric outlet; 
whether it be free and open, or contracted and shut. The explanation is more 
plausible than sound. It is not strictly consistent with facts. Vomiting of the 
food has been an urgent symptom, when there was no mechanical bar to its pas- 
sage into the duodenum. The pylorus is a sphincter muscle, of which the natural 
and habitual state is that of contraction. It yields, however, in health, to the 
pressure of the digested aliment, which is driven forwards by the muscular fibres 
that surround, and compress by their action, the pyloric end of the stomach. If 
there be a mechanical impediment, that affords a sufficient reason why the food 
should be thrown up again. But sometimes, I repeat, the orifice is wide open, 
and yet the food is rejected : and it is rejected because the disease so involves the 
pyloric end of the stomach, that the propelling force cannot be exercised. 

When there is a mechanical obstacle, the disposition to hypertrophy of the 
muscular coat is conservative. But in feeble and delicate persons, the baffled 
muscles may never acquire strength enough to overcome the impediment; and 
then the very opposite condition is apt to take place : the coats all become very 
thin; meal after meal is retained; the stomach is enormously distended, and 
relieves itself now and then, at distant intervals, by copious vomiting ; until at 
last it is unequal to that effort, and the patient dies. 

Sometimes the sickness and vomiting are urgent even when the stomach con- 
tains no food: and the matters rejected are of various character and appearance. 
They often resemble coffee-grounds, and consist, no doubt, of altered blood. 
Vomiting of this kind is a very pregnant sign of organic mischief in the stomach. 

Emaciation is another ugly circumstance in these cases ; and forms a strong 
ground of presumption that the symptoms depend upon structural disease. Yet 
it is not a uniform consequence, even of malignant disorganization of the stomach. 



HiEMATEMESIS. 781 



Napoleon Bonaparte was very fat when he died. His omentum is described as 
having been " remarkably fat:" and " the fat was upwards of an inch thick upon 
his sternum, and one inch and a half upon his abdomen." 

The existence of a palpable tumour strengthens the unfavourable diagnosis. 
But this is far from being a constant phenomenon. It is not even pathognomonic 
when it does occur. The diseased head of the pancreas has been mistaken for a 
thickened pylorus. The stomach is liable also to be dragged much out of its 
place ; and then a thickened pylorus may be mistaken for something else. Some- 
times the form of the stomach may be distinctly traced. In the person of a medi- 
cal practitioner who died lately in this neighbourhood, the shape of the organ, its 
occasional peristaltic motions, and the irregular and hardened pylorus, were plainly 
to be felt. They might indeed almost be seen, in the hollow and attenuated abdo- 
men. When a tumour is ascertained to belong to the stomach, it indicates disease 
of the pylorus rather than of the cardia. 

It is a curious feature in these malignant diseases of the stomach, that the 
symptoms sometimes remit, in a remarkable manner ; so as to excite a hope in 
the mind of the patient, and in that of his medical attendant, that the nature of 
the malady had been mistaken; and that recovery is about to take place. But the 
truce is not for long. Frightful disorganization is at length produced, ragged 
ulceration, perforation of the coats of the stomach, adhesion to the parts adjacent, 
which thus are constituted adventitious walls ; — and inevitable death at last. 

The treatment of this dreadful complaint can only be palliative. If there be 
^.pain, we are driven, sooner or later, to opium. Anodyne enemata have often as 
good an effect in relieving the pain as opium given by the mouth ; and they have 
this advantage, that their constipating properties are more easily obviated than 
when that drug is put into the stomach. Nutritive injections are proper when 
food taken through the natural channel is not retained. 

Other palliative measures may be aimed at particular symptoms ; of these I 
propose to speak when I come to the symptoms and remedies of dyspepsia. 



LECTURE L X I X. 

Hemorrhage from the Stomach : sometimes from a large vessel, usually by ex- 
halation. Idiopathic Hsematemesis. Vicarious Haematemesis ; Hsematemesis 
from Gastric disease or injury: from disease in other organs. Melsena, 
Haematemesis from a morbid state of the blood. General phenomena of Hse- 
matemesis. Diagnosis. Treatment. 

Hemorrhage from the stomach, to which I wish next to direct your attention, 
is of much more frequent occurrence than acute gastritis. It is a complaint, or a 
symptom, that presents several points of interest and importance. I use the phrase 
" hemorrhage from the stomach," rather than the single term " haematemesis," 
because that term, signifying strictly a vomiting of blood, does not necessarily 
imply hemorrhage from the stomach ; nor, indeed, does it always accompany such 
hemorrhage, although it is one of its most common and most striking symptoms. 

What I have so frequently mentioned in respect to hemorrhages from the mucous 
membranes generally, viz., that the efflux of the blood is seldom owing to the 
rupture of a large blood-vessel, holds true in this. It can rarely happen that any 
vein or artery belonging to the stomach is divided or laid open by accidental injury, 
so as to pour forth its blood. When hemorrhage does proceed from one or more 
of the larger blood-vessels, the opening by which the blood escapes is commonly 
the result of chronic ulceration; such as I spoke of yesterday. I have not, my- 
self, met with an instance of that kind. Andral states, that, at most, there are 
but five or six such cases to be found in the records of medicine. Since his work 



782 



HiEMATEMESIS. 



on Pathological Anatomy was published, another example of the same lesion has 
been detailed in the Journal Hebdomadaire for May, 1 830. I show you a drawing 
after Dr. Carswell, representing an ulcer which laid open the coronary artery of 
the stomach, and caused fatal hemorrhage. In these cases, we have, first, the 
symptoms of chronic gastritis ; next, faintness, or actual syncope, from the sudden 
abstraction of a large quantity of the vital fluid; and lastly, the visible eruption 
of the blood itself; for vomiting seldom occurs iintil a large quantity of blood has 
accumulated in the stomach. 

As this variety of gastric hemorrhage is rare, I will briefly relate an instance of 
it, which occurred in the year 1831, at St. Bartholomew's Hospital. Dr. Latham, 
who had charge of the case, was good enough, some time ago, to give me the 
following history of it. The subject of the disorder was a man thirty-eight years 
old. He was admitted on the 19th January. His countenance was dusky, but 
exsanguine; his pulse 100, and weak; his tongue pale, and slightly furred. He 
made no complaint of pain anywhere. 

He had been ailing for two years; had suffered much pain across the epigastric 
region; and had frequently vomited his meals. Two days before, he had been 
suddenly attacked with faintness and giddiness, and then vomited about two quarts 
of blood. He was an habitual spirit drinker. 

In the afternoon of the day on which he entered the hospital, he was again 
seized with giddiness ; and fell into a state of syncope, in which he remained for 
several minutes. Upon recovering, he vomited a large quantity of blood, not less 
than three pints. The next morning, early, he brought up a like quantity, under 
similar circumstances ; and he passed three evacuations from the bowels, all of 
them black. He was gradually sinking during the whole of that day, the 20th. 
Towards the evening, he vomited about half a pint more blood. He died quietly 
the next morning. 

When the abdomen was laid open, the stomach was seen to be distended. The 
intestines had, in several places, a black appearance, from the colour of their 
contents. The stomach contained about two pints of coagula, and of a dirty red 
liquid. At the upper part of its lesser arch was a small excavated ulcer, with 
hardened edges. In the centre of this ulcer there were visible the orifices of three 
or four arteries, filled with minute clots of blood. 

It would seem as if gastric hemorrhage, having this origin, were capable of 
being stanched by some natural process ; and as if the injury done to the stomach 
were susceptible of repair. Andral describes a curious case, in which an open 
blood-vessel was found in an ulcer of the stomach ; but no hemorrhage had occurred. 
That mere ulcers in the stomach may heal, there can be no doubt: two or three 
scars of healed ulcers are represented in Dr. Carswell's drawing. The patient 
whose case is related in the Journal Hebdomadaire had vomited considerable 
quantities of blood for eight days in succession, five years previously to the attack 
which terminated his life. So that haematemesis from this cause is not absolutely 
hopeless. 

But (as I have already said) hemorrhage from the mucous membrane of the 
stomach, and from that of the alimentary canal generally, takes place far more 
commonly by exhalation. The evidence that the blood really does ooze from the 
membrane is the same as that to which I have so often had occasion to advert ; 
and it is very satisfactory and conclusive in these cases, because we are able to 
scrutinize closely the whole extent of the mucous surface. This cannot so well 
be done in regard to the mucous membrane of the lungs. When death has 
followed immediately upon the hemorrhage, and has indeed been its rapid effect, 
the membrane has been found quite entire, and of its natural consistence and 
texture throughout. Sometimes partially red and pulpy, and vascular ; sometimes 
universally so, the submucous capillary net-work of vessels being still gorged with 
blood ; sometimes quite pale, the same system of vessels having been completely 
emptied by the last attack of hemorrhage ; and sometimes studded with minute dark 
points, which could be made, by slight pressure, to start from the surface, and 



HiEMATEMESIS. 



783 



looked like grains of black sand. This latter appearance, as I once before remarked, 
is very corroborative of the opinion that the blood escapes through the natural 
pores or channels : which it cannot enter so long as the solids and fluids of the 
body retain their healthy condition.. These sand-like bodies are, doubtless, small 
portions of blood, which have coagulated in the exhalant orifices of the membrane, 
and received from them their shape. 

This kind of hemorrhage happens under various circumstances; and is attended 
with different degrees of danger. 1. The bleeding may be idiopathic. 2. It may 
be vicarious of some other habitual hemorrhage. 3. It may depend upon disease 
or injury of the stomach itself. 4. It may be the consequence of disease situated 
elsewhere, and producing, mechanically, a plethora of the veins of the stomach. 
5. It may result from a morbid condition of the blood, and form one symptom of 
a more general disease ; as in the passive hemorrhages of purpura and sea-scurvy. 
Each of these varieties requires a short notice. 

1. Hemorrhage strictly idiopathic — i. e., independent of any apparent change 
of texture, whether in the surface itself, or in any part obviously capable of influ- 
encing its blood-vessels — is as rare, I believe, from the mucous membrane of the 
stomach, as from that of the lungs. I have never seen, nor do I recollect to have 
read of, any instance of haematemesis analogous to the epistaxis which is so 
common in children and young persons ; and which affords the most familiar 
example of idiopathic hemorrhage. 

2. But hemorrhage from the stomach, occurring in connection with other consti- 
tutional hemorrhages, or in their stead — and above all, occurring vicariously of 
menstruation — is abundantly common* It is the most common indeed of all the 
species of hemorrhage by deviation. I told you, in a former lecture, that patients 
will sometimes menstruate for years together through the lungs ; without any 
apparent injury to their general health. More commonly still do they menstruate 
through the stomach. I will mention one concise but singular example of this 
which I had from Dr. Latham, and which came within his own knowledge. A 
young woman became the subject of haematemesis, recurring at monthly periods, 
about the age of fourteen. She had never menstruated. This continued until 
she married, "and indue time, fell with child. Thereupon the haematemesis ceased. 
She brought forth and suckled her infant. During lactation the hemorrhage did 
not recur. It came on again soon after she ceased to nurse the child; no regular 
menstruation by the uterus having ever happened. This was the woman's own 
account, and there appeared no reason to question its accuracy. 

Gastric hemorrhage of this kind, vicarious of regular menstruation, is not gene- 
rally thought to have any tendency to shorten the existence of those who are 
afflicted with it. Cullen states broadly that this species of haematemesis is hardly 
ever a dangerous disorder: and this is true. Yet it is not so entirely free from 
peril as to preclude the necessity of some caution and qualification in stating the 
prognosis. The exhaustion from the mere loss of blood is sometimes so great as • 
to create serious alarm for the patient's safety. And Mr. North has recorded (in 
the London Medical and Physical Journal) two instances in which suppressed 
menstruation was followed by repeated and at length fatal haematemesis. In 
neither of these women was the health seriously deranged ; nor, previously to the 
hemorrhage, did there exist debility, or any other symptom calculated to excite 
the apprehension of danger. In fact, in both of these cases, a strongly favourable 
prognosis was given by experienced physicians a very short time only before the 
fatal event. 

3. Gastric hemorrhage, by the way of exhalation, is often a consequence of 
disease or injury of the stomach itself. It is sometimes one of the earliest 
declaratory symptoms of scirrhus or cancer of that organ — occurring long prior 
to ulceration. Haematemesis attends, also, very commonly, the ultimate stages of 
that fatal disease: and then it maybe owing to the erosion of some vessel of nota- 
ble magnitude, in the course of the process of disorganization, as in the examples 
already spoken of : or (what I believe is far more common) it may result from a 



784 



HJEMATEMESIS. 



kind of general oozing or exhalation from the ulcerating surface. Blood is often 
vomited soon after the reception of strongly irritant poisons into the stomach. I 
show you again Dr. RoupePs plate, representing the crimson surface of a portion 
of the stomach of a dog which had been killed shortly after the administration of 
a dose of alcohol. The intense congestion thus produced is doubtless active con- 
gestion ; congestion belonging to inordinate arterial action. Pushed a degree 
further, such congestion passes into hemorrhage. 

4. On the other hand, intense passive congestion — congestion arising from the 
detention of blood in the veins by some mechanical obstacle to its progress — is a 
very common source of gastric hemorrhage. Haematemesis is therefore an occa- 
sional symptom of obstructive disease of the heart. Much more frequently, 
however, it depends upon abdominal changes. The hemorrhage is symptomatic 
of disease situated not in the stomach itself, but elsewhere. And the viscera, 
with the diseases or morbid conditions of which, bleeding from the stomach is 
most often connected, are the liver and the spleen. 

All this is well known : and it is easy to see, from the peculiar construction of 
the venous apparatus in the abdomen, how disease of one or both of these viscera 
may produce mechanical congestion of the submucous capillary tissue ; and how 
that congestion may be relieved, under certain circumstances, by the effusion of 
serous fluid on the one or the other surface, constituting' ascites or diarrhoea, as 
the case may be ; or under other circumstances, not perhaps easily discriminated 
or well understood, by the extravasation of the collected blood itself. It would 
be superfluous to describe the peculiar distribution and functions of the vessels 
which return the main portion of the venous blood from the stomach and intes- 
tines towards the heart. It seems to me highly probable that one at least of the 
offices of the spleen is to provide a receptacle or reservoir for this blood when its 
free passage through the portal vessels is temporarily obstructed. It then becomes 
a sort of safety valve (if such an illustration be allowable), which obviates the 
danger that might otherwise arise to more vital parts from any great or sudden 
disturbance of the venous circulation. The stress of the congestion is continually 
felt in the submucous capillary system ; and the hemorrhage which is apt in such 
cases to occur from the loaded membrane, receives a simple solution upon princi- 
ples almost purely mechanical. Nay, the very circumstances which lead to the 
effusion of the blood from the mucous surface on the one side, rather than from 
the serous on the other, may perhaps (as I stated more at large in an early part of 
the course) be themselves susceptible of mechanical explanation. 

Gastric hemorrhage, symptomatic of hepatic disease, is chiefly to be looked for 
in those morbid conditions of the liver which imply obstruction of the portal vein 
and of its ramifications. We are not surprised, therefore, to find it coincident, 
often, with a contracted and shrunken state of that organ. The state of the spleen, 
on the contrary, for reasons that must be obvious to you, is uniformly, in the 
cases we are now considering, a state of enlargement. And the augmentation of 
bulk is not so much to be ascribed to disease inherent in its proper texture, as to 
distension by the mere quantity of blood which it holds. The internal structure 
of the spleen furnishes a credible presumption in favour of that view of one of its 
uses to which I just now alluded ; and this structure, and this presumed function, 
when considered together, throw a strong light upon some of the pathological 
relations of the spleen which #ell deserve attention. 

Numerous instances are on record of haematemesis going along with evident 
enlargement of the spleen ; and in some of them that organ has been observed to 
diminish in bulk, in proportion as blood was poured out by the stomach. If I 
am not greatly mistaken, I have more than once seen this myself. In such cases 
the tumid condition of the spleen may be regarded as an evidence of venous 
obstruction elsewhere; and, as depending, sometimes at least, upon disease of a 
less striking and prominent character in the liver, impeding the progress of the 
blood through the vena portae. Of this kind would seem to have been a case 
related by Morgagni, wherein, after repeated attacks of haematemesis, under which 



HJEMATEMESIS. 



785 



the patient sank at last, the spleen was found to weigh four pounds, and to be 
gorged with dark blood ; while the liver was pale and exsanguine. Frank gives 
the history of a patient, who had vomitings of blood, and whose spleen, taken 
from the body after death, weighed sixteen pounds : the ordinary weight of the 
spleen in a healthy adult being from eight to ten ounces. In Latour's work on 
Hemorrhage, which is remarkable for the number of examples it contains, col- 
lected from various sources, and amounting to nearly a thousand, several instances 
are detailed of this combination of splenic enlargement with haematemesis. One 
of these occurred in the person of a friend of his, who had been living in a mala- 
rious district, and who had laboured for nearly two years under obstinate inter- 
mittent fever. This was followed by an immense enlargement of the spleen — a 
great ague-cake — which came to occupy almost the whole of the abdomen. La- 
tour's experience enabled him to predict that haematemesis would probably super- 
vene upon this condition of the spleen ; and, accordingly, one night he was called 
in a hurry to his friend, and found that he had vomited an enormous quantity of 
clotted blood. A great deal passed away through the bowels also. The hemor- 
rhage recurred from time to time, till in the course of a month the spleen was so 
far reduced in bulk, that it could no longer be felt in the belly ; and the patient 
lived and enjoyed good health, for twenty-five years afterwards. 

It is necessary, therefore, in marking the connection which frequently subsists 
between haematemesis and enlargement of the spleen, to guard ourselves against 
concluding that these two circumstances hold always the relation of cause and 
effect. In many such cases, probably in most of them, they are simply concur- 
rent effects of one common cause ; and that cause is chiefly to be sought in such 
morbid conditions of the liver — or of other parts within the abdomen — as are 
competent to produce a considerable impediment to the free transmission of blood 
through the system of the vena portse. 

When gastric hemorrhage results from hepatic obstruction, there is almost 
always intestinal hemorrhage also. At any rate there are almost always black 
alvine evacuations', like tar or dark paint. This form of disease has therefore 
been called melsena. The ancients supposed that the unnatural stools consisted 
of black bile. 

Hemorrhage from the stomach, independent of disease in that or any other part, 
sometimes happens in the advanced periods of utero-gestation. Yet, though it 
does not result in these cases from disease, it is difficult to class it among idio- 
pathic hemorrhages. The want of periodical recurrence, and the absence of 
the hemorrhage during the earlier months of pregnancy, are circumstances which 
sufficiently refute the old notion, that this form of haematemesis depends also 
upon the suspension of the catamenia. It is caused, no doubt, by the pressure 
of the gravid uterus, which impedes mechanically the venous circulation in the 
abdomen. 

5. Gastric hemorrhage, resulting from changes in the blood itself, occurs in 
sea-scurvy, in purpura hemorrhagica, and in the yellow fever. Being merely a 
symptom in these cases, it requires no separate consideration here. 

When a large quantity of blood is poured into the stomach, whatever may- 
have been its source, it appears to have a nauseating and emetic effect. At least 
the blood ejected in haematemesis is'almost always considerable in amount. The 
vomiting may, for aught I know, be dependent on the mere distension of the sto- 
mach, which appears to be tolerant of the presence of the blood up to a certain 
point, but no further. A small quantity may, doubtless, pass all of it onwards 
through the pylorus, after undergoing, more or less completely, the process of 
digestion in the stomach; and a portion of the blood pursues that course in most 
instances. But when it is vomited, it comes up in large quantities, usually of a 
dark colour, and more or less coagulated. Sometimes the coagula have evidently 
been moulded in the stomach; and sometimes clots are thrown up, partially de- 
prived of the colouring matter of the blood, and resembling the fibrinous polypi 
50 



786 HiEMATEMESIS. 



so often met with in the cavities of the heart. Of course the degree of the coagu- 
lation of the blood, and of its separation into serum and crassamentum, will depend 
upon the time that it remains in the stomach ; and this again would seem to bear 
a proportion to the rate of its effusion. 

The blood that is vomited is almost always of a dark colour ; while that which 
is coughed up is most frequently florid and bright. Why is this? We are told 
that the blood which comes from the lungs is rendered florid by the admixture of 
atmospheric air. But this is not the whole of the matter. Neither can we say 
that the dark hue of the blood ejected in haematemesis is always, or solely, due to 
some morbid alteration effected in that fluid while yet circulating in its proper 
vessels. There is another cause, which till of late years, was much overlooked, 
but which frequently changes the colour and appearance of the blood after it has 
been extravasated into the stomach ; and that in so great a degree as sometimes to 
render doubtful, or to disguise altogether, the real nature of the fluid vomited. I 
mean the chemical agency of the gastric acid. The effect of acids in blackening 
the blood out of the body is well known ; and it is somewhat singular that the 
ascertained existence of an acid secretion in the stomach, varying in quantity at 
different times and under different circumstances, was not sooner applied in expla- 
nation of the dark colour of the blood, and its occasional blackness, when vomited. 
The degree of blackness will be in proportion to the relative quantity of acid 
which it meets with in the stomach, and the intimacy of the admixture. Some- 
times the blood is clotted and not very much altered in colour; sometimes it is 
grumous, brown, of a chocolate tint, or like coffee-grounds. This generally de- 
notes the existence of organic disease; and the appearance of the blood is probably 
modified in some degree by the morbid process that leads to its effusion. There 
is good reason for believing that in the black vomit of the yellow fever, the colour 
of the blood undergoes alteration, even while it is yet circulating through the 
blood-vessels : but that the black appearance of the matter vomited is in great part 
owing to the chemical action of the gastric acid, may be inferred from the fact, 
that the fluid so discharged is always (sol am informed) intensely acid. Andralhas 
described an effusion of black liquid into the stomach, as an example of melanosis. 
He states at the same lime that an accurate analysis of the liquid showed its com- 
position to be very nearly the same with that of the blood. May we not suspect 
that this inky fluid really consisted of blood that had been blackened, subsequently 
to its extravasation, by the acid with which it mixed in the stomach ? Upon the 
same principle may be explained the dark brown, or almost black colour of the 
spots which are sometimes seen (I presume when there has been a great pre- 
dominance of acid) in the substance of the mucous membrane of the stomach, or 
even beneath it; and which have also been set down as melanotic. They are so 
like, in all circumstances, except in the single particular of colour, to the crimson 
spots which are obviously formed by minute extravasations of blood in the same 
parts, that we can scarcely refer them to any other source. The slate-coloured 
patches, which I spoke of yesterday as being vestiges of chronic gastritis, depend 
likewise upon the blackening effect of the gastric acid upon the congested surface. 
We have the same dark colour of the effused blood-, in many cases, when it is 
poured out in the intestines. Here, of course, its colour is not referable to the 
gastric juice ; but it is blackened by some of the intestinal gases : probably by the 
sulphuretted hydrogen, for example, or the carbonic acid that enters into their 
composition. 

There can be no doubt that this gastric acid, when intense in strength, or copious 
in quantity, is capable of changing the colour of the blood, after death, even while 
it is contained in the sub-mucous blood-vessels. In these cases it must be con- 
veyed to the blood by imbibition. And the very same thing takes place when 
strong acids are introduced into the stomach from without. When, for instance, 
the sulphuric acid, or what is perhaps more to our present purpose, the vegetable 
oxalic acid, has been taken as a poison, it has the effect of blackening, and, as it 
were, charring the blood, with which the membrane becomes loaded in consequence 



DIAGNOSIS OF GASTRIC HEMORRHAGE. 



787 



of the irritation produced by the poison. It does this when no destruction of the 
mucous membrane has been produced. 

It is but justice to observe, that the credit of having been the first to perceive, 
and to explain, this cause of the blackened state of the blood, while yet remaining 
in its proper vessels, is due to Dr. Carswell. 

When the blood is injected through the oesophagus and mouth, we have demon- 
strative evidence of the existence of hemorrhage; and the diagnosis of hasma- 
temesis may appear to be so simple as to admit of neither mistake nor doubt. 
The diagnosis of hemorrhage from the stomach, however, is really oftentimes 
difficult and obscure, and to be established by presumptive evidence alone. 

In the first place, bleeding may take place from the mucous membrane of the 
stomach, and no haematemesis ensue, especially when the blood is poured forth in 
small quantities and slowly. In these cases the blood becomes visible only in the 
stools, where it may not be looked for, and where, if seen, it may not always be 
recognized, in consequence of the changes it has undergone during its passage 
through the intestinal canal. And even supposing that its presence is detected in 
the alvine evacuations, it will remain uncertain in what part of that long canal it 
was effused. The hemorrhage may even be profuse, and the patient may die, 
without any escape of the blood externally. There is a case related by Frank, in 
which death took place from hemorrhage of the stomach without haematemesis ; 
and both the stomach and the intestines were found distended by an enormous 
coagulum of blood which had assumed their form. 

Even when the blood is ejected by the mouth, the exercise of some care and 
sagacity is occasionally, though not always required, in order to determine the 
part from which it was originally poured out. 

Thus blood may be swallowed, and afterwards vomited : and so we may have 
haematemesis without hemorrhage from the stomach; just as we may have he- 
morrhage from the stomach without haematemesis. There are cases of slow bleed- 
ing from the lungs, the fauces, the mouth, or the nasal cavities, where the blood, 
collecting in the pharynx, provokes, from time to time, an instinctive and invo- 
luntary act of deglutition ; and thus is gradually accumulated in the stomach up to 
that point at which the organ becomes impatient of its contents, and ejects them 
by vomiting. This is very apt to happen during sleep, and especially to young 
children: and as the blood, when vomited, is coagulated, and in considerable 
quantity, it is scarcely possible to conclude, from its mere appearance, that it has 
proceeded from any other source than the stomach itself. If, however, we mis- 
take such cases, our error is likely to produce much needless alarm, and to lead 
us to unnecessary activity in treating them. We are assisted towards forming a 
right judgment (when our attention happens to be directed to this source of fal- 
lacy), partly by the general history and symptoms, and partly by an examination 
of the mouth, fauces and nostrils, to ascertain whether any coagula, or other 
marks of hemorrhage, are visible on the mucous membrane belonging to those 
parts. 

But blood may be swallowed knowingly and purposely by impostors, and after- 
wards vomited. Haematemesis is one of the complaints which have frequently 
been feigned ; either for the sake of avoiding some imminent punishment, or dis- 
tasteful service; or with the view of exciting compassion, and of profiting by the 
contributions of the charitable and the credulous ; or sometimes from a kind of 
wilful perversity, akin to insanity. In treatises on forensic medicine, you will 
generally find reference made to an instance of this kind recorded by Sauvages, in 
his Nosology. A young girl, who was anxious at all hazards to escape the con- 
straints of a convent, pretended that she was suffering from violent haematemesis. 
In faet she did, for several days in succession, vomit large quantities of blood in 
the presence of the physician who had been summoned to her assistance. It was 
afterwards discovered that on each of those days she had swallowed blood which 
had been secretly conveyed to her from the neighbouring shambles. A case of 



788 



DIAGNOSIS OF GASTRIC HEMORRHAGE. 



precisely the same kind occurred (as I was informed by a gentleman who wit- 
nessed it) in the Bristol Infirmary some years ago. A girl had long been a pa- 
tient there, labouring (as was supposed) under haematemesis ; but it was at length 
discovered that she was a malingerer. She was in the habit of assisting the nurses 
in their work ; and this afforded her opportunities — of which she availed herself 
— of drinking the blood which had been drawn from the veins of other patients : 
and this blood she afterwards vomited. 

And even where no fraud is attempted, nor any blood swallowed, it occasion- 
ally becomes a nice matter to determine the origin of the hemorrhage, when blood 
is ejected in large quantities from the mouth : to decide, namely, whether the 
blood has come originally from the lungs or from the stomach. In copious haemo- 
ptysis, the blood issues from the mouth in gushes as it does in haematemesis ; 
and the reflux of the blood into the pharynx, the tickling sensation it there pro- 
duces, and the cough (which we know, even when the expectoration is not of 
blood, frequently excites retchings) ; these causes, acting singly, or together, occa- 
sion sometimes a convulsive contraction of the muscles of the thorax, which 
looks like the effort of vomiting': and they often indeed give rise to actual vomit- 
ing. On the other hand, in sudden and profuse haematemesis, the irritation caused 
by the blood as it passes over the upper part of the larynx, is apt to provoke a 
paroxysm of choking cough. 

Now when I was speaking, some lectures back, of haemoptysis, I promised 
that I would point out the means of distinguishing it from haematemesis, when I 
came to the consideration of the latter complaint. I have now therefore to re- 
deem my promise. 

However equivocal certain cases may be at first sight, we may generally guide 
ourselves to a correct decision by a careful investigation of the circumstances that 
precede, accompany, and follow the hemorrhage. Vomiting of blood is com- 
monly preceded by a sensation of weight and uneasiness in the epigastrium ; and 
by nausea. Haematemesis is also, more frequently than haemoptysis, ushered in 
by paleness of the face, dimness of vision, and an approach to syncope, or even 
actual fainting. These symptoms are not to be regarded (I apprehend) as pre- 
monitory of the hemorrhage, although they have been so considered by some; 
they are rather a sign that it has already taken place; and yet they are prelimi- 
nary of the haematemesis. Occurring before the blood comes up, they cannot be 
ascribed to alarm at the sight of it. On the other hand, hsemoptysis is wont to 
be announced by dyspnoea, cough, tickling in the throat, and a sensation as if of 
bubbling within the thorax. Most commonly, too, before the expulsion of much 
blood from the lungs, some sputa are coughed-up, composed more or less of that 
fluid. The symptoms that usually succeed the hemorrhage, in either case, afford 
equally valuable assistance to our judgment, in eases that might otherwise be 
doubtful. Generally copious haemoptysis goes on, in a succession of mouthfuls, 
for some time : whereas there is, mostly, only one access of full vomiting. At 
any rate, at the close of abundant pulmonary hemorrhage, the patient manifestly 
coughs up, and expectorates, smaller quantities of blood ; while we usually 
may observe that, a few hours after haematemesis has occurred, slight griping 
pains come on in the abdomen, and a portion of blood is got rid of from the 
bowels. 

Other questions, often of much importance in regard to the ultimate diagnosis, 
when the blood is traceable with certainty to the stomach, are, whether it be idio- 
pathic, if, indeed, it ever be so : whether it be supplemental of some other dis- 
charge : whether it depend on disease of the stomach itself ; of one, or more, of 
the contiguous viscera ; or of the system at large. Certainly, in a very great 
majority of cases, gastric hemorrhage is symptomatic ; and the nature and seat of 
the disease of which the bleeding is a symptom, may, in many instances, be deter- 
mined without much difficulty. That which depends upon incipient cancer of the 
stomach, while it is by no means of rare occurrence, is also, (I think,) more fre- 
quently than other forms of hemorrhage from that organ, obscure. It must be 



DIAGNOSIS OF GASTRIC HEMORRHAGE. 



789 



obvious to you, and therefore I need not dwell upon this part of the subject, that 
a little attention to the symptoms and past history of the patient will usually suf- 
fice to elucidate the nature of the case, where haematemesis supervenes immedi- 
ately upon the introduction of corrosive poisons, or within a certain interval after 
they have been swallowed : where it depends upon the bursting of a large aneu- 
rism: where it breaks forth among other symptoms of scurvy or purpura: where 
it is the result of an advanced stage of cancer of the stomach: where it accom- 
panies organic disease of the liver, spleen, or heart : where it occurs as a symp- 
tom of yellow fever: where it takes the place of suppressed or imperfect men- 
struation ; or where it is occasioned by the pressure of the gravid uterus. In all 
these cases, there is, ordinarily, no room for mistaking the one disease for the 
other; or for regarding the hemorrhage as idiopathic. 

With respect to the treatment that should be adopted in eases of hemorrhage 
from the stomach, it must be apparent, from what has just been said of the many 
different morbid conditions upon which it may depend, or with which it may be 
essentially connected, that remedies are, in most cases, rather to be directed 
against the disease of which the hEematemesis is a symptom, than against that 
symptom itself. But sometimes we are obliged to treat the symptom : either 
because we are not certain of the exact nature of its cause ; or because the condi- 
tion out of which it springs is not within our reach. 

Cases of melaena (I have told you what is meant by that term) require hard 
purging : and many patients recover thoroughly under that mode of treatment. 
You may prescribe five grains of calomel every night, and a black dose every 
morning, till the stools lose their pitchy colour. Do not be afraid of purging your 
patients in such cases. If they are curable at all, that is the way to cure them. 
I have pursued that plan with perfect success, even with patients whom th£ pre- 
vious hemorrhages had blanched, and whose pulse was feeble and irregular. You 
may sustain them, at the same time, by a full allowance of nourishing broths. 
The portal system is drained and unburdened by this active depletion. And if there 
be no irremediable change of texture in the liver, the recurrence of the hemor- 
rhage may often, by a proper regulation of the habits and diet, be obviated. The 
ancients had learned by observation, the efficacy of treatment of this kind ; but they 
used a different form of medicine, and purged away the atra bills with hellebore. 

It is plain that for melaena, dependent on mechanical congestion, styptic sub- 
stances would be worse than useless. They are more adapted to those cases 
(could we but surely distinguish them) in which the hemorrhrge proceeds from a 
bleeding vessel. This is indeed the mode whereby we often succeed in stanching 
external hemorrhages ; namely, by applying astringents to the very part. Similar 
means may be employed when haematemesis, of a purely passive character, de- 
pends upon some modification of the circulating blood. There is one remedy 
which is thought to have a sort of specific effect upon hemorrhages of the gastro- 
intestinal canal: I mean the oil of turpentine, given in small doses; from twenty 
minims to half a drachm every four or six hours. I cannot say that I have had 
much experience of it. Of course the patient must be kept cool and quiet; what- 
ever he drinks he should drink cold; even ice is ofteji both grateful and effectual. 
If ordinary measures fail, recourse may be had to the acetate of lead ; or even to 
the quack medicine, Ruspini's styptic. Not that I think you will often find the 
latter expedient successful, when more rational treatment has failed ; but in obsti- 
nate and dangerous eases it ought to be tried. If, with the haematemesis, there be 
any fever, it may be proper and necessary to abstract blood from a vein, and to 
employ refrigerant substances as remedies : and if, with or without much fever, 
there be tenderness at the epigastrium, leeches, or a blister, should be applied. In 
cases where the catamenia desert their natural channel, and seek an outlet through 
the mucous membrane of the stomach, it will be well, while means are taken to 
discourage the haematemesis, as iced drinks and so forth, to endeavour to solicit 
the discharge in the right direction. And we often succeed in this object, by 
placing leeches upon the groins of these patients immediately before the period 



790 DYSPEPSIA, 

when the vicarious menstruation is expected; and by putting their feet, at the 
same time, into hot water ; or even laying them in a warm hip bath, 



LECTURE LXX. 

Dyspepsia. Physiology of digestion. Symptoms of Dyspepsia. Treatment 
and Prevention, Dietetic and Medicinal. 

It is my intention to appropriate this evening^ lecture to a cursory account of 
dyspepsia; by which I mean some evident derangement in the natural process of 
digesting and assimilating our food ; and more especially, a faulty performance of 
the functions of the stomach. Indigestion is the prevailing malady of civilized 
life. We are more often consulted about the disorders that belong to eating and 
drinking, than perhaps about any others : and I know of no medical topic con- 
cerning which there is afloat, both within and beyond the profession, so much 
ignorant dogmatism and quackery. 

Cullen, in his definition of dyspepsia, enumerates the various symptoms, by 
the occurrence of more or fewer of which, that complaint is most commonly 
manifested. " Anorexia, nausea, vomitus, inflatio, ructus, ruminatio, cardialgia, 
gastrodynia : pauciora saltern vel plura horum simul concurrentia, plerumque cum 
alvo adstricta, et sine alio vel ventriculi ipsius, vel aiiarum partium, morbo." 

The variety in the actual presence and combinations of these symptoms is very 
great ? and any attempt to give a perfect or complete history of dyspepsia in these 
lectures is quite out of the question. But I will endeavour to draw such a general 
outline of the disorder as may assist and direct your observation of it hereafter. 

I shall first take a brief view of the pathology of indigestion, so far as it is un- 
derstood : and to make this intelligible, it will be necessary to interweave some- 
thing of the physiology of the subject. To these preliminary considerations, I 
shall add a short comment upon the several symptoms of dyspepsia, enumerated 
in Cullen's definition ; and, lastly, I shall state what I know respecting the means 
of curing, and preventing, this familiar disorder. 

The conditions of healthy digestion are these : that the food should be masti- 
cated, mixed with saliva, and swallowed into the stomach : that in the stomach it 
should be reduced to a semi-fluid consistence, and converted into a uniform pulp, 
called chyme : that the chyme should be transmitted through the pylorus into the 
duodenum, and there mixed with the bile, the pancreatic secretion, and the intes- 
tinal ,mucus ; in consequence, as it would seem, of which admixture, the whole 
is separated into two parts, viz., the chyle or the nutritive portion of the food, now 
in a fit state to be taken up by the laeteals which open upon the mucous surface 
of the intestines, and to be carried by them into the blood ; and the exerementi- 
tious portion, which at length is conveyed out of the body. 

The food is dissolved and^transformed, in the stomach, by the chemieal agency 
of the gastric juice. This is a secretion peculiar to the stomach. All that need 
be stated of it here — almost all indeed that is known — is, first, that it oozes forth in 
minute drops from the mucous surface ; but only when food (or some solid sub- 
stance), is present in the stomach ; and secondly, that it is always acid. It 
appears to owe its solvent power to a special principle, which chemists have 
named pepsin. 

The food, having arrived in the stomach, is moved about, by a sort of churning 
or revolving movement, and mixed with the gastric juice, and gradually changed into 
chyme : which also is acid. Finally, the ehyme is propelled by degrees into the 
duodenum by the pressure of the transverse band of muscular fibres whieh embraces 
the pyloric extremity of the stomach. The time in which the whole operation is 
completed varies from two to four or five houffs. 



DYSPEPSIA. 



791 



Liquids introduced into the stomach disappear much more speedily ; either by 
direct absorption, or through the pylorus. 

All this we know, not from mere speculation on the anatomy and uses of the 
organ, but from actual observation. An American physician had, for several 
months in succession, the curious privilege of looking, whenever he pleased, into 
a healthy human stomach, and of watching its condition, its movements, and its 
contents, during the process of digestion. A young Canadian had a portion of 
the skin, muscles and ribs of the left side of the body blown away in a gun- 
shot wound, which laid open the stomach also. He recovered from this frightful 
injury with a permanent aperture in the side, communicating directly with the 
stomach. Through this loop-hole Dr. Beaumont was allowed to introduce various 
articles of food ; and to withdraw from time to time the gastric secretions ; and 
the aliment, in the different stages of its digestion. He has published a very 
interesting account of these experiments, which have set at rest some points in 
the physiology of the stomach that were previously uncertain. I shall embody 
his deductions in what I have further to say on the subject. 

In order that digestion may be perfect and easy, it is requisite that the food be 
in a state of minute division. This object is attained by mastication. A weak 
dyspeptic stomach acts slowly, or not at all, on solid lumps and tough masses of 
food. The delayed morsels undergo spontaneous changes, promoted by the mere 
warmth and moisture of the stomach : gases are extricated : acids are formed : 
perhaps the half-digested mass is at length expelled by vomiting ; or it passes 
undissolved into the duodenum, and becomes a source of irritation and disturb- 
ance during the whole of its journey through the intestines. Here then we have 
one common cause of dyspepsia ; and an easy and obvious preventive. Dyspeptic 
persons should not eat in a hurry, as busy men, and studious and solitary men, 
are apt to eat. They are to be cautioned against bolting their food: it must be 
well ground in the mill that nature has provided for that purpose. I am not at all 
sure that the increased longevity of modern generations is not, in some degree, 
attributable to the capability of chewing their food which the skill of the dentist 
prolongs to persons far advanced in life. 

There are certain things upen which the gastric juice has no power. The 
green colouring matter of certain vegetables ; the husks of seeds ; the rinds of 
many fruits. You may perhaps have observed that dry currants, and the pips of 
apples, swallowed entire, reappear, unchanged, among the egesta. Whatever 
passes the stomach untouched by the gastric liquor, passes undissolved through 
the whole of the alimentary canal ; provoking disorder sometimes in its transit ; 
forming sometimes a nucleus for intestinal concretions. These substances are 
therefore unfit for a weak stomach. When the digestive powers are active, and 
the bowels slow, they may perhaps occasionally be even useful. Thus brown bread 
— i. e., the indigestible bran, or tegument of the kernel of wheat — stimulates the 
peristaltic motions of the intestines, and averts, in certain persons, the necessity 
of more direct purgatives. Unbruised mustard-seed, once so much in vogue, 
owed much of whatever virtue it possessed to this principle. But if these intract- 
able substances fail to excite the proper action of the bowels, they are apt to 
accumulate, and to lay the foundation of serious disease. 

Indigestible matters, to which the pylorus refuses a passage, may remain in 
the stomach, and disturb its functions, for days, or even sometimes for weeks, 
together. If we could ascertain their presence, an emetic would be the remedy. 
And sooner or later vomiting is set up, and the offending substance expelled. I 
lately saw a mass of hard curd — a small cream cheese in respect to consistence — - 
which was thrown up after several days of severe gastric pain and disorder. The 
relief was immediate and complete. The patient had been taking large quantities 
of cream with his tea and coffee. In another person, a similar fit of indigestion 
terminated in the ejection of a mass of snuff. This is no unusual source of 
derangement of the stomach among those who use lavishly that nasty luxury. 

The essential change which the chyme undergoes after leaving the stomachy , 



792 



DYSPEPSIA. 



appears to consist in its separation into two parts: namely, into chyle, which is 
taken up by the lacteals; and into excrement, which is discharged from the body; 
Any undissolved portions of the food become attached to this last part. We do 
not know exactly what is the function or agency of the pancreatic liquor; but 
with regard to the bile our knowledge is somewhat more definite. The acid 
developed in the stomach combines in the duodenum with the alkali of the bile, 
and is more or less neutralized. Dr. Prout conjectures that in a healthy state of 
the organs it is entirely neutralized. Bile is, moreover, the natural stimulus of 
the intestines : when its secretion is stopped, or its passage into the duodenum 
prevented, digestion and assimilation may go on, but the bowels are usually slug- 
gish. The hepatic secretion has, doubtless, other important uses ; but with these 
we are not at present concerned. It is pretty evident that the state of the biliary 
functions can have no direct influence in the production of mere dyspepsia. 
When the constituents of the bile are imperfectly eliminated from the blood, 
various parts of the body may suffer detriment. And when the functions of the 
stomach and the functions of the liver are both disordered, it may be that the for- 
mer organ sympathizes indirectly with the morbid state of the latter : or it may 
be that one and the same cause operates in producing the derangement of both 
organs. 

Let us now review the symptoms of dyspepsia which are mentioned in Cullen's 
definition. The first of these is anorexia : want of the natural appetite. Some- 
times this is almost the only symptom observable. The patient is warned, by 
loss of appetite, not to take too much food ; he refrains instinctively from certain 
kinds of food ; or he feels perhaps absolute repugnance and disgust at the very 
thought of eating. Various have been the speculations respecting the immediate 
cause of hunger. It has been ascribed to the action of the gastric juice upon 
the surface of the empty stomach. But during health the gastric juice is never 
present in an empty stomach. Neither can the appetite depend upon contrac- 
tion of the muscular fibres of the stomach ; for the empty stomach, during 
health, is always contracted upon itself. No doubt the sensation of hunger, like 
all other sensations, arises from some particular condition of the nerves of the 
part. It returns periodically, acknowledging in this respect the influence of habit. 
It is sensibly affected by agencies which operate upon and through the nervous 
system. The receipt of a piece of bad news will destroy, in a moment, the keenest 
appetite. 

Sometimes there is no anorexia. The appetite may even be morbidly craving 
and ravenous ; or capricious and uncertain. 

When defect of appetite is the only symptom, it may be remedied, often, by 
the employment of bitters, or of the mineral acids, taken twice or thrice daily, 
for some time together. It would be out of place for me to speak in detail of 
particular medicines of this kind ; it is enough if I indicate quina, columbo, gen- 
tian, quassia ; the dilute sulphuric and nitric acids ; or a mixture of the nitric and 
muriatic. 

Nausea — vomitus. These are, in some instances, the most distressing results 
and signs of the dyspepsia. Sometimes nausea comes on soon after the food is 
swallowed. Sometimes there is no nausea ; but after the lapse of a certain period, 
an hour or two generally, the food is rejected by vomiting. The matters thus 
thrown up are most frequently sour. Not seldom they are mixed also with bile, 
especially if the retching has been violent, or long continued ; and then the patient 
is apt to ascribe the whole of his complaint to "an overflow of bile," although in 
fact the secretions of the liver have nothing whatever to do with it; the appear- 
ance of bile in the fluids ejected from the stomach proceeding from an inverted 
action of the duodenum. The effort of vomiting, however induced, will, if often 
repeated, be attended with the expulsion of yellow bile. I have more than once 
referred you, for an illustration of this fact, to the phenomena of sea-sickness. 
The fallacy I now point out has been one cause of the notion that is prevalent 
among patients, and the public — and not unfrequently perhaps among practi- 



DYSPEPSIA. 



793 



lioners — that dyspepsia very commonly depends upon a disordered, state of the 
biliary organs. 

The vomiting which occurs in dyspepsia is often connected with a morbid 
irritability of the stomach ; and it is sometimes a very troublesome symptom to 
treat. The carbonic acid has certainly a marked effect in allaying it, in many 
cases. We give it, as you know, in the effervescing saline draught, made with 
the carbonate of potash, or soda, and lemon-juice. Sometimes the mineral acids 
answer better. Sometimes, on the other hand, alkalies — -the liquor potassse, for 
example — or lime-water, are more effectual. In these latter cases we may pre- 
sume that there is a morbid acidity of the stomach. Small doses of opium are 
occasionally successful when other means fail. Opiates thrown into the rectum 
— opium plasters to the epigastrium — blisters to the same part: these are measures 
which you will sometimes have to try one after another. There are two special 
remedies which have been greatly extolled for their virtue in abating sickness: 
the hydrocyanic acid is one of them ; creasote is the other. The hydrocyanic 
acid I have found exceedingly useful in obstinate cases. It may be given alone 
—or mixed with the effervescing draught — or combined with a few grains of the 
sesquicarbonate of soda. The creasote has disappointed me oftener than it has 
answered my hopes from it. Yet it has a decided influence in checking some 
forms of nausea ; and it is the more likely to succeed, in proportion as the condi- 
tion of the stomach is remote from inflammation. 

But after all, the grand principle on which to treat chronic vomiting — not de- 
pendent upon disease in other parts, as the head, the kidney, or the uterus — is 
that laid down by Dr. William Hunter; of reducing the quantity of food to that 
amount, whatever it may be, which the stomach is able and willing to retain, and 
of making its quality as bland and nutritious as possible. The most satisfactory 
case which I have had to treat upon this principle occurred some years ago, in the 
person of one of my hospital patients. She was brought out of Kent by her father. 
She had been under the care of several medical men, one of whom had been a 
pupil at the hospital, and recommended her as a proper patient for admission 
there. Her age was sixteen. She and her father both agreed in the same story ; 
viz., that she constantly vomited her meals; the food generally coming up again 
immediately after it was swallowed, and never remaining longer in her stomach 
than ten minutes. The vomiting was described as being easy ; and was neither 
preceded nor accompanied by nausea. 

She had been ill for four years : ever since a severe attack of scarlet fever. At 
first she vomited her meals now and then — three or four times a week — but the 
vomiting gradually became more and more frequent ; and at the time of her ad- 
mission she had vomited after every meal, for three months in succession. She 
had grown considerably in the four years ; and was tolerably plump ; and looked 
healthy ; and the catamenia had begun to appear, though scantily, in the same 
period : but they had been altogether suspended for a year. 

It was clear that a good deal of her food must have remained : and, bearing 
William Hunter's case in mind, I directed that she should have a very small 
quantity of roast meat for dinner, and a coffee cup of milk occasionally during the 
day ; and no other food. I prescribed also some pills consisting of aloes and soap, 
to act moderately on the bowels. I expected to have been obliged still further to 
limit her food : but she never vomited again, from that time. This distressful and 
protracted disorder, after long and fruitless treatment previously, yielded thus at 
orice and easily to very simple means. 

Inflatio- — ructus. Flatulence, and belching. The gas that produces these 
symptoms is sometimes extricated from undigested food detained in the stomach, 
and in a state of fermentation : sometimes secreted, apparently, by the stomach 
itself ; for the flatulence comes on when the stomach is empty of food. It is apt 
to arise, in dyspeptic persons, if a meal happens to be delayed beyond the accus- 
tomed hour. Patients complain grievously of these symptoms, and accuse the 
" wind in their stomach," as being at once the essence and the cause of all theup 



794 



DYSPEPSIA. 



complaints. They ask for medicines to get rid of the wind ; and its escape may 
indeed be promoted by warm aromatics, and carminatives, as they are called : the 
relief thus afforded to the distended stomach being so sudden, and for the time so 
complete, that the sufferer ascribes to the medicine vim carminis, the power of a 
charm. One of the most effectual and popular of these carminatives is pepper- 
mint water. A due regulation of the periods for taking food will often suffice 
to obviate the flatulence that belongs to emptiness. That which follows eating 
may, in many cases, be prevented, by swallowing, immediately before the meal, 
five or six grains of the extract of rhubarb, with or without a grain of cayenne 
pepper. If the ascending wind brings into the throat and mouth a portion of the 
solid contents of the stomach, the patient is said to ruminate. The regurgitated 
matters are often intensely acid ; and then an alkali may remedy the flatulence ; a 
teaspoonful of sal volatile, for example. 

Indigestion is, in many instances, attended with scarcely any pain; while in 
Others the pain is very tormenting. Cullen speaks of it under the terms cardial- 
gia; and gastrodynia. Cardialgia is that less violent and more permanent unea- 
siness which in popular language is called heart-burn. Gastrodynia is that more 
severe, and usually more transient pain, which is commonly denominated spasm 
or cramp of the stomach. 

Dr. Abercrombie has some useful practical observations in respect to pain of 
the stomach. He speaks of it as occurring under four different forms, and I am 
able to bear witness to the reality of the distinctions that he has drawn. In the 
first place, some persons suffer pain, occasionally, when the stomach is empty, 
even when there is no flatulence ; and they are comforted and relieved by taking 
food. It is reasonable to suppose that this kind of pain depends upon some 
degree of acrimony of the fluids of the stomach itself. It is often removed at once 
by alkalies, or absorbent medicines. A teaspoonful of the aromatic spirit of 
ammonia, or a tables poonftil of the liquid magnesia, in a wineglass of camphor 
julep, will still the whole uneasiness sometimes in a moment, as if by magic. 

A second form of pain in the stomach is when it occurs immediately after tak- 
ing food, and continues during the whole process of digestion, or until vomiting 
ensues, which gives instant ease. In such cases we have reason to suspect the 
existence of chronic inflammation, or of some undue sensibility of the mucous 
membrane of the stomach. The suitable remedies are such as I spoke of in the 
last lecture. I might have mentioned a form of medicine which Dr. James John- 
son has found especially serviceable against this morbid sensibility ; I mean the 
nitrate of silver, in small doses. 

In a third species of gainful disorder of the stomach the pain does not begin 
till from two to four hours after a meal, but continues for several hours. This is 
a very common form of complaint. Dr. Abercrombie is of opinion that the pain 
is seated in the duodenum, and connected with inflammatory action, or with mor- 
bid sensitiveness of the mucous lining of that bowel. He says it is frequently 
accompanied by pain and tenderness of the right hypochondrium ; and that the 
liver is often blamed when it really is not in fault. This last remark I well be- 
lieve ; but I am not so easily persuaded that the pain is duodenal. I believe it 
depends upon acidity in the primse vise. It has been ascertained by several che- 
mists, that the acid which is present in the gastric juice is the muriatic. Dr. 
Prout holds that the source of this muriatic acid is the common salt which exists 
in the blood, and that the decomposition of this salt is owing to the immediate 
agency of some modification of electricity ; and he conceives that the principal 
digestive organs represent a kind of galvanic apparatus, of which the mucous 
membrane of the stomach and intestinal canal may be considered as the acid or 
positive pole, while the hepatic system is the alkaline or negative pole. How- 
ever this may be, it is certain that the muriatic acid contained in the stomach is often 
in excess : other acids are also found there— the acetic, and more especially the 
lactic; and when the food, now converted into chyme, passes into the duodenum, 
the remaining superfluous acid teazes the stomach. I think this explanation of 



DYSPEPSIA. 



795 



the cause of the pain is a more probable one than Dr. Abercrombie's, because you 
may generally mitigate or remove the pain by introducing an alkali into the sto- 
mach, whereby the acid is neutralized : even the swallowing a cup of warm tea, 
by which the acid is diluted or washed away, often stops the pain. And I have, 
in numerous instances, succeeded in preventing the recurrence of this pain by 
directing the patient to take a small quantity of alkali, in some aromatic water, 
immediately after his dinner. According to Dr. Abercrombie's theory the pain 
ought not to be so immediately allayed by these remedies ; and, since the food is 
gradually propelled into the duodenum as it is digested, the pain should begin, I 
think (supposing him right), earlier than it does. Dr. Abercrombie has found 
nothing of more general utility in these cases than the sulphate of iron, combined 
with one grain of aloes, and five grains of aromatic powder, taken three times a 
day. He praises lime-water, also, and small opiates, and a combination of bis- 
muth and rhubarb. What its modus operandi is I know not, but I am sure that 
bismuth is a very effectual remedy for some kinds of gastric distress. 

Cases now and then occur in which this pain, succeeding a meal, and the de- 
posit of lithates in the urine, would seem to indicate the propriety of an alkaline 
treatment, but which really are more benefited by the mineral acids. How to 
distinguish these exceptional cases, unless by trial, I have not yet learned. Any 
detected admixture of phosphates might perhaps furnish the requisite clue. 

Pain in the stomach occurs in a fourth form, coming on at uncertain intervals 
in most violent paroxysms, and properly called gastrodynia. It is often accom- 
panied by a sensation of distension, much anxiety, and extreme restlessness. In 
females it is frequently combined with hysterical symptoms. This form Dr. 
Abercrombie supposes to depend upon over distension of the stomach ; and it may 
be so ; certainly great quantities of air are sometimes extricated ; and the pain is 
not confined to the stomach, but shoots through to the back and between the 
shoulders. I suspect that the pain is sometimes neuralgic. It is often very in- 
tractable ; occasionally it yields to carminatives. Dr. Abercrombie states that he 
has observed the most effectual relief in such cases to have been obtained from 
exciting a brisk action of the bowels by means of a strong purgative enema. He 
makes this practical remark, which is worth attending to. From the facility with 
which such affections often yield to the remedy just mentioned, it appears not 
improbable that the pain may be sometimes situated in the arch of the colon. 
Wherever its seat may be, I know that it is frequently removed by a mustard 
poultice laid upon the epigastrium. Opium also is of eminent use in many of 
these cases; and bismuth; and cordials: but I have seen more rapid and decided 
relief afforded by the prussic acid than by any thing else; and the cure so wrought 
is often permanent. It does not bring ease in all cases, nor is it a medicine that 
is any particular favourite of min^ yet its good effect is in some instances so 
striking, that if this were its only virtue I should esteem the hydrocyanic acid a 
most valuable remedy. 

You will meet sometimes with what is called spasm of the stomach (and I 
suppose it is such) in gouty people ; who are then said to have gout in the sto- 
mach. The pain comes on in sudden and severe paroxysms ; and is removable 
in general by laudanum and stimulants, brandy, for example ; or by the mustard 
poultice. On these cases, however, we look with jealousy and apprehension. 
In some instances the attack is really inflammatory, and would then be aggravated 
by a stimulant treatment. 

There is yet another modification of uneasiness and disorder of the stomach, 
of which the distinguishing characteristic is the vomiting, or rather the eructation 
of a thin watery liquid, sometimes sourish, but usually insipid and tasteless, and 
often described by the patients themselves as being cold. This is what Cullen 
calls pyrosis, the water-brash. It is a disorder much more frequent in the lower 
ranks of society than in others. It is particularly common in Scotland, and is 
there ascribed to the large employment of farinaceous substances as food, and 
especially of oat-meal, But it is said to be still more common in Lapland, Dr, 



796 



DYSPEPSIA. 



Cullen, who saw a great deal of it, says that its paroxysms " usually come on in 
the morning and forenoon, when the stomach is empty. The first symptom of it 
is a pain at the pit of the stomach, with a sense of constriction, as if the stomach 
was drawn towards the back. The pain is increased by raising the body into an 
erect posture, and therefore the body is bended forward. The pain is often very 
severe ; and after continuing for some time, it brings on an eructation of a thin 
watery fluid in considerable quantity." Such is Cullen's description of pyrosis. 
He states that the complaint often occurs without other evidence of dyspepsia; 
but this is not consistent with the experience of subsequent observers. It is a 
symptom sometimes of organic disease of the stomach. In one remarkable case 
of pyrosis which I saw, and in which not less than three pints of this thin tasteless 
liquid was brought up every day, the stomach, after death, was found to all appear- 
ance healthy ; but it had been pressed upon by an enormous liver. I mention these 
facts that you may not suppose pyrosis to be always, as Cullen has described it, 
a substantive and idiopathic malady. 

When pyrosis is not caused by organic disease in the stomach or in the liver, 
it will yield in general to opium, and especially to opium in combination with 
astringents. The pulvis kino compositus of the Pharmacopoeia is an admirable 
remedy for it. But we often have to contend with this difficulty, that the bowels, 
in cases of pyrosis, are generally confined, and that the opium tends to aggravate 
this unnatural condition ; so that it becomes necessary to administer some aperient 
daily while the kino and opium are given : castor oil, or confection of senna, or 
cathartic extract. 

Costiveness is, in fact, a very frequent concomitant of dyspepsia, as Cullen's 
definition affirms (plerumque cum alvo adstricta). And this sluggish state of the 
bowels often aggravates, if it does not produce, the dyspepsia. At any rate the de- 
fective powers and uneasy sensations of the stomach are rectified, in many instances, 
by measures which promote the regular and healthy evacuation of the intestines. 
Without professing to go into detail in this matter, I may state that, in our reme- 
dial attempts, we should imitate, as much as we can, the processes of nature. 
The mixed contents of the small intestines furnish the natural stimulus of their 
peristaltic movements ; and the excrement excites the larger bowels. When this 
natural stimulus is insufficient, the want may be supplied by some substance which 
is involved in the food, and accompanies it in its progress — -as the bran of brown 
bread, already mentioned, or a few grains of rhubarb or of aloes swallowed 
immediately before dinner. In adjusting the proper quantity of the drug the 
patient must assist the physician. It should be just so much as suffices to effect 
what nature neglects to do, and no more. With some persons an aperient pill 
acts more comfortably and opportunely if taken at bed-time. Sometimes diar- 
rhoea is associated with indigestion. This is usually connected with an excess of 
acid in the primx vise. The principle of treatment in such cases is obvious. 

There are innumerable sympathies of distant parts with a dyspeptic stomach, in 
respect to which I can do little more than barely enumerate a few. Thus indi- 
gestion is often accompanied by pain in the head, with some confusion of thought : 
or at all events, with a loss of mental energy and alertness. Together with a violent 
headache there are frequently nausea and vomiting; and the complaint is popularly 
known by the name of the sick-headache; or, in the fashionable jargon of the 
day, as a bilious headache. I must refer you to a paper of Dr. Fothergill's, in 
the sixth volume of the Medical Observations and Inquiries, for a very good 
account of this troublesome complication. 

I shall hereafter have a good deal to say respecting certain morbid conditions 
of the urine, which take their rise sometimes from faulty digestion in the stomach, 
sometimes from faulty assimilation of the digested aliment in the more advanced 
stages of the process of nutrition. These conditions of the urine, indicating grave 
derangements of the whole system, furnish the characters and the names of several 
distinct maladies. 

I told you, in a former lecture, that certain affections of the viscera of the thorax 



DYSPEPSIA. 



797 



are liable to be produced by mere indigestion. Palpitations of the heart, irregu- 
larities of the pulse, fits of asthma, are no uncommon accompaniments of a disor- 
dered stomach. This is partly to be ascribed to that reflex sympathy between 
the parts concerned, which I have so frequently mentioned ; partly to the effect 
of flatulence, which, by resisting the descent of the diaphragm, impedes the free 
working of the lungs and of the heart. I told you, at the same time, that these 
symptoms torment many persons with the belief that they spring from organic 
disease. This notion is particularly apt to infest the minds of medical students. 
I suppose most teachers in our profession partake of that sort of experience which 
Dr. James Gregory, of Edinburgh, used to speak of in his lectures. He said 
that scarcely a winter passed over in which several of his pupils did not apply 
to him on account of palpitations supposed by them to depend upon structural 
disease of the heart : and in no single instance were their apprehensions well 
founded. They were all cases of mere dyspepsia and hypochondriasis. 

Dyspepsia is often connected with phthisis, with leucorrhcea, with amenor- 
rhoea and chlorosis : and some persons imagine that these diseases are caused by 
the dyspepsia. Indigestion may lead indirectly to the development of consump- 
tion, by producing debility ; but the truer view of the matter seems to be that the 
dyspepsia is a consequence, rather than an exciting cause, of these complaints. 
When, for instance, leucorrhcea is cured by topical astringents, as it often may 
be, the indigestion frequently is cured too. 

One of the worst occasional concomitants of dyspepsia is that peculiar state of 
the mind to which I just now alluded under the term hypochrondiasis. This is, 
in truth, a species of insanity : but it is so often connected with disorder of the 
digestive organs, that Cullen, whose descriptions of disease are admirably clear 
and true, however faulty many of his theories may be, defines hypochondriasis 
to be " Dyspepsia — cum languore, m<estitia, et metu, ex causis non aequis." In 
the following short paragraph he completes the picture. " In certain persons 
there is a state of mind distinguished by the concurrence of the following circum- 
stances. A languor, listlessness, or want of resolution and activity with respect 
to all undertakings : a disposition to seriousness, sadness, and timidity : as to all 
future events, an apprehension of the worst or most unhappy state of them; and 
therefore, often upon slight grounds, an apprehension of great evil. Such persons 
are particularly attentive to the state of their own health, to every the smallest 
change of feeling in their bodies : and from any unusual feeling perhaps of the 
slightest kind, they apprehend great danger, and even death itself. In respect to * 
all these feelings and apprehensions, there is commonly the most obstinate belief 
and persuasion." 

Now when the attention of the hypochondriac is thus morbidly fixed upon the 
states and sensations of his digestive organs (as it is very apt to be) the patient 
becomes a plague to his physicians as well as to himself. 

, There are a few simple rules which ought always to be kept in mind in our 
treatment of dyspepsia ; although we can seldom enforce them, as they ought to 
be enforced, upon our patients. What patients want, in general, is some medi- 
cine that will relieve them from their discomfort and uneasy feelings, and allow 
them, at the same time, to go on in the indulgence of those habits which have 
generated the discomfort. And such remedies have not yet been discovered. 

One great and indispensable principle in the treatment of indigestion, is that of 
restricting the quantity of food taken at any one time. The gastric juice is pro- 
bably secreted in a tolerably uniform quantity. The muscular contractions of 
the stomach must needs be impaired or impeded by much distension of that organ. 
For both these reasons the amount of food introduced into the stomach should be 
kept within the limits of its capacity and powers. The great good which the late 
Mr. Abernethy unquestionably did to a host of dyspeptic patients, was owing 
much more, I am persuaded, to the rules of diet, and the restrictions as to quan- 
tity, which he laid down, than to his eternal blue pill. 



798 



DYSPEPSIA. 



Again, as Dr. Abercrombie has well remarked, and as Dr. Beaumont actually 
saw, various articles of food are soluble in the stomach with various degrees of 
readiness. Therefore, when the digestion is liable to be easily impaired, it is of 
great importance, not only to refrain from those substances which are known to 
be soluble with difficulty, but also to avoid mixing together in the stomach differ- 
ent substances which are of different degrees of solubility. Hence there are two 
reasons why it is salutary to dine off one dish. 1st. Because we avoid the inju- 
rious admixture just adverted to ; and, 2dly, because we escape that appetite, and 
desire to eat too large a quantity, which is provoked by new and various flavours. 

And another very important principle, greatly insisted on by Mr. Abernethy, 
is, that the stomach should have time to perform one task before another is im- 
posed upon it. He always made his patients (at least he always strongly ex- 
horted them) to interpose not less than six hours between one meal and another. Al- 
lowing from three to five hours for the digestion of a meal, and one hour over for 
the stomach to rest in, Mr. Abernethy's rule seems as much founded in reason as 
it is justified by experience. But we preach in vain on these topics. Mr. Aber- 
nethy was in the habit of saying that no person could be persuaded to pay due 
attention to his digestive organs, till death, or the dread of death, was staring him 
in the face. I have now in my mind a family consisting of a mother and three 
grown-up daughters, who are continually ailing and valetudinary. They profess 
to have great respect for my professional advice : yet I never can induce them to 
think that their plan of eating is a bad one. They are not early risers. They 
get to breakfast about half after ten or eleven. At two they think it absolutely 
necessary to eat luncheon, which consists of a mutton chop or some hashed meat, 
with vegetables. At six they dine : and at eight they drink tea : and then they 
eat no more till the next breakfast. And this is just a picture of the habits of 
scores of families. They huddle all their food into the stomach, at four periods, 
within seven or eight hours ; and leave it idle for sixteen or seventeen. 

Dyspeptic patients are very importunate to know what they may eat, and (more 
so still) what they may drink. It is of course impossible to lay down any gene- 
ral rules which will suit every case. The stomach has its idiosyncrasies. I re- 
member seeing a publication some years ago, one section of which had this start- 
ling title, " Cases of poisoning by a Mutton Chop." Dr. Prout knew a person 
who could not eat mutton in any form. He was thought to be whimsical, and 
mutton was frequently served up to him under some other guise, without his 
knowing it ; but it invariably caused violent vomiting and diarrhcea. Yet, for the 
average of stomachs, mutton is probably the most digestible of all meats. And 
for the average of stomachs some useful general directions may doubtless be 
given. 

In fevers and inflammatory disorders, experience has taught us to forbid or limit 
the use of flesh meat on account of its stimulating qualities. And when the sto- 
mach itself is affected with chronic inflammation, or with morbid sensibility, a 
diet restricted to farinaceous substances, and milk, is sometimes attended with the 
happiest consequences. I suspect that a false analogy has led some into the mis- 
take of supposing that animal food ought to be refrained from, or taken in a scanty 
proportion, in merely dyspeptic complaints. Animal food is easier of digestion, 
in the human stomach, than vegetable food. It is nearer, in its composition, to 
the textures into which it is to be incorporated by assimilation. There is less of 
** conversion" requisite. Indeed we may look upon the appropriation of vegeta- 
ble matter, by granivorous and graminivorous animals, as one stage of the process 
by which such vegetable matter is prepared for the sustenance of carnivorous 
animals : even as one great end of vegetable life seems to be that of generating or 
concocting matter for the nutrition of the former class, out of inorganic materials, 
not fitted for that purpose. A more elaborate digesting apparatus is provided for 
the vegetable eaters. Man, indeed, is omnivorous. But his organs of digestion 
are more like those of the carnivorous than of the granivorous races. And it is 
notorious that vegetable food, when the stomach is weak, is followed by more 



DYSPEPSIA. 



799 



flatulence, that is, is digested with more tardiness and difficulty, than animal food. 
Nevertheless, a mixture of the two, of well roasted or boiled flesh or fowl, with 
a moderate portion of thoroughly cooked vegetables, is better suited, in my opin- 
ion, for a feeble stomach, than a rigid adhesion to either kind of aliment singly. 
Each of the four great classes o( alimentary principles specified by Dr. Prout 
should be represented ; the aqueous, the saccharine, the albuminous, and the olea- 
ginous. All meats that have been hardened by culinary art, or by condiments, 
should be avoided by him, who, as the vulgar express it, has " a bad digester 
all cured meats I mean — ham, tongue, sausages, and so forth. Mutton is thought 
to be more readily digestible than beef. Pork, its lean part at least, is much less 
so than either. All raw vegetables also must be eschewed ; salads, cucumbers, 
pickles. But if we press our prohibitions much more strictly than this, we incur 
the risk of fixing the patient's attention too curiously upon his diet, and upon the 
sensations of his stomach ; and of rendering him hypochondriacal alive to the 
miserable subject of his feeding. 

Again, you will be continually asked whether you recommend malt liquor or 
wine, wine or brandy and water, white wine or port, sherry or madeira. Now 
it would be very easy to propound some positive rules in this matter, but it would 
not be so easy to vindicate them. Some allowance must be made, no doubt, for 
custom. I believe, however, that most dyspeptic persons would be better with- 
out any of these drinks. But it is very difficult to persuade them that the habitual 
use of strong liquors in small quantities can have any injurious effects. "It is 
not easy (says Cullen) to engage men to break in upon established habits, or to 
renounce the pursuits of pleasure; and particularly to persuade men that those 
practices are truly hurtful, which they have often practised with seeming impu- 
nity.' They are too ready to believe that it is unsafe to abandon their accustomed 
indulgence. A friend of mine, who visited, some years since, many of the 
American prisons, tells me that the health of even the most inveterate spirit- 
drinkers improves, instead of suffering, upon the sudden and total abstinence from 
spirits, which the regulations of those prisons enforce. There certainly are cases 
in which the digestion seems to be helped by a moderate quantity of wine, or 
beer, or spirits ; yet no one can say before-hand — at least I cannot — which of 
them is to be preferred. Upon these points patients should interrogate their own 
sensations and experience, instead of seeking the oracular counsel of a physician. 
Drinks which are followed by evident disturbance and discomfort are manifestly 
unfit. And even when a favourable effect, for the time, appears to be produced, 
there is always a risk of ultimate detriment to the powers of the stomach from this 
habitual excitement. 

There are states-of mind and habits of life, which, having no direct relation to 
the organs of digestion, yet exercise a material influence over their functions. 
Mental distress; mental solicitude; mental toil; over-much study; want of exer- 
cise : these are all prolific sources of dyspepsia. Sedentary habits, when their 
injurious effects are known, may be altered : excessive intellectual labour may be 
abandoned : but it is seldom that we can minister to a wounded or an anxious 
spirit. Our task is hardest of all when the patient's anxiety relates to his own 
complaints ; when he is morbidly engrossed by his bodily feelings, and despondent 
about its recovery. The management of the mind of a hypochondriac is peculiarly 
nice and difficult. It will not do to treat him as if his ailments were imaginary. 
He disbelieves you, contemns your judgment, and deserts you: to be fleeced per- 
haps by some villanous quack. You must hear what he has to say ; show an 
interest in his case; and prescribe for him: assuring him that you understand his 
malady, that it is curable, and that he will be cured provided he follows your 
directions. If you can succeed in gaining his confidence, and in persuading him 
of this, the battle is half won. To tell such a person, however, not to think of 
his grievances would be worse than useless. The very effort to drive a subject 
from our thoughts fixes it there the more surely. But you must endeavour to turn 
his attention to other things; and to awaken in him some new interest. Prescribe 



800 



ENTERITIS. 



change : change of air ; change of place and of scenery ; change of society. Get 
him to travel in search of health ; and the chances are in favour of his rinding it. 
A tour, in fine weather, and through a pleasant country, combines almost all the 
ingredients which are, separately even, desirable : the withdrawal of the mind 
from its ordinary pursuits and cares ; the diversion of the attention from one's self, 
by new and varied objects ; exercise, carried on in the open air; a holiday from 
intellectual toil. Six weeks among the mountains of Switzerland, or upon the 
rivers of Germany, will often do more towards restoring a dyspeptic hypochon- 
driac than a twelve month's regimen and physicking at home. 

With these disjointed hints, gentlemen, I must request you to be satisfied in 
respect to the principles upon which dyspepsia — and the hypochondriasis, which 
is in general so closely linked wtth dyspepsia — are to be managed. A full dis- 
cussion of these subjects in detail would furnish matter for several lectures. 



LECTURE LXXI. 

Enteritis: its symptoms; causes; treatment. Mechanical occlusion of the Intes* 
tinal Tube. Colic. Colica Pictonwn : its symptoms, complications, treatment, 
and prevention. 

Some of the diseased, states of the intestinal canal, while they differ a good deal 
in their essential nature, have yet many characters in common. Colic; ileus; 
enteritis; mechanical obstruction of the tube. It will be convenient, therefore, to 
consider these disorders in succession, and, in some degree, in connection with 
each other. 

In colic we have pain of the abdomen ; pain of a twisting or wringing kind, occu- 
pying generally the umbilical region; vomiting; and costive bowels. Similar 
pains are apt to occur in diarrhoea ; but they are transitory, and are then termed 
gripings, or more learnedly, tormina. When they are violent, and more perma- 
nent, and above all, when attended with constipation, they constitute colic. 

You have not forgotten the symptoms of peritonitis. They are, briefly, pain 
in the abdomen, increased on pressure ; and fever. 

Now, if to the symptoms of colic, you add the symptoms of peritonitis, you 
have the symptoms of enteritis: by which word I desire to express the disease 
that is commonly called inflammation of the bowels. The term has lately been 
extended so as to signify any and every form of inflammation- which any portion 
or tissue of the intestinal canal within the belly may suffer ; but I use it in the 
old-fashioned meaning. Cullen makes two species of enteritis. One of these 
consists in inflammation of the mucous membrane of the intestinal tube : he calls 
it enteritis erythematica. That is not the disorder I am about to speak of; but 
the other of his species, the enteritis phlegmonodea. I say that in colic, we have 
abdominal pain, constipation, and vomiting. In peritonitis, the functions of the 
stomach and intestines are not, necessarily, affected : in enteritis they are. There 
is inflammation, not merely of the peritoneal coat, but of the areolar tissue uniting 
the several tunics, probably of the muscular tissue also, and often of the whole 
substance of the bowel at the inflamed part. 

When the intestinal channel is any how closed up, ai\d a bar placed to the pas- 
sage of its contents, the symptoms of colic are very apt to ensue; and at length, 
the obstacle continuing, fatal inflammation is set up. 

The term ileus is applied, I believe, to those cases, whether inflammatory or 
not, in which, by an inverted action of the intestines, their contents are carried, 
in a retrograde course, into the stomach, and thence out of the body by vomiting. 

Having made these explanations, I shall now address myself more especially 
to the consideration of enteritis. 



ENTERITIS. 



801 



It is of much practical importance to discriminate between enteritis and the 
disorders that resemble it; and particularly to distinguish it from colic. When it 
commences, as it sometimes does, with distinct rigors, and is attended by thirst, 
a hot skin, and a hard and frequent pulse, there is no room for doubt. But it 
often begins insidiously, with mere colicky symptoms; the pain, at first, is not 
much augmented, it may even be somewhat eased, by steady pressure. If we 
mistake colic for enteritis, the error is of no great moment; but the opposite mis- 
take, which is more common, may be fatal. Blood-letting, and the other remedies 
of enteritis, will not aggravate the mere colic ; they may even, though unneces- 
sary, relieve the patient. Some of the remedies of mere colic are, however, highly 
dangerous when there is inflammation of the bowel. Physicians may fall into 
this error: patients who choose to prescribe for themselves, commonly do so. 
They take stimulants, cordials, carminatives — the pleasantest and nearest at hand 
is a glass of brandy, or of gin. And in true colic these means are frequently of 
great service; but they exasperate the symptoms, and increase the mischief when 
the disease is enteritis. Indeed, treatment of this kind will sometimes urge colic 
into enteritis. If the case be ambiguous, you must act upon the most unfavour- 
able supposition, and treat the complaint as if you were sure that inflammation 
was present. 

The pain of enteritis is increased by pressure. The pain of colic is not only 
not made worse, but it is actually mitigated often, by pressure; and it usually 
intermits entirely. I know that when there is simply flatulent distension of the 
intestines, pressure does sometimes increase the patient's uneasiness; but the 
uneasy sensation is very different from that acute sensibility which belongs to 
inflammation of their peritoneal covering. In enteritis there are also paroxysms 
of severe pain, determined, probably, by the peristaltic movements, or by the 
temporary distension of the inflamed parts of the bowel; and the pain has fre- 
quently a twisting character: but there is not any thorough intermission. There 
is a duller abiding pain between the sharper fits. It is to be observed also, as a 
diagnostic circumstance, that, as in peritonitis, the patient lies on his back, with 
his knees drawn up, and is fixed in that position, and for the very same reasons. 
If, in his agony, he tosses about his arms, the trunk is kept motionless, and the 
respiration is thoracic: whereas in mere colic the mode of breathing is not altered, 
and the patient is apt to be turning and writhing in all postures, and out of one 
posture into another. 

The nausea and vomiting are often most distressing. The patient not only 
rejects immediately whatever food, drink, or medicine he swallows, but he has fits 
of retching when the stomach is empty. In some instances, matters are cast up 
having the appearance, and something of the odour, of liquid feces: or resem- 
bling, at any rate, the offensive fluids which are found in the small intestines after 
death in these cases. I cannot say that I have ever seen genuine excrement 
ejected, unequivocal ordure: yet this may well happen if it be true that clysters, 
introduced into the rectum, have been voided through the mouth. Such a phe- 
nomenon would show that the whole tube was pervious ; that there was no me- 
chanical obstruction. 

Although the fever, in the outset, may be high, and the pulse strong and hard, 
it soon becomes (as in all acute abdominal inflammations) small and wiry; or 
weak, and like a thread. In bad cases, as the disease proceeds, the abdomen 
begins to swell, becomes tympanitic; hiccup sometimes comes on ; the pulse in- 
termits or beats irregularly; the extremities grow cold ; the features are sharpened 
and ghastly ; cold sweats break out ; the pain ceases perhaps ; and the sphinc- 
ters relax. The head is generally unaffected. Now and then delirium occurs 
late in the disease; but much more frequently the intellect remains clear to the 
very last. Death begins at the heart, and takes place in the way of asthenia. 

You may probably have observed that the symptoms which I have been de- 
scribing are just the symptoms which the surgeon so frequently encounters in 
cases of strangulated hernia. The symptoms of that surgical complaint are, in 
51 



802 



ENTERITIS. 



truth, most commonly at least, the symptoms of enteritis, caused by the forcible clo- 
sure of the bowel. Obstruction to the passage of the contents of the gut gives rise to 
its inflammation. And we often find, after death preceded by the signs of enteritis, 
an internal mechanical obstruction — -an internal strangulated hernia. In some cases, 
bands or strings of coagnlable lymph, the products of bygone inflammation, have 
formed snares (so to speak) for the gut, which at length they catch and constrict. 
They do no harm till some coil of intestine gets beneath or beyond them ; and 
then they strangle it, as the phrase is. I have twice seen (as I think I formerly 
stated) the appendix vermiformis prove the immediate cause of fatal internal her- 
nia. In one of these cases, the person had been a private patient of Dr. Macmi- 
chael ; and I went with him to examine ihe body. The free end of the appendix 
had become adherent to the mesocolon; and so a loop was made, through which 
a portion of the gut had passed. In the other instance, which I saw in Edin- 
burgh, the appendix was literally tied round a piece of the intestine. Sometimes, 
again, there is intussusception: the upper part of the tubes slips into the lower, 
fills it up; obstructs it; and inflammation fixes it there. Or it may be that a chro- 
nic thickening of the coats of the intestine has narrowed its channel; or a tumour 
presses upon the intestine from without ; or some foreign substance, or morbid 
accumulation, plugs it up within ; in all which cases a chronic disorder passes at 
length into acute inflammation. A very small hernia at one of the usual orifices 
— not large enough to manifest itself externallv — is sometimes the cause of the 
obstruction; even though only a portion of one side of the- gut may be nipped in 
the aperture. 

Sometimes, but according to my experience less frequently, there is no mecha- 
nical impediment to account for the constipation. In all cases, whether there be 
mechanical obstruction or not, the inflamed portion of the gut is of a red or dark 
colour; distended by its gaseous or liquid contents; covered often, on its perito- 
neal surface, with coagulable lymph ; or adherent to the contiguous organs. When 
the gut is mechanically closed, the part which lies on this side the obstacle, as we 
follow the natural course of the channel, is inflamed ; the part which lies beyond 
it is pale, contracted, and to all appearance, healthy. The line of demarkation is 
abrupt and strong; and it is determined by the obstacle. And the distinction 
between the healthy and inflamed portions is usually as sudden and decided, when 
there is no apparent obstacle. I mean that up to a certain spot the intestine is 
red like a cherry, or dark like a grape, large, and smeared (perhaps) with lymph 
or with pus ; while immediately beyond that point, and throughout the remainder 
of its course, it is white, empty, and shrunk up into the semblance of a cord. 
The pathology of these last forms of the disease is full of difficulty. Some have 
held that the contracted part was the original seat of disease, namely, of spasm; 
and that the upper adjoining portion of intestine became distended and inflamed 
in consequence of such spasm. Without attempting to explain these phenomena, 
which are comparatively unfrequent, I content myself with observing that it is the 
distended part which is the really inflamed part, and that its muscular coat ap- 
pears to have lost its natural contractile power — not (I fancy) from over-stretch- 
ing, as now and then happens to the urinary bladder — but from the effect of the 
inflammation. 

The inflamed portion of bowel is often of a very dark colour, and even 
almost black, from the geat congestion of blood in its tissues. Now this black 
colour has sometimes been erroneously set down as an evidence of gangrene. 
You must not trust to the mere colour, however. If the coats of the bowel be 
firm, and if the peculiar odour of gangrene be wanting, you are not to conclude 
that mortification has taken place, simply from the dark appearance of the intestine. 

Enteritis, not dependent upon any mechanical occlusion of the bowel, may 
arise under the operation of the ordinary causes of internal inflammation : cold 
and wet, for instance, applied externally, and especially to the feet and legs. Cold 
is thought to be particularly injurious in this way when the exposure happens soon 



ENTERITIS. 



803 



after a meal: probably because at that time the digestive organs, being in activity, 
receive a more copious supply of blood. 

The mechanical impediments that occur within the bowel, are still more various 
in kind than those which constrict it from without. Hardened fecal matters : 
intestinal concretions. Some of these are curious, and I shall hereafter have a 
word or two to say respecting their composition. Persons who are in the habit of 
taking a good deal of magnesia, or of chalk, to relieve acidity and heartburn, are 
liable to have these substances accumulate, and become indurated in the intestines. 
They generally begin to collect, I believe, around some accidental nucleus : and such 
a nucleus may very readily be supplied. A cherry-stone, a fish bone, a gall-stone 
that has found its way into the bowel. Even a pill, prescribed to cure, may thus 
come to kill one's patient. Dr. Prout was asked to analyze certain odd-shaped, 
triangular bodies which had been voided at stool, and were supposed to be gall- 
stones : but he found that they were specimens of Plummer's pill, which had 
defied the solvent action of the gastric juice, and had passed into, and lingered in, 
the bowels. Unbruised mustard-seed, and carbonate of iron, are other reme- 
dial substances which, injudiciously administered, have collected in hard masses, 

0 and caused intestinal disease. It is seldom that we can discover, during life, What 
is the exact nature of the mechanical obstacle: but I have observed this peculi- 
arity in most of the cases in which I have known it produced by intussusception, 
that after severe and sudden symptoms of obstruction and inflammation, blood has 
been passed by stool. Sometimes the included portion of bowel itself sloughs 
away, and is expelled per anum. 

Inflammation of the bowels requires very much the same kind of treatment as 
peritonitis: indeed, the disease is in most cases peritonitis, and something more. 
The patient must strictly abstain from every sort of stimulus, and confine himself 
as much as possible to the horizontal position. He must lose blood also from the 
arm, and the earlier the better. The lancet is not to be withheld merely because 
the pulse is small. If the artery becomes fuller, and its beating more distinct, 
under venesection — nay, if the patient does not become faint— the first bleeding 
should be a large one. This is not only the safer plan, but in the long run it is 
the most economical of the blood and strength of the patient. As in simple 
peritonitis, the abdomen must be covered with leeches, and afterwards with 
fomentation cloths. Should one spot or region be more painful and tender than 
another, on that part the leeches are to be accumulated. It may be requisite to 
repeat the venesection and the leeching once, or twice, or many times ; the pro- 
priety of such repetition depending upon the urgency and Obstinacy of the symp- 
toms, and upon the age and state of the patient. I am speaking of idiopathic 
enteritis, and of its earlier stages. In the advanced periods, when feeblenesss of 
the pulse is associated with tympany of the belly and coldness of the surface, it 
betokens weakness and sinking, and the tendency to death by asthenia; and, 
consequently, it then indicates support rather than depletion. So also when the 
enteritis is not idiopathic, hut consecutive — when we have reason to believe that 
it arises out of a firm mechanical impediment — our employment of blood-letting 

- must needs be modified by that circumstance. 

One point in the management of enteritis, requiring great caution and judgment, 
relates to the exhibition of purgative medicines. The costive state of the bowels 
is apt to be looked upon as the main evil, and their evacuation as the chief indica- 
tion of treatment; but great mischief, I apprehend, is likely to arise from the 
exclusive pursuit of that indication. I am still speaking of the idiopathic disease, 
where it is presumable that no mechanical obstacle exists to render the passage of 
the feces impossible. Purgatives given by the mouth are often rejected by the 
stomach, with great distress to the patient. If they are retained, and fail to ope- 
rate, they must do more harm than good. Certainly they should not precede the 
venesection. I will remember, though it is now many years ago, being myself 
badly treated for enteritis. Being ill, in a strange place, I sent for the nearest 
practitioner, who happened to be a very ignorant man. Finding that I was sick, 



804 



ENTERITIS. 



and lhat my bowels did not act, he gave me, for two or three days in succession, 
strong drastic purges, with no other effect than that of increasing my sickness, and 
adding to the abdominal pain I suffered. 1 was then seen by a most intelligent 
physician (this was before I had paid any attention to physic myself), and the 
first thing he did was to have me copiously bled ; and the immediate effect of 
that bleeding was to send me to the night-chair. And I am persuaded lhat when 
evacuations follow the administration of purgatives in such cases, they are often 
owing to the blood-letting and other antiphlogistic measures that are employed at 
the same time. These are the opinions of Dr. Abercrombie also, who says, "I 
confess my own impression distinctly to be, that the use of purgatives makes no 
part of the treatment of the early stages of enteritis; on the contrary, that they 
are rather likely to be hurtful until the inflammation has been subdued." It is an 
instructive fact, that when purgative medicines do operate during the height of the 
inflammation, the stools they produce are merely watery ; and it is only after the 
inflammation has been reduced that feces are discharged, and then in such quan- 
tity sometimes as to show that they must have been shut up in the bowels during 
the period of active inflammation. 

You should wait, then, for the effect of other measures, blood-letting, leeching, 
fomentation, before you give active purgatives by the mouth ; and in all stages of 
the disease, whatever laxatives are given should be of the mildest kind, such as 
are least likely to excite irritation of either the stomach or bowels. 

The same objections do not apply to enemata, which soothe while they evacu- 
ate the lower parts of the canal. You will read or hear of great service done by 
an infusion of tobacco, or by the smoke of tobacco, thrown into the bowels through 
the rectum. Dr. Abercrombie speaks of a weak infusion of the leaves as being a 
remedy of very general utility. It should, I apprehend, be a weak infusion to be 
at all safe ; but, of my own knowledge, I can tell you little or nothing about it. 
I do know, however, that the injection of a large quantity of merely warm water 
is often of much use; from two to six pints, for example, thrown up gradually 
and gently- Indurated feces are softened and brought away in this manner, and 
the warm water acts as an internal fomentation. 

Of internal medicines I believe the best you can give is a combination of calo- 
mel and opium, in such proportions as will restrain the purgative qualities of the 
calomel. The opium allays pain, and, perhaps, relaxes spasm; mercury tends 
to arrest the inflammatory action; and the more immediate effects of this combi- 
nation are often found to be, a settling of the irritable stomach, a disposition to 
diaphoresis, and an improved pulse. 

To sum up, then, bleeding, and calomel and opium are to be resorted to for 
checking the inflammation: and when that Is in great measure abated (and proba- 
bly not before), it will be right to gtve some mild laxative to clear out the bowels. 
There can be none more suitable or convenient than castor oil. But before we 
venture upon purgatives by the mouth it will be proper to wash out the bowels 
by lavements of tepid water. These injections may sometimes have mechani- 
cally a beneficial effect upon the parts concerned in the inflammation ; untwisting, 
for example, a twisted bowel ; or setting free the half-incarcerated intestine. It 
is often expedient to administer them through a long tube passed as far as possible 
into the rectum.. 

There is one very important point in the treatment of enteritis that I have ye 
to mention. I have told you that in the advanced stage of the disease symptoms 
of sinking often come on ,* a total cessation of pain, failure of the vital powers, 
and coldness of the body. These symptoms, this collapse and approach to syn- 
cope, are generally considered to denote gangrene, and, therefore, a hopeless 
state of disease. Yet in many eases which have proved fatal after similar symp- 
toms, not a trace of gangrene has been discoverable. So that this unpromising 
change in the symptoms does not always indicate a morbid condition which is 
necessarily mortal. And if the patients are to be saved at all, they are to be 



MECHANICAL OCCLUSION OF THE INTESTINAL TUBE. 



805 



saved by wine and support. We must combat the obvious tendency to death by 
asthenia. 

** A man, aged forty, was affected with enteritis in the usual form, for which 
he was treated in the most judicious manner by a respectable practitioner. On 
the fifth day the pain ceased: the pulse was 140, and extremely feeble and irre- 
gular; his face was pale, the features were collapsed, and his whole body was 
covered with cold perspiration; his bowels had been moved. 44 In this condition 
(says Dr. Abercrombie, from whom I quote the case) I saw him for the first 
time. Wine was then given him, at first in large quantities, and upon the whole, 
to the extent of from two to three bottles during the next twenty-four hours. On 
the following day his appearance was improved; his pulse 120, and regular; the 
wine was continued in diminished quantity. On the third day his pulse was 1 12, 
and of good strength, and in a few days more he was well." 

Dr. Abercrombie relates other cases to the same effect; and most physicians, 
I suppose, have occasionally seen such. They teach us that we must not abandon 
our patients in t despair, even under the most adverse circumstances. If diarrhoea 
should supervene with this state of collapse, opiates must be joined with the wine. 
External warmth is also a powerful auxiliary. 

I know of no cases of disease more painful to witness or to treat than those 
which result from invincible obstruction of the intestinal tube. They are usually 
attended, at length, with enteritis ; but they differ much in some respects from 
what I have called idiopathic enteritis. The inflammation is an accident or con- 
sequence of the obstruction ; or of the means used to overcome it. They happen 
usually somewhat in this manner. A person thinks it expedient to take some 
aperient medicine. It has no effect. He repeats the dose. It causes pain and 
gripings, and probably sickness also; but still the bowels are not moved. Ene- 
mata are employed. They bring away, perhaps, some hardened feces, but there 
is no further relief. Meanwhile the patient may have a clean tongue, a quiet 
pulse, a cool and soft skin, and a supple and painless abdomen. Purgatives of a 
more drastic kind are tried, but tried in vain ; and the physician is summoned. 

Now the first thing which you have to do, when called to a case of " obstruction 
of the bowels," is to search narrowly whether there be not some unsuspected 
external hernia. Ail delicacy must be waived ; and every part of the body, where 
hernia may possibly show itself, must be submitted to inspection. If none be 
found, the rectum, and in women the vagina, must be severally explored. Stric- 
ture, or a quarry of impacted feces, may possibly be detected in the one : a uterine 
or other tumour, pressing upon the bowel, may perchance be felt through the 
other. I shall never forget the shock I once experienced on being sent for to see a 
woman, of middle age, who was in articulo mortis, and who, as 1 was told, had 
for some days been labouring under sickness, pain in the abdomen, and constipa- 
tion. In her left groin there was a large palpable strangulated hernia, which had 
not been detected by the practitioner in attendance, simply because it had not been 
looked for; and which was discovered only when it was too late. 

Remember, therefore, that in every case of obstinate costiveness, with signs of 
inflammation within the abdomen, it is absolutely necessary, for your own credit 
and subsequent comfort, as well as for your patient's safety, to make diligent and 
thorough inquiry after such hernia as may be recognized externally. 

But often you find nothing of the sort, and then you are at liberty to prosecute 
with more energy and decision the purgative plan of treatment. You prescribe 
strong doses of jalap and calomel; black draughts. The stomach being irritable, 
you give pills of cathartic extract, and repeat them at short intervals ; or large 
doses of calomel, ten grains or a scruple, three or four times in succession. You 
inject stimulating clysters. Then you are driven to croton oil: and at last, in 
some vague hope of relaxing spasm, to opiates. If symptoms of inflammation 
spring up, you put fairly in force the remedies of inflammation ; and especially 
blood-letting. But all is in vain. The medicines are vomited ; or, if retained, 



806 



MECHANICAL OCCLUSION OF THE INTESTINAL TUBE. 



they serve but to augment the patient's distress, producing or renewing the pain 
and the nausea. It is extraordinary how comfortable the patient sometimes be- 
comes upon the intermission of these active attempts. Now and then he suffers 
tormina, or has fits of retching; but in the intervening periods his sensations and 
outward condition may be those of perfect health ; only there is no alvine dis- 
charge, i 

Now, under these afflicting circumstances, the question will force itself upon 
you — -how long am I to pursue the purgative system ? Common sense, and 
common humanity, answer — you must stop it the instant you are convinced that 
ihere is a mechanical obstacle, which cannot be overcome. To persist in me use 
of drastic purgatives after that conviction, is to inflict wanton and needless torture 
upon the patient. But how are you to know this ? That is one difficulty. And 
how are you, believing that it is so, to satisfy the patient's friends that his disorder 
is irremediable; and to resist their importunity to try this and that: how persuade 
them to look passively on, while their relative is slowly perhaps, but surely, 
perishing? These are great and terrible difficulties. 

You will be urged by all imaginable suggestions : even the most absurd. Crude 
mercury may perhaps be one. Pounds of this metal have been swallowed in 
such cases ; in the hope, I suppose, that it would force a passage by its weight. 
But the obstacle may be in an ascending coil of intestine. And if not, experience 
does not teach us to put any faith in this rude mechanical remedy. It has often 
done mischief, and seldom or never done any good. The metal is apt to become 
oxidized in the body, and then to produce very distressing salivation. This is an 
evil which I have known to occur, and to trouble the patient greatly, some time 
after the ineffectual exhibition of large doses of calomel. 

Dashing cold water over the abdomen, and the lower extremities, is another 
rough expedient, which is sometimes successful in producing evacuations. It 
was adopted, after various other measures had failed, in the case in which the 
bowel was tied down by the adherent appendix vermiformis ; and it caused the 
emptying of that part of the canal which lay beyond or below the internal hernia. 
It is plain that this partial success can be of little or no use ; certainly of none that 
can compensate for the shock and annoyance of the cold effusion. 

Let me not, however, be misunderstood. I do not say that you are to abandon 
all hope when purgatives (and, if need be, blood-letting) have failed, after a few 
trials, to obtain evacuations from the bowels. Nor even that you are necessarily, 
for that reason, to give up the use of purgatives. The intestines may be torpid 
and insensible to ordinary stimuli, and really require strong rousing. Dr. Aber- 
crombie mentions the case of a gentleman whose bowels were locked up by an 
accumulation, as the result showed, of black hardened feces. The obstruction, 
which had resisted the most active purgatives, and was accompanied by an evident 
and painful distension of a part of the abdomen, yielded at once to the repeated 
application of galvanism to that part: each application being immediately followed 
by a copious evacuation. Here the flagging muscular action was restored appa- 
rently by the galvanic stimulus. Very lately I attended an elderly lady, who 
from Wednesday morning to the next Monday noon, had had no alvine relief, 
notwithstanding the employment of the most active cathartics. She suffered fre- 
quent paroxysms of pain and vomiting: but the abdomen was scarcely, if at all, 
distended; nor was it tender. At length she complained that what she vomited 
was stercoraceous— to use her own word?-, " what came upwards ought to have 
passed the other way." It was a thin, brown-coloured, ill-smelling fluid. Dr. 
Mayo and Mr. Arnott were now associated with me in this case, and they touched 
and felt the abdomen as I had previously done. The lady observed that their 
hands were heavy ; and she fancied that the pressure they made had displaced 
something within. And I believe that it was so: for before our consultation in 
the next room was over, word was brought us that the bowels had acted. She 
had passed a liquid motion precisely resembling the stuff she had last vomited. 



MECHANICAL OCCLUSION OF THE INTESTINAL TUBE. 807 



The next day, with one of several similar stools, a hard lump was voided, which 
proved to be a gall-stone, as big as a small walnut. 

As large quantities of warm water had without difficulty been injected, I infer 
that the concretion had been impacted high up in the bowel, probably at the valve 
of the caecum. Some years previously the lady had suffered severe abdominal 
pains, which at the time were ascribed to the passage of a biliary calculus through 
the gall-ducts. 

In this instance there was no evidence of any strong contractile efforts of the 
bowel above the place of obstruction. 

Large enemata— -as much as the intestines will patiently receive — gradually and 
gently introduced, and repeated three or four times a day, may sometimes succeed 
in breaking down and washing away masses of hardened excrement. And if these 
enemata are composed of milk or beef-tea, and are suffered to remain as long as 
they will, they may answer another important purpose ; they may contribute sen- 
sibly to the nourishment of a patient who cannot retain food in his stomach. They 
are generally very soothing and comfortable; allaying tormina, and abating sick- 
ness: and they are adapted to every stage and variety of the complaint. 

There are, however, cases in which we arrive at the melancholy but sure con- 
viction that some mechanical impediment has rendered the bowel absolutely and 
hopelessly impassable. We fear this when, the constipation being obstinate, we 
discover a tumour, or hardness, in some part of the belly : or when we receive a 
history of some former inflammatory attack, since which the bowels have been 
habitually difficult to regulate. Our fears are strengthened when the patient feels 
that the injections reach a certain spot, and there always stop ; and that the intes- 
tines rumble, and roll, and propel their contents downwards to the same spot, and 
no further. And this is the distinctive symptom upon which I desire to fix your 
attention. The abdomen gradually enlarges, especially if the patient is able to 
retain food. The intestines fill up above the obstacle ; and then throes of pain 
occur, spasms the sufferers usually call them, attended with sickness ; and during 
these pangs you may fee], and if the abdomen be uncovered, you may see, im- 
mense coils of intestine, as big perhaps as one's arm, rise and roll over, like some 
huge snake, with loud roarings and -flatulence. When this takes place the time 
for giving purgatives is certainly over. The distended bowel requires no stimu- 
lus ; it acts, and strives with all its power, but strives in vain, to overcome the 
opposing barrier. If you would consult your patient's ease, if you would not 
embitter and abbreviate his slender remnant of life, harass him no further with 
active remedies. In some cases violent inflammation quickly supervenes, and 
death arrives in a few days: in others, the patient survives, without any evacua- 
tion from his bowels, but with long intervals of ease and comfort, for four, or five, 
or six weeks. Even a brief respite may be of infinite value; giving time for the 
arrival of distant friends—for the settlement of worldly concerns — and for prepa- 
ration of the spirit against the inevitable hour. 

It is to these circumstances of irremediable disease that opiates are eminently 
adapted. Even when the symptoms are less desperate, they are not without their 
use. I cannot better express what I think upon this point than in the words of 
the first Heberden, who says: " The probability of advantage from anodynes has 
determined me to recommend them; and experience has strongly confirmed this 
judgment. Under the protection of an opiate I have successfully given more and 
stronger purges than would have stayed without its help. The patient's strength 
has been kept up by some refreshing sleeps : and even in hopeless cases, in which 
the dying person is harassed by unspeakable inquietude, he may be lulled into some 
composure; and without dying at all sooner, may be well enabled to die more 
easily. Lord Verulam blames physicians for not making the euthanasia a part 
of their studies : and surely, though the recovery of the patient be the grand aim 
of their profession, yet where that cannot be obtained, they should try to disarm 
death of some of its terror: " and if they cannot make him quit his prey, and the 



808 



COLIC. 



life must be lost, they may still prevail to have it taken away in the most merciful 
manner." 

I have spoken of these cases as being irremediable : but perhaps I have spoken 
somewhat too absolutely. Life may sometimes be saved by a surgical opera- 
tion. The gut may be punctured above the seat of obstruction, and suffered to 
discharge its contents through what is called an artificial anus. This expedient 
is feasible, however, in those cases only in which the obstacle is situated near the 
termination of the large intestine ; i. e., in the rectum, or in the lower part of the 
descending colon : for here only can we ascertain, with any thing like certainty, 
the exact place of the impediment, and here only may the colon be pierced, from 
behind, without injury to the peritoneum. Under no other circumstances, in my 
opinion, would an attempt to relieve the patient by cutting down upon and open- 
ing the bowel, be justifiable. An artificial outlet in the loin would probably be 
less disgusting to the patient, and less offensive to others, than if it were in front 
of the body. I am not aware that the operation has ever been done in this coun- 
try. It has been practised successfully in France. The mode of performing it I 
am not competent to teach you. In an appropriate case I should think it right to 
mention, though I should be slow to recommend, this anceps remedium. The risk 
of failure, and the penalty of success, should both be set fairly before the patient. 
The choice between certain death, on the one hand, and the chance of living with 
a very loathsome bodily infirmity, on the other, must be made by himself. 

For further information upon this subject, I would refer you to an interesting 
essay, by Mr. Erichsen, published in the 28ih vol. of the Medical Gazette, 

It remains that I should say something more respecting colic: which may exist 
independently of enteritis, and of mechanical occlusion of the bowel ; although 
the three are very often combined and intermixed in the course of the same dis- 
ease. 

In colic there is pain in the abdomen, constipation of the bowels, vomiting 
often : and these are symptoms which occur also in enteritis. The pain is a 
twisting or wringing pain generally, round the navel; and such is the character 
of the exacerbations of pain experienced when the bowels are inflamed. These 
are the points of resemblance between the two maladies : and it is of much im- 
portance, as I told you before, to observe their differences; and to note the marks 
by which the one may be distinguished from the other. It is, then, an essential 
difference that enteritis is attended with fever, and with tenderness of the belly. 
The pain is increased by all kinds and every degree of pressure ; and the patient, 
fixed in the supine position, breathes with the intercostal muscles only, and care- 
fully avoids any movement which would call the abdominal muscles into action, 
and so compress the inflamed bowel. In colic, on the other hand, the circulation 
is tranquil; there is no fever; and the pain is even mitigated by pressure. The 
patient will lie on his belly for ease: nay, he will press it, with the whole weight 
of his body, across the back of a chair, and obtain comfort by that manceuvre. 
During the paroxysms the pain is often most violent: what the old writers call 
dolor atrox — atrocious pain : but there are intervals of complete ease. Even 
when the pain is worst, the patient tosses and shifts from one posture to another 
in search of relief ; and he does not wear that anxious and apprehensive aspect 
which we see in those who are labouring under enteritis. The pain arises, I ima- 
gine, from the distension of the bowel, here and there, by gas ; or, it may be, 
from spasm ; or from both these states at once. At any rate, it is ofteYi associated 
with audible flatulence, and with evident outward spasm. The abdomen is hard, 
and drawn spasmodically inwards towards the vertebral column; and its muscles 
are partially and strongly contracted, gathered up into lumps and knots. None 
of these circumstances belong to enteritis. 

However, there is good reason for believing that, even in mere colic, the pain 
may sometimes be augmented by pressure. When a portion of the gut has be- 
come rapidly distended, considerable uneasiness may result from its forcible com- 



COLICA PICTONUM. 



809 



pression ; although, as Dr. Abercrombie states, the kind of pain can generally, by 
attention, be distinguished from the sensitive tenderness of an inflamed perito- 
neum. Luckily, if such pain on pressure should lead us to mistake a case of pure 
colic for a case of enteritis, the error is on the safe side: and we must always 
bear in mind the tendency remarked in colic, when the complaint is neglected, or 
badly treated, to run into actual inflammation. In fact, as any obstacle to the 
passage of the alimentary matters through the bowels may give rise to colic, colic 
is sometimes merely the first step towards acute inflammation arising out of a 
continuance of the obstruction. And having told you that colic may be thus pro- 
duced, I have at once introduced you to a large class of its causes which have 
already been spoken of in the present lecture as frequent causes of inflammation 
also. 

But colic, like inflammation of the bowels, sometimes arises without any ap- 
parent or detectable obstruction, of a mechanical kind, to the free transit of the 
contents of the alimentary tube. And there is one particular form of colic, that 
requires a separate notice. The colica Pictonum — so called from its great fre- 
quency, heretofore, among the Pictones, or inhabitants of Poictou — is produced 
by the slow introduction of the poison of lead into the system. 

Now the colic which has this origin is not to be distinguished, in its ordinary 
symptoms, from any other kind of colic. But the abdominal pain is usually, in 
such cases, a part only of more general disease. It has received, in different places, 
a variety of names. Colica Pictonum ; the painter's colic; the Devonshire colic ; 
the bellain of Derbyshire ; the dry belly-ache of the West Indies. In all cases it 
acknowledges the same cause — the gradual entrance of lead into the body. 

In this country we see the disease more often in painters than in any other 
persons. They use, as you know, white lead in the preparation of their colours; 
and they are perfectly familiar with this terrible colic. We see it also in all 
workmen whose occupations bring them habitually into contact with preparations 
of lead. No doubt there are very great differences in the susceptibility of this 
effect of the poison of lead. Persons have been known to suffer colica Pictonum, 
in consequence of their sleeping for a night or two in a recently painted room. 
On the other hand, I have myself seen a patient who became affected with the 
disease, for the first time, after working with white lead for nineteen years. 
Generally the first attacks of colic are well recovered from. The obstinate con- 
stipation of the bowels is at length overcome ; the patient obtains ease ; and 
forthwith recurs to his previous habits; and after a period, which varies in dif- 
ferent individuals, he is again laid up with the colic. Even the primary attacks 
are usually attended with pains in the head, and in the limbs ; sometimes with 
cramps; sometimes even with epilepsy and coma. At length, in one of these 
attacks of colic, or after one of them, when the violence of the pain, and the cos- 
tiveness, have yielded to treatment, the patient finds that he has lost the full power 
of using one or both of his hands. The wrists, as the patients express it, drop. 
You see at once what is the matter, by the characteristic slate of the arms and 
hands. The extensor muscles of the hands and fingers are palsied : so that when 
the arms are stretched out, the hands hang dangling down by their own weight; 
and the patient is unnble, by any effort of his will, to raise them. The palsy is 
local ; it does not proceed from any diseased condition of the nervous centres. 
The affected muscles waste ; and the atrophy is very remarkably seen in the 
bundle of muscles composing the ball of the thumb. Even from this condition 
the patients often are capable of complete recovery. But if they persist in fol- 
lowing their former calling-— or if, without knowing it, they continue to be habi- 
tually exposed to the exciting cause of the disease — they become miserable crip- 
ples, fall into a state of general cachexia, and sink at length under some visceral 
disease. The poison accumulates in the body, and saps the powers of life. 
Francis Citois, a native of Poictou, who published an excellent and one of the 
earliest accounts of the disease, in the year 1617, has drawn the following graphic 
picture of its effects. Its cause was not at that time suspected. Speaking of the 



810 



GOLICA PICTONUM. 



wretched sufferers, he says, " Per vicos, veluti larvae, aut arte progredientes 
statute, pallidi, squalidi, macilenti conspiciuntur ; manibus ineurvis, et suo pon- 
dere pendulis, nec nisi arte ad os et easterns supernas partes sublatis, et pedibus 
non suis sed crurum musculis, ad ridiculum ni miserandum incassum corapositis, 
voce clangosa et strepera." 

The course of the disease is usually such as I have just described it. The 
colic happens first, perhaps several times: and then arrives the palsy. But in a 
few instances I have known this order reversed. The wrists have dropped, when 
there had been no preceding colic. 

The great cause of this fearful malady was first made out by our distinguished 
countryman, Sir George Baker. He set on foot an inquiry into the origin of what 
was called the Devonshire colic ; so common was it in that county. He found, 
first, that it occurred chiefly in persons who drank the cider manufactured there: 
and, by degrees, he traced the source of the malady to the admixture of lead with 
the cider; either designedly, for the purpose of sweetening it; or by the inad- 
vertent employment of lead in the construction of the cider mills and vats. It 
was under circumstances of the same kind that the colic of Poictou originated. 
Preparations of lead were used — not fraudulently, but openly and honestly — to 
prevent the wines of the country from turning sour; the injurious influence of 
lead upon the human body not having then been ascertained. So also, equally 
convincing proofs of the adulteration of rum by means of lead, giving rise to fre- 
quent attacks of dry belly-ache in the West Indies, are given by Dr. John Hunter, 
in the Medical Transactions. I invite your attention to his papers, and to Sir 
George Baker's on this subject. They afford a capital specimen of medical 
research and reasoning. Various causes, as you may suppose, had been assigned 
for this disorder. These are one by one investigated, and set aside; until, by 
this method of exclusion, the real source of all the mischief is detected. Sir 
George Baker's papers contain a great deal of curious and useful information in 
respect to the various modes in which this poison of lead may find its way, with- 
out being suspected, into the animal economy. The subject is one of vast im- 
portance in its relation to medical police; but my limits will not allow me to 
follow it beyond the point where it ceases to be directly connected with the prac- 
tice of physic. 

Colica Pictonum is seldom fatal as colic ; or during the persistence of the abdo- 
minal symptoms: yet instances enough of death occurring while the colic was 
present, but from other accidental causes, have now been collected, to enable us 
to say, that no appearances have been met with in the intestinal canal, calculated 
to explain the pain or the constipation. Andral relates five cases, in which the 
body was carefully examined after death preceded by the painter's colic. He 
found neither inflammation, nor any remaining trace of spasm. The intestines 
were neither dilated nor contracted, but of their natural texture and appearance. 
Merat, who has written a good treatise on this form of colic, gives the dissections 
in four fatal cases: fatal, as I mentioned that they sometimes are, by the super- 
vention of coma. There was no discoverable mark of disease; the alimentary 
canal was empty, and the large bowels contracted ; as they were also found to be 
in rabbits which had died of lead colic. For animals are susceptible of the dis- 
ease, and it may be produced in them by the slow impregnation of their bodies 
with the specific poison. Dogs, cats, and rats, that inhabit houses and manufac- 
tories wherein lead is much used or prepared, are known to be attacked both with 
colic and with palsy. With respect to the contraction of the large intestines in 
these cases, we must not be too ready to attribute it to spasm ; for the bowel, 
when empty, is apt to be contracted. - 

When the palsy has been of any continuance, the affected muscles not only 
shrink and waste, but undergo a structural change, which is obvious to the sight. 
They become pale, almost white, dry. John Hunter examined the muscles of 
the hand and arm of a house-painter, who died, while thus paralytic, in St. 
George's Hospital. He found them of a cream colour and opaque ; instead of 



COLICA PICTONUM. 



811 



being of a purplish red, and semi-transparent. And, since his time, lead has been 
detected in the palsied muscles, and in the brain, by chemical analysis. It is 
doubtless, conveyed by the blood, to ail parts of the body. Why it fastens solely 
or chiefly on particular muscles, or particular nerves, nobody knows. The pain 
it occasions, whether in the abdomen or in the limbs, is generally thought to be 
neuralgic. It is one of the poisons that do not appear to find a ready exit from 
the body. Very recently, a most curious symptom, pathognomonic, I believe, of 
the presence of lead in the system, has been pointed out by Dr. Burton : and now 
that it has been pointed out, one can hardly understand how it escaped discovery 
so long. It is a blue or purplish line running along the edges of the gums, just 
where they meet the teeth. Dr. Burton first noticed this six years ago, but wisely 
refrained from making his observations public until he had had time and oppor- 
tunity enough to satisfy his mind that he was not mistaken. A paper of his on 
the subject was read at the Medical and Chirurgical Society last January (1840). 
I cannot resist the temptation to read to you the notes of a case which has subse- 
quently occurred to me in the hospital. Mary Anne Davis, a middle-aged woman, 
presented herself with dropped wrists. It was an exquisite example of palsy of 
the extensor muscles of the hands and fingers. She could raise her arms, but 
her hands hung down like the talons of a bird, or like the fore paws of an erect 
kangaroo. This began nine weeks before. She complained of pain, beginning 
under the nails, stretching up the backs of her hands, and reaching sometimes to 
the elbows. The bottoms of her feet had also been tender; and at night were 
burning hot. 

Seeing the dropped wrists, we thought immediately of the poison of lead. But 
the patient was a female. We do not often see these effects of that poison in 
women; for obvious reasons. At first we could get no clue to the mode in which 
lead could have found its way into her system. Her husband was a broker. She 
had not been living in a newly-painted house: and had (she said) no concern with 
lead in any way. Lead often creeps in, however, through undetected channels, 
and I could not help suspecting it here. Mr. Pyper, my clinical assistant, soon 
elicited another part of her history, which added to our suspicions ; namely, that 
before the palsy occurred, she had had pains in the abdomen, and costive bowels, 
for five days together. Nay, she had a recurrence of colic after her admission. 
This was a strongly corroborating fact; but what clenched the proof was the dis- 
covery of a decided blue rim along the edges of nearly all her gums. This con- 
clusive evidence led to further cross-examination ; and at last it came out that some 
of her sons (she had seven)Jiad occupied their leisure time in the preceding sum- 
mer with making bird-cages, and painting them green, in the one room in which 
she habitually lived. The case altogether was a very neat one. 

Mr. Tomes pointed out to me some interesting circumstances, which led him, 
at one time, to think it probable that the colour might be produced by some 
chemical action between the tartar that forms on the teeth, where they meet the 
gums, and the lead which pervades the system. This woman's teeth, like those 
of many in her rank of life, were loaded with tartar. In one place was visible 
a stump, level with the gum, and surrounded by a ring of tartar; and there was 
also a corresponding border of blue. In other places there were gaps, where teeth 
once were; here there was, of course, no tartar; and here there was no blue line 
on the edge of the gum. The blueness may however appear when there is no 
tartar at all. I do not know exactly in what manner the chemical union arises, 
but the colour depends, I believe, upon a sulphur et of lead, formed somehow by 
the action of sulphuretted hydrogen upon the metal. It is curious that the edge 
of the gum should always be the part thus marked; that very part which first 
exhibits he influence of another metal, mercury, when ptyalism is about to ensue. 

This discovery of Dr. Burton's is not a mere piece of curiosity, but is likely to 
be of use in various ways. In the first place, it may settle the nature and cause 
of many doubtful cases; as it did, indeed, of the one just narrated. The poison 
of lead produces pains which resemble, and no doubt are sometimes mistaken for, 



812 



COLICA PICTONUM. 



the pains of rheumatism ; it has other obscure consequences too : and an inspection 
of the gums may often greatly elucidate such cases. Dr. Burton finds that small 
quantities of lead given as a medicine will produce the phenomenon. In two in- 
stances it occurred within two days. One of these patients had taken fifteen 
grains of the acetate of lead in that time ; the other twenty-four grains. A corre- 
spondent of his produced the blue rim in twenty-four hours; viz., by four doses, 
of five grains each, exhibited every six hours. He finds too that the line remains 
distinct after death ; even more so than during life. It may afford valuable infor- 
mation therefore to the medical jurist in cases of suspected poisoning with the 
salts of lead. It is, I say, an early consequence of the absorption of lead. It will 
teach us, as the mercurial affection of the gums teaches us, that the medicine is 
pervading the system ; and admonish us to look out for, and guard against, colic. 
It may apprise workers in lead that their caution has been insufficient; that the 
poison has entered ; and that they are in peril of belly-aches and palsy. It is a 
capital diagnostic sign also between colic so arising, and colic from other causes ; 
and between colica Pictonum, and the pain of inflammation of the bowels.* 

* [The symptoms of colica pictonum, or lead colic, are in some respects different from 
those of ordinary colic. There is usually, at first, a loss of appetite, with some degree, 
more or less in different cases, of nausea, and very commonly an increased discharge of 
saliva. The patient's sleep is disturbed, or more frequently, there is an inability to sleep; 
according to M. Ranque, of Orleans, he exhibits various other symptoms of a disordered 
condition of the nervous system. The attack of colic usually commences with vomiting; 
the matter discharged being, at first, whatever has been taken into the stomach mixed with 
bile and the gastric secretions, very generally changed from their healthy condition; if the 
vomiting continue these latter are alone discharged. Pain of the abdomen is next com- 
plained of; it is most severe about the navel, the epigastrium, the hypochondria, the loins 
and above the crest of the ileum. The pain, in general, commences at the hypogastric 
region, or, as a cramp, at the pit of the stomach, and from thence extends, in a short time, 
over the rest of the abdomen. The pain is at first paroxysmal, with intervals of ease; these 
intervals being the longest at the commencement of the attack. More commonly there 
occur remissions rather than intermissions of the pain ; and it is remarked, that both the 
remissions and exacerbations are much longer than those of ordinary colic. As the dis- 
ease advances the pain is almost constant, but is usually most severe at night. It is not 
increased by pressure, on the contrary, pressure very generally, but not invariably, affords 
relief, provided it be not made upon the epigastrium; according to Merat, patients have 
been known to bear, with relief to the paroxysms, the weight of two or three persons stand- 
ing on the belly. The abdomen is almost invariably hard and flat from a contraction of 
its muscles; the navel is sometimes drawn in so as almost to approach the spine; in a few 
instances there exists some fullness of the abdomen, and occasionally it has an irregular, 
knotty feel. There generally occur, within the first day or two, sometimes within the first 
few hours of the attack, headache, and a dull, anxious or depressed expression of the coun- 
tenance; to these symptoms are soon added, pains of the limbs, especially of the inside of 
the thighs, calves of the legs, ankles, and soles of the feet; these pains are worst at night; 
they are often accompanied with cramps, and according to Tanquerel, are relieved by 
pressure. The disease is seldom attended with febrile excitement. The skin is of a dull, 
dirty, cadaverous appearance; it is frequently hot, and almost invariably bedewed with 
irregular, clammy, and often cold, perspiration. The pulse, according to MM. Ranque and 
Merat, is rarely accelerated, but often below 60° in a minute; others, however, notice a 
considerable acceleration of the pulse, which we have remarked in many cases, the pulse 
being at the same time, hard, and communicating to the finger a peculiar thrill. Obstinate 
constipation of the bowels is an almost invariable symptom ; although it does not always 
occur at the very commencement of the attack; in a few instances, it is said that the 
attack has been attended with diarrhoea; such an occurrence, however, we have never ob- 
served. On the contrary, in all the cases that have fallen under our notice, either no dis- 
charge has taken place from the bowels, or a scanty stool has occurred composed of a few 
lumps of dry, hardened feces, passed with much straining and pain. The urine, though 
generally natural in appearance, is often diminished in quantity. 

From an attack of colica pictonum, particularly a first attack, the patient may, under a 
judicious and timely treatment, recover perfectly; and with a careful avoidance of any of 
its exciting eauses, and of the poison of lead, he may remain ever after free from a recur- 
rence of the disease. When the disease, however, is neglected, or badly managed, or the 
patient is constantly or repeatedly exposed to the influence of lead, he becomes affected 
either with a peculiar form of partial palsy, which is well described by Dr. Watson in the 
text; or, instead of this gradual loss of voluntary motion in the muscles of the extremities, 



COLICA PICTONUM. 



813 



In the treatment of colic — and especially of the lead colic — the great indication 
is to get the bowels to act. If the pain of the belly be increased on pressure, if 
the pulse be at all accelerated, if the face be flushed, and there be the slightest 
approach to fever, it will be right to take blood from the arm. It is a measure of 
safety as regards the possible existence of inflammation : and if there be no in- 
flammation present or impending, it will tend to remove the spasmodic state of 
the muscles which goes along with, and perhaps chiefly constitutes, the disease. 
External warmth should also be applied ; diligent friction, with some stimulating 
liniment; or, what is much better, a mustard poultice, or a turpentine stupe. My 
colleague, Dr. Wilson, has been very successful in relieving these patients, by 
putting them into a hot bath, and having a large quantity of the water in which 
they are immersed, thrown gradually into their bowels by means of a proper 
syringe. The bath presently becomes polluted, to the great satisfaction and 
refreshment of the patient. It will generally be expedient to give a full dose of 
calomel and opium ; ten grains of the one with two of the other. Sometimes the 
effect of the opiate is to suffer the bowels to empty themselves ; showing that the 
previous difficulty was probably spasmodic. Usually the calomel and opium will 
soothe the vomiting, the restlessness and the pain ; and then a full dose of neutral 
salts, or of castor oil ; or (if these do not succeed) of the last named remedy, 
castor oil, quickened by one or two drops of the oil of croton, will produce free 
evacuations from the bowels; and the patient soon returns to his ordinary state of 
health. It is sometimes necessary to repeat this practice, this alternation of pur- 
gatives and anodynes: but when once the bowels have been freely moved, the 
disease, in general, becomes very tractable. 

At La Charite, in Paris, there is what is called a specific mode of treatment fol- 
lowed. It is complicated and rough, but not a whit more successful than the sim- 
pler plan which is universally adopted in this country. You may see it described, 
if you are curious on the subject, in most of the French books. I think it is 
given in detail in Ratier's Formulary of Hospital Practice. 

Some have recommended salivation for the cure of the painter's colic, on the 
principle, I conjecture, of driving out one metallic poison by another. But the 
two may combine, for aught I know, to plague the patient. The practice is quite 
unnecessary. 

You will be consulted about the palsy which arises from lead, and especially 
to remedy the dropped wrists, which render the patient incapable of earning his 
livelihood. ""Now in the early stages of the palsy, and in its primary attacks, you 
may often succeed in effecting a cure. Electricity has been thought useful, ap- 
plied in the way of sparks at first, and of slight shocks afterwards, along the 
muscular parts of the extensors of the fingers. It accelerates the recovery to give 
the hand and fingers the mechanical support of a splint, made for that express 
purpose, and so contrived that the hand and fingers are kept extended through the 
greater part of the day. Patients labouring under this kind of palsy resort to the 
Bath waters for a cure : and I learn from a gentleman who once held the office of 
house-surgeon to the hospital there, that the physicians have much more faith in 

there occur another set of symptoms, which very generally terminate speedily in death. 
The patient after a few days becomes affected with giddiness, gre^.t debility, torpor, and 
sometimes delirium; as the torpor advances, the pains in the abdomen and extremities 
abate; at length convulsions, and a comatose condition ensue, from which very few re- 
cover. Cases are recorded by Louis and others in which death suddenly occurred during 
the first stage of the disease, without the occurrence of any symptoms that would cause 
such a result to be suspected. Drs. Elliotson and Copland each relate a case in which 
death was caused by perforation of the stomach. To a paralytic affection of the muscles of 
the extremities, as a very common effect of repeated attacks of colica pictonum, we have 
already referred; and two cases are related by Dr. Alderson, of Hull, England, in which 
the disease was attended with paralysis of the nerves of vision ; Tanquerel states that this 
is not uncommon in Paris, the paralysis being attended with dilated and immovable pupils; 
he met, also, with one instance in which deafness was present, no doubt from paralysis of 
the auditory nerve.— C] 



814 



COLICA PICTONUM. 



the use of the baths, with shampooing, and in splints and blisters to the palsied 
muscles, than in electricity. The warm douche is a promising expedient: the 
electro-magnetic apparatus, perhaps, still more so. 

According to Andral and others, who have had more experience of that drug 
than I have, there is no form of palsy so likely to be benefited by strychnine as 
this which proceeds from the poison of lead. I should recommend you to try 
the safer methods of binding the hand to a splint, and stimulating the muscles by 
friction, shampooing, or electricity, before you resort to that active poison. 

It is observable of this disease, as of many, and, indeed, of most others, ex- 
cept certain contagious febrile diseases, that when once it has occurred, it is much 
more liable to occur again, upon a repetition of the exciting cause, than before. 
It is of very great moment, therefore, that they who are necessarily exposed to 
the poison of lead — as painters, plumbers, printers (who handle leaden types), 
colour-grinders, potters, and glass-blowers (who use the oxide of lead in their 
respective manufactories), shot-makers, workers in lead mines, and so on — it is of 
great importance that these persons should be made aware of the means which 
are best adapted for their protection against the injurious agency of the poison: 
and we ought to be able to give them advice in that matter. The rules for their 
guidance are short and simple; and, if carefully observed, I believe they will 
generally prove successful. They resolve themselves into cautions against the 
admission of the* metal or its compounds into the body through any channel. 

1. To prevent its introduction through the skin minute attention to cleanliness 
is necessary. The face and hands should be washed, the mouth rinsed, and the 
hair combed, several times in the day; and bathing and ablution of the whole 
body should be frequently performed : also, the working-clothes should not be 
made of woolen, but of strong compact linen; and they should be washed once 
or twice a week at least; and they should be worn as little as possible out of the 
workshop : and some light impervious cap might protect the head while the per- 
son is at work. 

2. Care should be taken that none of the poison be admitted into the system 
with the food. The workmen, therefore, should not take their meals in the work- 
room, and should be scrupulous in cleansing their hands and lips before eating. 

3. The entrance of the poison into the air-passages during respiration should 
be guarded against as much as possible. Masks have been recommended for this 
purpose: none, probably, would be more convenient or more effectual, than Mr. 
Jeffrey's orinasal respirator. 

There is a notion prevalent in some places, which apparently has some foun- 
dation, that the free use of fat, and of oily substances, as food, is a preservative 
against the colic. A physician, near Breda, informed Sir George Baker that the 
village in which he lived contained a great number of potters, among whom he did 
not witness a single case of lead colic in the course of fifteen years ; and he attri- 
buted their immunity to their having lived very much on butter and bacon, and 
other fat kinds of food. De Haen also was told by a physician, the proprietor of 
a lead mine in Styria, that the labourers there were once very subject to colic and 
palsy ; but that after they were exhorted by a quack doctor to eat a good deal of 
fat, especially at breakfast, they were exempt from these disorders for three years. 
This is a kind of prophylaxis that is very easily adopted. 

More recently Liebig has asserted that " the disease called painter's colic is 
unknown in all manufactories of white lead in which the workmen are accustome'd 
to take, as a preservative, sulphuric acid lemonade, a solution of sugar rendered 
acid by sulphuric acid." 

If i his be so, the lemonade must protect the system by converting any other 
salt of lead, which might find entrance, into an insoluble sulphate : solubility being 
requisite to give efficacy to any poisonous substance. 

Mr. Benson, the manager of the British white-lead works, in Birmingham, 
states (in the Lancet) that he has tried this method of prevention. Under his 
direction sulphuric acid was first added to the treacle-beer, used as a beverage by 



DIARRH(EA. 



815 



the workmen, in the summer of 1841. Lead colic, which had prevailed before 
" to a distressing extent," soon began to diminish in frequency: and from October 
in the same year, np to the date of Mr. Benson's communication in December, 
1842 — a period of fifteen months — not a single instance of the disorder had occurred 
amongst them. This is very encouraging. 



LECTURE L X X 1 1 . 

Diarrhoea. Sporadic Cholera. Epidemic Cholera. 

The morbid fluxes which proceed from the long tract of mucous membrane that 
lies between the stomach and the anus are many in number : and they vary much 
both in kind and in cause. Hemorrhages are not uncommon. I have already 
described the disease called melsena, which is characterized by the discharge of 
black semifluid matters, resembling tar, from the bowels, and in most instances 
from the stomach also by vomiting. The matters vomited, and the matters passed 
by stools, are composed principally of blood, which has been rendered black, and 
otherwise modified in appearance, during its progress outwards in the one direction 
and in the other. Again, hemorrhage from the bowels is apt to occur in continued 
fever ; as I shall show you when we come to that disease. Hemorrhage takes place 
also from the rectum in hsemorrhois, or bleeding piles : a malady that falls chiefly 
to the care of the surgeon. Blood comes away, too, mixed with a greater or less 
quantity of mucus, in dysentery. 

The remaining forms of profluvia from the intestinal canal I shall proceed to 
consider seriatim ; at least the most important of them. 

There are several very different affections classed together under the head of 
diarrhoea; by which term is usually signified the occurrence of frequent, loose or 
liquid alvine evacuations. Thus diarrhoea is a very common symptom of pulmo- 
nary phthisis; and this form of the disorder has been already mentioned. It is 
very often met with also in continued fever, and during the decline of the febrile 
exanthemata, of which I have yet to speak. But diarrhoea is not unfrequently the 
main symptom of the illness under which the patient labours ; and constitutes, at 
any rate, the chief object of our treatment. I shall touch briefly on some of its 
varieties. 

In the first place, there is that common form of the complaint which proceeds 
from over-repletion of the stomach ; or from the ingestion of food that is not 
wholesome: food that disagrees (as the phrase is) with the patient's stomach and 
bowels at that particular time. We may call it, with Cullen, by way of distinc- 
tion, diarrhoea crapulosa : in which feces are discharged in a more liquid state, and 
more copiously, and more often, than is natural. These cases are in truth slight 
cases of irritant poisoning. The ingesta irritate the mucous surface, and probably 
the muscular coat also ; the secretions of the inner membrane are poured forth in 
unusual abundance, and the peristaltic motions of the intestines become more strong 
and active; the object of these changes being that of getting rid of the offending 
substances : a salutary and conservative effort, which we assist and imitate in our 
treatment of this form of diarrhoea. 

The symptoms by which this species of diarrhoea is marked, must be well 
known to us all. There are often nausea ; flatulence ; griping pains in the bowels, 
succeeded by stools of unnatural appearance and odour, and of fluid or watery 
consistence. There are often, also, a furred tongue and a foul breath: but the 
disorder is attended with little or no fever ; the pulse remains of the ordinary 
frequency; and the temperature of the body does not rise. 

There are certain things which, more than others, tend, when taken into the 



816 



DIARRHOEA. 



stomach, to cause this crapulous diarrhoea: and there are certain circumstances 
which increase the disposition to be affected by the ordinary exciting causes. 

We frequently see this disorder supervene upon a debauch, in which case the 
mixture ot" various articles of food, and of drink, each of which in itself might 
have been perfectly innocent — and the actual quantity of the mixed ingesta — have 
occasioned the irritation and disturbance. But where there has been no intempe- 
rance in eating or drinking, some kinds of food are more likely than others, 
cseteris paribus, to provoke diarrhoea. I do not speak of idiosyncrasies, which 
show the truth of the old proverb, that what is one man's meat is another man's poi- 
son, and which cannot be reckoned upon beforehand ; but I refer to the average 
of systems and stomachs. And among these indigestible and irritating substances 
we may place raw vegetables of many kinds ; such as cucumbers and salads, sundry 
kinds of fruit, especially if they be hard, immature and acid; plums, melons, 
pine-apples, nuts, and so forth. Mushrooms may be added to the list, even when 
they are cooked. Putrid food, or food which, in the more refined phraseology of 
gastronomers, is termed high, has the same effect upon some persons : and so, in 
a particular manner, have some kinds of fish; shell-fish, crabs and muscles, for 
instance, in this country; and in other countries, in the West Indies, there are 
several species of fish which are actually poisonous, and cannot be safely eaten at 
all. And similar disorder is frequently produced in children by any sort of food, 
other than the natural sustenance furnished by the mother. The new kind of 
nutriment disagrees with them: and the very same thing is apt to occur in adult 
persons. An article of diet which is perfectly wholesome and digestible, and 
which the stomach bears well after a little habit, will sometimes cause griping and 
purging, when it is taken for the first time. It is upon this principle that the 
diarrhoea to which Englishmen are subject upon first visiting the towns upon the 
continent, is to be explained. I do not know that it is so, but I think it very likely 
that Frenchmen, and Germans, and Italians, suffer in the same way when they 
first come to this country, and adopt our habits and regimen. 

Another curious exciting cause is to be found in certain mental emotions, and 
especially the depressing passions : grief, and above all, fear. A sudden panic 
will operate on the bowels of some persons as surely as a black dose, and much 
more speedily. Among the circumstances which predispose most persons to this 
kind of malady, we may particularly specify season — the hot weather of summer 
and autumn. And it is probably consistent with the experience of most of you, 
that the atmosphere of the dissecting-room has a similar tendency. 

Now this diarrhoea, from occasional irritation, produced by the presence of 
substances that offend the stomach or bowels, will generally cease of itself. The 
purging is the natural way of getting rid of the irritant cause. We may favour 
the recovery by diluent drinks, and by making the patient abstain from all further 
use of food which is not perfectly easy of digestion ; and we may often accelerate 
the recovery by sweeping out the alimentary canal by some safe purgative, and 
then soothing it by an opiate. Or we may give the aperient and the anodyne 
together, and the one will not interfere with the operation of the other. A table- 
spoonful of castor-oil, with six or eight minims of laudanum dropped upon it: or 
from fifteen grains to a scruple of powdered rhubarb, with half as much of the 
pulvis cretse compositus cum opio. By some such medication as this, emptying 
the bowels, and quieting them, the cure is generally accomplished with ease, and 
speedily : tutb, citd, et jucunde. 

We sometimes, however, meet with cases in which diarrhoea runs on; the stools 
being composed of fecal matter in an unnaturally fluid state ; and the precise 
condition on which this disposition to an over-loose state of the bowels depends, 
escaping detection. If the disorder be slight, it will often yield to the astringent 
and bitter medicines. The infusion of cusparia, with the tincture of cinnamon, 
supplies a convenient formula. If it be more severe, or obstinate, we have recourse 
to a chalk mixture, which neutralizes acidity ; combined with catechu, which is 
a direct astringent of the tissues ; and with laudanum, which calms irritation. 



DIARRHOEA. 



81*7 



And in extreme cases the sulphate of copper has been found to have a powerful 
effect in restraining the flux. It is apt to gripe, and should be combined there- 
fore with opium. A quarter of a grain of each, in a pill, given three or four 
times a day, I have frequently found successful, when previous attempts to remove 
the diarrhoea had failed.* 

* [A much more effectual remedy is the acetate of lead, combined with opium and ipe- 
cacuanha; one grain of the first, from a fourth to the half of a grain of the second, and from 
half a grain to a grain of the latter, combined in the form of a pill, or in a powder, mixed 
with a little simple syrup, may be given to an adult, and repeated every three or four hours 
according to circumstances. 

Diarrhoea in a chronic form is that which the practitioner will be the most frequently 
called upon to treat in the adult; and it, in general, requires for its complete removal a 
cautious and judicious course of treatment persevered in for a length of time. The slightest 
deviation from the strict diet and regimen required in each case, will often very consider- 
ably protract the cure ; while a too early abandonment of the appropriate remedies will 
frequently be quickly followed by a return of all the worst symptoms of the disease. 

In chronic diarrhoea there exists a morbid excitability of the intestinal canal, so that 
almost every thing taken into the stomach, as food or drink, brings on quickly repeated 
discharges by stool consisting of the ordinary secretions of the digestive tube, more or less 
changed in character, mixed with portions of half digested aliment; and the looseness con- 
tinues, often unattended with griping, or any other uneasy sensation save those connected 
with the debility and emaciation produced by the interruption to the digestive and nutritive 
functions generally, which the rapid passage of the aliment through the bowels occa- 
sions. There is no doubt, that frequently the. morbid excitability of the digestive canal is 
due to a chronic inflammation, often follicular, and attended with ulceration of some por- 
tion of its mucous membrane; when this is the case, we have repeated discharges by stool 
without apparently any exciting cause other than the morbid secretions of the liver, 
pancreas, or of the stomach and intestines themselves. The discharges are, in general, 
dark-coloured and offensive, very fluid, and small in quantity, and are often preceded 
and accompanied by griping pains more or less severe. There is, very commonly, some 
degree of nausea, and occasionally vomiting, the appetite for food is generally destroyed, 
though in many cases, it continues unimpaired. The patient becomes more and more 
emaciated and debilitated; his skin assumes a dirty sallow hue and a dry harsh feel; the 
palms of the hands become hot and dry; the countenance has, in many cases, a dull, de- 
sponding expression; the features acquire considerable sharpness, and the eyes become 
sunken and surrounded by a broad leaden-coloured ring. The abdomen is frequently flac- 
cid, and exhibits no tenderness upon moderate pressure; occasionally, however, it becomes 
swollen and tympanitic, and is now and then decidedly tender to the touch. We have known 
in cases of chronic diarrhoea, an effusion of serum to occur within the peritoneal cavity, 
and to produce a very decided intumescence of the abdomen. In protracted cases, the body 
exhales a peculiar sickly odour, the tongue becomes of a dark; mahogany hue, and often, to- 
gether with the parietes of the mouth, is covered with aphthae.- The pulse is usually small 
and feeble, often quick and frequent. Febrile symptoms are not generally present; in many 
cases, however, there is observed some degree of febrile excitement towards evening — very 
protracted cases we have repeatedly known to be accompanied with well-marked hectic 
symptoms — more or less puffmess of the face, and oedematous swelling of the extremities, 
very commonly occur in the course of the disease. The discharges by stool, while they 
are always fluid and vitiated, exhibit considerable variety in their appearance; most gene- 
rally they are dark-coloured and exhale a rancid or fetid odour; occasionally, however, 
they have a jelly-like consistence, and very little smell; at other times they consist of a 
small quantity of a dirty yellow fluid, and when they contain solid matter this will generally 
be found to consist of portions of half digested aliment. All these changes in the character 
of the discharges, may present themselves in the same case, and often within a very short 
period. In protracted cases, the discharges would appear to acquire an acrid property, 
producing an erythematous inflammation of the verge of the anus, and often of the nates. 
The frequency of the stools varies very much in different cases, and, at different periods in, 
the same case. Occasionally, the diarrhoea takes place only after the ingestion of food 
or drinks, or of particular kinds of food, and the discharges from the bowels continue to 
recur at short intervals until the offending matters are got rid of; in many cases, repeated 
stools occur in the course of the day, whether food is taken or not, and are suspended during 
the night; in other instances, the evacuations from the bowels often cease for a day or even 
longer, and then return, and for a short period with increased frequency. 

The duration of chronic diarrhoea is very various ; unless arrested by a proper course 
of treatment — its spontaneous cessation being a thing of very rare occurrence — it will 
run on for weeks, often for months, and the patient finally sinks from extreme exhaustion, 
52 



818 



DIARRHOEA. 



I have alluded to the influence of hot weather in predisposing the system to be 
affected by the exciting causes of diarrhcea. And there is a complaint of which 
diarrhoea is one prominent symptom, but which is something more than mere 

Occasionally perforation of the intestines occurs from ulceration or softening, and the fatal 
event is preceded by peritonitis. 

The causes of chronic diarrhcea are the same as those of the acute or simple form of the 
disease; frequent attacks, within a short period of an ordinary bowel complaint, will very 
commonly induce a chronic affection. — Improper articles of diet, and acescent drinks, 
habitually indulged in; exposure to a cold, and, at the same lime, humid atmosphere ; 
the abuse of purgatives, and intemperate habits generally, are among the most common 
causes of chronic diarrhcea. It is an affection much more readily induced in those of a lax, 
and feeble, excitable and broken-down constitution, than in those of an opposite condition. 

The state of the intestinal tube in those who have fallen victims to the disease is very 
various. In some cases, the mucous coat, particularly of the large intestines, is somewhat 
thickened, spongy, and pale — in others its anatomical characters are entirely changed, 
large portions of it presenting a smooth, glassy, mottled appearance, as though its surface 
had been covered with a thin coating of dirty varnish. Occasionally large patches of the 
mucous membrane of the colon or rectum are of a dark mahogany or of a slate colour — the 
traces of follicular inflammation, or of ulcerations, more or less extensive, are not unfre- 
quently met with, especially in the ileum and colon. Dr. Stokes notices a form of chronic 
diarrhoea as of common occurrence, dependent upon ulcers situated close to the verge of the 
anus; these ulcers occur chiefly in persons of a broken-down constitution, and those who 
have taken a great deal of mercury; we have repeatedly observed them, also, in individuals, 
who have been in the habit of using almost daily, the various pills composed chiefly of aloes, 
soap andscammony, or gamboge, vast quantities of which are vended in the United States 
as a popular remedy for almost every ailment. The ulcers situated just within the anus 
produce irritation in the colon, tenesmus, griping, frequent discharges by stool, and most 
commonly during the straining a little blood is passed. The presence of the ulcers may be 
at once detected by an examination of the rectum; which examination, as Dr. Stokes very 
correctly remarks, should invariably be made in all cases where the diarrhcea has been of 
long standing, and has resisted a great variety of treatment; where it is attended with 
tenesmus, and a desire of sitting on the night chair after a stool has been passed; and, 
finally, where the patient's health does not appear to be so much affected as it naturally 
would be from long-continued disease of a large portion of the great intestine. 

In the treatment of chronic diarrhcea our leading indications are, to control the morbid 
irritability or excitability of the intestinal mucous membrane, and restore it as quickly as 
possible to its healthy condition and functions. To effect these objects is not always, how- 
ever, a very easy task, and always demands considerable judgment on the part of the prac- 
titioner, and considerable patience, and an implicit obedience on the part of the patient to 
the medicinal directions and dietetic rules laid down. The first and all-important conside- 
ration is that of diet — so that, while the patient is supplied with aliment calculated for his 
support, as little irritation as possible of the intestines shall be excited by it. The food 
taken by an individual labouring under chronic diarrhcea, should be easy of digestion, of the 
mildest quality, and such as leaves, after undergoing digestion, but a small quantity of ex- 
crementitious matter; and even of such food but a small portion should be taken at a time. 
Rice is probably the best article of diet in the generality of cases of chronic diarrhcea ; 
when well boiled, with the addition of a little salt, while it is sufficiently nourishing it is 
extremely mild and unirritating, by no means difficult of digestion, and scarcely affords any 
excrementitious matter to be transmitted along the intestines. It may, generally, be eaten 
mixed with a very moderate quantity of plain beef or mutton broth; plain meat broths pre- 
pared with the addition of a large amount of rice, will often furnish a very suitable food in 
chronic diarrhcea, and are to many stomachs more palatable ; rice, also, boiled with milk and 
sweetened, but not too heavily, with the best loaf sugar, or fresh milk thickened with rice 
flour, may be occasionally given. Should either preparation, however, be found to disagree 
with the patient, or to augment or keep up the diarrhcea, it should be at once relinquished. 
We have indeed, in numerous instances, found plain broths, when well prepared, or the 
juice of roasted meats with a portion of stale bread or cracker broken into it agree better 
than any preparation of rice. Tapioca, sago, or arrow root we have seldom found an 
appropriate aliment for persons labouring under the chronic form of diarrhcea. As soon 
as it can be borne, and this can only be ascertained by a cautious trial, a small portion of 
tender chicken, turkey, or mutton, plainly boiled or roasted, may be eaten with rice. Pure 
water, toast water or rice water, taken cold and in very moderate quantities at a time, 
should be the only drink allowed. 

_ Next, or more properly perhaps, equal in importance to a well regulated diet, is an atten- 
tion to the clothing and regimen of the patient. Individuals affected with chronic diar- 
rhcea are particularly susceptible to the influence of a cold and damp atmosphere— a slight 



SPORADIC CHOLERA. 



819 



diarrhoea — that shows itself in this country, more or less every autumn, and pre- 
vails extensively in some years, as a minor epidemic. It is rightly enough named 
cholera; for it is attended with, and consists mainly of, a remarkable flux of bile. 

exposure to which will often increase their disease, or when we have succeeded in dimi- 
nishing the frequency of the discharges cause them to return as before.— It is essential, 
therefore, that independent of cautiously avoiding every species of exposure, the patient 
should be suitably lodged and clothed. The chamber he occupies at night, as well as during 
the day, should be dry, of a comfortable and equable temperature, perfectly clean, and well 
ventilated: his elothing should be adapted to the season and state of the weather— flannel 
next the skin should always be worn; a belt of flannel around the abdomen, or enveloping 
this part with a flannel roller nicely adjusted, and renewed daily, will always be found ad- 
vantageous. In obstinate and protracted cases, the removal of the patient from a cold, 
damp and changeable, to a more equable, warmer, and drier climate, whenever practicable, 
is a measure from which the very best results are to be anticipated; it has, in numerous 
instances, been known to effect a speedy cure, when all other means have failed. 

In regard to exercise, even the gentlest kind whether passive or active, cannot sometimes 
be undertaken, from the frequent and pressing calls to evacuate the bowels which occa- 
sionally are found to be excited by motion of every kind: in other cases, short walks in the 
open air, in suitable weather, or a gentle ride in an open carriage or sailing in a boat are 
advantageous, and should be repeated daily if the patient's strength will admit of it. 

The warm bath, followed by brisk friction of the surface, is a remedy from which the best 
effects are to be anticipated in most cases of chronic diarrhoea; it may be repeated daily, 
the temperature of the water being carefully graduated by the condition of the patienL's 
surface; when this is dry and warm, a tepid bath should be preferred, but if the surface is 
cool or its heat is not well sustained, the water should be decidedly warm. The tempera- 
ture Of the bath should never be so low as to cause the patient when immersed in it tke 
sightest sensation of chilliness on the one hand, nor so high on the other, nor the continu- 
ance in it so long, as to produce profuse perspiration. 

By a few physicians the effects of leeches to the abdomen or to the anus, in cases of 
chronic diarrhoea, are spoken of in the highest terms of commendation. Drs. Crampton 
and Forbes, in their very excellent essay on the disease under consideration, contained in the 
Cyclopaedia of Practical Medicine, {Philadelphia Edition, vol. i., p. 640,) speak of leeches 
applied to the anus, as a remedy " possessed of remarkable powers— often working," ac- 
cording to the common expression, "like a charm, even in cases of diarrhoea of very lung 
standing, and of different external characters. Combined with proper diet, indeed, we are 
persuaded," they remark, " that the greater number of diarrhoeas, both acute and chronic, 
will yield to this method, with little or no aid from other medicine." — ''Although, in our 
practice, we always," they add, " combine with the use of leeches, in the cases, where they 
are indicated, a proper diet, yet we have had ample evidence of their unassisted powers in 
checking or removing diarrhoeas of great severity and obstinacy." 

It is certain that many of the most obstinate cases of chronic diarrhoea are kept up by 
a subacute inflammation of some portion of the mucous membrane of the large intestines, 
and in such cases a well-timed application of leeches to the anus will be productive of the 
best effects. In such cases, the earlier the leeches are applied the better. In detecting the 
cases in which leeching is indicated, will demand a good deal of tact, and close habits of ob- 
servation on the part of the practitioner — his judgment must be made up from an inquiry 
into the history, and a careful analysis of all the circumstances of each case, for we know 
of no leading phenomena by which those cases where leeches are calculated to do good can 
be distinguished from those to which they are not adapted ; as a general rule, however, we 
are persuaded that in well-marked cases of chronic diarrhoea, particularly when the disease 
has existed for any length of time,leeches are at best a doubtful, if not an improper remedy. 

Blisters to the abdomen Will, we apprehend, be found more generally advantageous than 
leeches; we have found them to produce a speedy, marked and prompt amelioration in the 
prominent symptoms of the case; the frequency of the stools, under their use, being speedily 
diminished, and the discharges assuming a more natural appearance. In many instances, 
however, we confess that no benefit whatever has resulted from repeated blisters. They 
are a remedy, nevertheless, which so generally do good that they should not be overlooked. 
Keeping on the blister for a few hours, and then replacing it by a soft emollient poultice; 
repeating it as soon as the vesicated surface has healed, is a preferable plan to allowing 
the blister to remain on until complete vesication is produced, and keeping up the irritation 
thus produced by stimulating dressings. 

The principal internal remedies from which any good effects are to be anticipated are. 
opiates and astringents. Opium either by the mouth or introduced into the rectum in the 
form of an injection, acts beneficially by quieting the pain and other uneasy sensations under 
which the patient labours, as well as by allaying the irritability of the bowels, and thus 
suspending the frequency of the stools ; it aids in this manner the efficacy of whatever 



820 



SPORADIC CHOLERA. 



Sydenham held that the disease is limited to the month of August ; and that bowel 
affections, with vomiting, occurring at other times, are not genuine cases of cho- 
lera. But this was one of that great man's crotchets. The symptoms that mark 

astringent is made use of. The Dover's powder will frequently be the best form in which the 
opium can be administered; or if this be found to disagree with the stomach, as will some- 
times be the case, the opium may be given in the form of a pill; combining it with a small 
portion of ipecacuanha, we have generally found advantageous: or the opium may be given 
as an enema rubbed up with starch. The dose of the opium,and the period of its repetition 
must be left to the judgment of the practitioner. — We have not derived the same advantage 
in cases of chronic diarrhoea, from the salts of morphium as from the opium itself. 

Of astringents, nearly the whole list, both vegetable and mineral, has been recommended, 
and each one is praised by different practitioners as particularly efficacious in the disease 
under consideration. The vegetable astringents most deserving of attention are, the catechu, 
kino, galls, logwood, blackberry root, and the root of the geranium maculatum. The first 
may be given in the form of the infus. catechu comp. Dr. Pemberton prefers the kino to 
all other astringents, in chronic diarrhoea; he gave it in doses of a scruple made in a bolus 
with opiate confection (on Diseases of Abdom. Viscera). More recently an extensive series 
of experiments on the effects of kino in diarrhoea were made in the hospital La Pitie, in 
Paris, by M. Bally. In chronic diarrhoea, unaccompanied by fever or marks of inflamma- 
tion in the mucous membrane, the continued use of the remedy, even for a short time, was 
found almost invariably to be effectual in stopping the diarrhoea. In one case of three years 
standing it effected a cure. But the most remarkable result of M. Bally's experiments is 
the. alleged fact — that the kino, given in doses of twelve or fifteen grains, for several days 
in succession, succeeded in curing diarrhoea attended by febrile and inflammatory symp- 
toms. (Crampton and Forbes, from Med. Gazette, v. 700.) We have repeatedly employed 
both the catechu and kino in cases of chronic diarrhoea where astringents were evidently 
indicated, and although their beneficial effects were often promptly exhibited, they have, 
nevertheless, repeatedly failed in diminishing the frequency of the discharges ; we have 
found the galls, either in powder — combined with camphor or opium and not unfrequently 
with both — or in decoction, a much more effective astringent in protracted and obstinate 
cases of diarrhoea, than either the kino or catechu. The logwood in decoction, is a favour- 
ite remedy with many practitioners; we have, however, been disappointed in its effects; it 
may serve as a useful vehicle for more active remedies. The dewberry root is unques- 
tionably a very powerful astringent, and well adapted to the disease under consideration ; 
in infusion or decoction it is extensively employed by the physicians of the United States, 
as is also the root of the geranium maculatum, the effects of which latter, in chronic dis- 
charges from the bowels, are very highly spoken of by many practitioners. 

Of the mineral astringents, we know of none superior, in cases of chronic diarrhoea, to 
the acetate of lead ; in the dose of one grain, combined with a quarter of a grain of opium 
and the same quantity of ipecacuanha, repeated every three hours, it will, in a large num- 
ber of cases, promptly arrest the disease. The alum will, also, be found a good astringent in 
chronic diarrhoea; it may be administered in the form of alum whey, or in substance, com- 
bined with opium. We have given it in conjunction with powdered galls and with the best 
effects. The sulphate of copper, which has been employed in combination with opium by 
Dr. Elliotson with the most decided success, has repeatedly succeeded in our hands in 
arresting the disease under circumstances the most unpromising. The mode in which we 
have generally employed it, has been in a quarter or one-third of a grain doses combined 
with two grains of extract of quinia and a fourth of a grain of opium every three hours. 
The protocarbonate of iron, the tincture of the chloride of iron, and the solution of the per- 
sesquinitrate of iron, we have repeatedly employed, and in cases of long standing, have 
found them, especially the two first, very efficacious. They are particularly well adapted 
to protracted cases of the disease, attended with great prostration, and more or less infiltra- 
tion of the subcutaneous cellular tissue. 

The balsam copaiba and spirits of turpentine are among the remedies from which, in 
numerous cases of chronic diarrhoea, the very best effects may be anticipated. When the 
discharges from the bowels are small in quantity, and resemble in consistence thin starch 
or mucilage, or when they are dark-coloured and of a rank offensive odour, we are ac- 
quainted with no remedies from which the same amount of good may be anticipated. They 
may be combined with opiates and astringents where these are considered necessary. The 
spirits of turpentine we employ more frequently than the copaiba; it is, we believe, equally 
efficacious, while it is more easily taken by the patient and agrees better with the stomach; 
it may be combined with simple syrup and water by adding a few grains of magnesia. 

A variety of other remedies are recommended by different writers, the efficacy of which 
is highly extolled. The most prominent are Hope's Mixture, which is a mixture of nitrous 
acid, camphor water and laudanum— the nux vomica and its active principle ; the ferro. 



SPORADIC CHOLERA, 



821 



this complaint are vomiting and purging of liquid matter, deeply tinged with, and 
principally composed of, bile; violent pains in the stomach and bowels ; cramps 
of the legs and of the abdominal muscles ; a great depression of the vital powers, 
and a tendency to syncope or collapse. 

The attack is generally sudden. At first the contents of the alimentary canal 
are evacuated ; and then a quantity, an enormous quantity sometimes, of a turbid, 
yellowish, acrid fluid, is expelled with violence both from the bowels, and by 
vomiting. The patients complain of a burning sensation in the epigastrium. As 
the vomiting and purging go on, clonic spasms of the lower extremities, and 
especially of the gastrocnemii, occur; the surface of the belly is drawn up into 
knots : and after a while, the patient, exhausted by the pain and the spasms, and 
still more so by the copious discharges, grows cold and faint. Sometimes actual 
syncope happens : and sometimes death. 

Death, however, is an uncommon event of this form of cholera, in this country. 

The chief cause of cholera, such as has now been described, appears to be 
casual exposure to cold, after a continued high temperature of the atmosphere : 
and the great irritation of the stomach and bowels evinced by the symptoms, 
proceeds from the presence of bile in the intestines in undue quantity, and ren- 
dered more acrid than usual by some morbid alteration of its quality. The attack 
seems to be often determined by some of those causes of irritation which I just now 
mentioned when speaking of simple diarrhoea ; and particularly by imprudence in 
eating and drinking. 

I believe that no better treatment can be followed in this disease than that long 
ago laid down by Sydenham. He observes that any attempt to stop the purging 
and vomiting by strong drastic aperients, under the notion of expelling the irritant 
matter, would be like endeavouring to extinguish fire by pouring oil upon it; and 
that to try to lock up the acrid discharges in the alimentary canal by means of 
narcotics or astringents, would be equally hurtful. He therefore was accustomed 
to dilute the contents of the stomach and bowels by emollient drinks, and injec- 
tions, especially by chicken broth ; and so to favour their expulsion ; and when 
any faintness or sign of sinking began to show itself, to administer laudanum in 
full doses. We are seldom summoned to these cases in the outset. Generally the 
vomiting and diarrhoea have continued for some hours before we see the patient: so 
that it is expedient to give the opiate as soon as we can. If the stomach be very 
irritable, solid opium in the form of pill may be preferable to laudanum ; or an 

cyanuret of iron ; the nitrate of silver, and the resinous extract of the artemisia vulgaris. Of 
the effects of these we have had no experience. 

In those cases in which the diarrhoea appears to be kept up by ulceration seated just 
within the verge of the anus, very speedy and permanent relief will always be obtained by 
touching the ulcers with nitrate of silver. 

We have given above an outline of the treatment demanded in the chronic form of diar- 
rhoea; in conclusion, we would remark, that the management of this disease always re- 
quires the exercise of great judgment and discretion on the part of the practitioner. Nothing 
would appear more easy than by opiates and astringent remedies to arrest the inordinate 
discharges from the bowels, and thus to effect the cure of the patient, but it will be found 
that, in many cases, when astringents are too early resorted to, the disease instead of being 
removed is aggravated, or if by our astringents we do succeed in suspending the discharges 
from the bowels, a swollen and painful state of the abdomen quickly succeeds, producing 
greater distress to the patient and terminating more promptly in death than had the diar- 
rhoea been allowed to run its course. In numerous instances, chronic diarrhoea may be 
very effectually cured by a proper regulation of diet and regimen, the warm bath, blisters 
to the abdomen, and internally the blue pill or calomel combined with opium and ipeca- 
cuanha, and, perhaps, the use, at the same time, of moderate doses of copaiba or turpen- 
tine, without astringents. There are, however, unquestionably, many cases in the course 
of which astringents, and of the most powerful kind, are demanded in order to effect a re- 
moval of the disease, and others, in which mild astringents early administered will very 
materially shorten its duration; and it is in rightly determining the cases and period of the 
disease, in which astringents are indicated, that the success of the practitioner in effecting 
its cure will frequently depend. — C.J 



822 



EPIDEMIC CHOLERA. 



opiate clyster — or an opiate suppository — may be introduced into the rectum.* 
When the skin is cold, and the pulse sinking or irregular, carbonate of ammonia, 
or brandy and water, may be given by the mouth ; and a mustard poultice, or a 
bag of hot salt, or a moist and hot flannel sprinkled with oil of turpentine, should 
be applied to the abdomen. The cramps of the extremities may be relieved by 
diligent friction with the hand ; or some stimulating liniment may be rubbed upon 
the affected muscles. When the collapse is great, the patient should not be allowed 
to raise himself out of the horizontal posture, lest fatal syncope should follow. 
Opium, however, is our sheet-anchor in this complaint: it sustains the flagging 
powers, while it quiets the gastro-intestinal irritation. 

After an attack of severe cholera, the patient is apt to be left extremely feeble ; 
with soreness of the muscles of the trunk and limbs: and sometimes, symptoms 
of inflammation of the mucous membranes will supervene; pain and tenderness 
of the belly, a white tongue, thirst, and fever. And these symptoms may require 
some of the remedies of inflammation. 

Such is the disease which has long been familiar to English practitioners, as 
cholera: but about twelve or thirteen years ago, this country was visited by a 
severe epidemic disorder, which was also called cholera; or by way of emphasis, 
the cholera; or sometimes spasmodic cholera ; ox Asiatic cholera ; or malignant 
cholera. The symptoms of this new disease resembled, in some points, those of 
the old-fashioned cholera: but differed from them in more, and in more important, 
particulars. So that the application of the term cholera, or cholera morbus, to 
both these morbid affections, is very much to be regretted, for it has produced a 
great deal of confusion and inconvenience. 

I scarcely know how to name the newer and severer disorder. I have no right 
to alter the received nomenclature ; and choosing from among the many appella- 
tions which have been given to the complaint, that epithet which seems the least 
objectionable, I may call it epidemic cholera: although this term is objection- 
able, since the other malady, the English or sporadic cholera, is sometimes also 
epidemic. 

The epidemic cholera so far resembled the sporadic, that it was attended by 
profuse vomiting and purging, by extreme prostration of strength, and by cramps. 
But it differed remarkably in these respects; in the circumstance that the matters 
ejected from the stomach and bowels contained no bile (and this alone is a good 
reason against calling the disease cholera) ; in the early supervention of the symp- 
toms of collapse ; and in the great mortality of the disorder. 

The amount of the fluid matters thrown up from the stomach and discharged 
by the bowels, was really in many cases wonderful. At first, perhaps, the patient 
would have so copious a stool — a consistent dejection it might be, but so large in 
quantity — as to lead him to conclude that the whole contents of the intestines had 
been evacuated at once. Yet soon afterwards a turbid whitish liquid would agaiu 
and again pour from his bowels in streams ; and be spouted from his mouth as if 
from a pump: not in general with much effort, but easily and abundantly. The 
matters thus discharged were thin, and for the most part of a whitish colour, like 
water in which rice has been boiled ; without fecal smell ; and containing small 
white albuminous flakes. There were some varieties in the evacuations, but the 
kind I have mentioned, resembling rice-water, was the most common and the 
most characteristic : and however else their sensible qualities might vary, this 
circumstance was universal, that they contained no bile. 

With all this there was early sinking, and collapse, as it was called. This 
term collapse expressed a general condition, made up, in the most exquisite cases, 

* [In such cases we know of no remedy more effectual than a pill composed of opium, 
camphor and acetate of lead, in the proportion of one grain each. When the stomach is so 
irritable that the pill is quickly rejected, a solution of acetate of lead, eight grains to two 
ounces of water with the addition of one grain of the acetate of morphia, in the dose of a 
teaspoonful, repeated at proper intervals, will very generally be retained. — C] 



EPIDEMIC CHOLERA. 



823 



of the following particulars : — A remarkable change took place in the circulation, 
and a striking alteration in the appearance of the patient. The pulse became fre- 
quent, very small and feeble, and at last, even for hours, sometimes, extinct at the 
wrists. The surface grew cold ; and in most, or in many instances, blue as well 
as cold. The lips were purple ; the tongue was of the colour of lead, and sensi- 
bly and unpleasantly cold to the touch, like a frog's belly ; and the breath could 
be felt to be cold. With this coldness and blueness there were a manifest shrinking 
and diminution of the bulk of the body. The eyes appeared sunk deep in their 
sockets ; the cheeks fallen : in short, the countenance became as withered and 
ghastly as that of a corpse. The cadaverous aspect that sometimes precedes death 
in long-standing diseases, would come on in the course of an hour or two, in this 
complaint. If the physician left his patient for half an hour, he found him visibly 
thinner on his return. The finger nails became blue; the hands and ringers 
shriveled, white, corrugated, and sixlden, like those of a washerwoman after a 
long day's work. The skin was bathed in a cold sweat. The voice became 
husky and faint. So peculiar was this change, that the sound was spoken of as 
the vox cholerica. These are the symptoms which the single word collapse was 
meant to express. 

Another very striking feature of the disorder was the muscular cramp ; affecting 
the muscles of the thighs and calves of the legs, rendering them as hard and rigid 
as wood ; and drawing up into knots the muscles of the abdomen. These spas- 
modic contractions were attended with severe pain, and constituted the greater 
part of the patient's suffering. During the continuance of the symptoms that I 
have been endeavouring to describe, not a drop of urine was passed or secreted. 
One man, who was under my own observation and care, and who recovered, did 
not void a drop of water from Sunday morning till the afternoon of the following 
Wednesday. 

Even in the extreme state of collapse the intellect remained quite clear : the 
patients would continue to talk rationally to the last moment of their lives ; and, 
for the most part, they seemed singularly indifferent and apathetic about their 
condition. 

In the fatal cases — and a very fearful proportion of the whole number were 
fatal — death took place sometimes in the course of two or three hours ; and it 
was seldom delayed beyond twelve or fifteen. In those that recovered, the 
favourable symptoms were the cessation of the vomiting, purging, and cramp ; 
the return of the pulse, and of warmth to the surface; the disappearance of the 
blueness of the skin, and of the hippocratic countenance ; the re-appearance of 
bile in the alvine evacuations ; and the restoration of the secretion of urine. 

The course of the symptoms varied a good deal in different persons. Some- 
times the vomiting and purging soon ceased, and sometimes there was neither 
sickness nor diarrhoea at all, but rapid collapse and sinking. These were thought 
the most formidable cases. However, the peculiar secretions were poured forth, 
in some, at least, of the instances in which none of them were ejected from the 
body. A patient died of cholera in the Middlesex Hospital without any vomiting 
or purging: but on examining the dead body, we found the intestines quite full of 
the rice-water serous fluid. Sometimes the cramps were not very troublesome. 
The cutaneous blueness was not a universal phenomenon. The patients were in 
general tormented by thirst: and when attempts were made to bleed them, the 
blood was found dark and thick, like treacle, and scarcely moving, if moving at 
all, in the veins : in some cases it could not be made to flow out. Considerable 
hurry and anxiety of the hreathing were also symptoms that I omitted to mention 
before. 

Examination of the dead bodies threw no light, that I know of, upon the nature of 
this frightful disease. The alimentary canal generally was found to contain a 
white liquid, having whiter flakes in it; such as had previously issued from the 
bowels : and the mucous glands of the intestines, both the solitary and the agmi- 
nated, were usually large and conspicuous. The veins were loaded with thick, 



824 



EPIDEMIC CHOLERA. 



black, tar-like blood ; and the urinary bladder was always found empty, and con- 
tracted into the size of a walnut. Even when the blue colour had existed in a 
marked degree during life, it often quickly disappeared after death. And another 
most singular phenomenon was occasionally remarked in the dead body. A quarter 
or half an hour, or even longer, after the breathing had ceased, and all other signs 
of animation had departed, slight, tremulous, spasmodic twitchings and quiverings, 
and vermicular motions of the muscles would take place ; and even distinct move- 
ments of the limbs, in consequence of these spasms. 

The disease, of which I have drawn but a faint outline, was not known in this 
country till the autumn of the year 1831. There are persons, I am aware, who hold 
that it has always existed among us ; only not in such numerous instances as at that 
period ; and they appeal to Morton, and other early writers on the diseases of this 
country, in support of their opinion. But the malady was too striking to be over- 
looked, or ever forgotten, by any one who had once seen it. Certainly, till that 
year I never saw anything like it. To be sure I had not at that time been very 
many years in practice here. The late Dr. Babington, however, told me that it 
was quite new to him. He had, for a very long period, been in extensive prac- 
tice, in those parts of the metropolis and its vicinity where the epidemic cholera 
raged most ; and when it first came among us he had the curiosity to ask every 
medical man whom he met, whether he had seen any case of the cholera ; and if 
the answer was "?/es," he went on to inquire whether, before that year, the per- 
son had ever met with the same complaint ; and the reply was always, without a 
single exception, "no." Yet I say there were, and are, a few practitioners who 
denied, and deny, that it was anything more than the common and well-known 
English complaint, raging with unusual frequency and violence. 

But we have evidence of a different kind of the newness of the epidemic cho- 
lera to these kingdoms. Its approach was discerned afar off, as distinctly as a 
storm is foreseen by the rising of the clouds from the horizon in the direction of 
the wind. The disorder began to rage with terrible severity, in India, in the year 
1817. I do not mean that it then broke out there for the first time. It had visited 
those regions again and again before. But from its irruption in the year I have 
mentioned, when it committed frightful devastation in the armies in the north- 
eastern districts of India, its course can be distinctly traced to our own shores ; 
towards which it approached with slow and halting, but with sure steps, in a 
north-western direction. From India it spread to Persia; and thence to Russia; 
and across through Poland to Germany : and at length it was found at Hamburgh. 
It was predicted before that time, that the distemper would at length reach Great 
Britain. Our government had even sent two physicians into Russia to investigate 
its nature, in the fearful anticipation that its march across the earth would continue 
progressive ; and accordingly at the expiration of fourteen years, it made its ap- 
pearance on the eastern coast of this country ; in Sunderland : and in due time 
extended over every part of these islands. I say its arrival had been foreseen and 
foretold ; and it is absurd to suppose that a vast number of persons would fall sick 
and die, with symptoms quite strange to the great mass of practitioners here, 
merely, to fulfil this prediction. 

The progress of the disorder did not end here. Crossing the Atlantic, it in- 
vaded America; turning, at the same time, in a south-easterly direction, it ravaged 
France and Spain, and the north coast of Africa, and Italy. 

Moving thus onward, as it did, in defiance of all natural or artificial barriers, 
under opposite extremes of temperature and climate, in the teeth of adverse 
winds, over lofty mountain chains, across wide seas, through " hot, cold, moist, 
and dry" — in what manner, you will probably ask, was this wasting pestilence 
propagated ? 

Upon this point various and discordant opinions are entertained. Many per- 
sons believe that the complaint spread by contagion : more, however, that it was 
not contagious at all, but arose from some deleterious cause with which the 
general atmosphere of the place was pregnant. Now I cannot reconcile the 



EPIDEMIC CHOLERA. 



825 



phenomena of the appearance and extension of the malady with either of these 
hypotheses exclusively. It must, I think, be granted that the complaint, in every 
instance, was excited by the application of some noxious material to the body, 
some positive poison. It is certain, also, whichever hypothesis may be chosen, 
that many more individuals were exposed to the agency of this poison, than were 
injuriously affected by it. This exemption from the disease no more invalidates 
the doctrine of contagion, than it invalidates the doctrine of some diffused atmo- 
spheric influence ; nay, it is more explicable upon the former than upon the latter 
supposition; for while many may avoid a specific contagion, all are immersed in, 
and all breathe, the common atmosphere. But the exemption shows this; that 
the exciting cause, to be effective, required a fit recipient: that the susceptibility 
of being hurt by the poison in its ordinary dose and intensity varied much in 
different persons ; and in the majority was very faint, or wanting. It is clear 
that the poison traveled. It is equally clear to my mind, that it was portable; 
and therefore communicable from person to person. I even believe that it was 
capable of being conveyed, and was actually conveyed, from one spot to another, 
by persons who were themselves proof against its effects. The innumerable 
authentic instances of coincidence, in point of time, between the first outbreak of 
the disorder in a particular place, and the arrival at that place of some person or 
persons from an infected locality, prove that the poison could be thus carried. 
Of this direct importation of the disorder into new and distant places, by infected 
individuals, and of its subsequent extension from those individuals to others who 
had intercourse with them, you may see a vast number of examples, collected by 
Dr. James Simpson, in the 49th volume of the Edinburgh Medical and Surgical 
Journal. The evidence there adduced of the portability of the poison is abun- 
dant, and to my mind, irresistible. Whether the malady was contagious in the 
same sense in which small-pox is contagious — whether, I mean, the cholera 
poison had the power of multiplying and reproducing itself in the human body, 
as yeast multiplies itself during the fermentation of beer — is a different and a 
much more doubtful question. A disorder may be contagious, without this 
property of reproduction in the animal fluids. The itch is contagious. The itch 
is produced by a minute parasitic animalcule, whose existence has, of late years 
only, been assured to us by the microscope. Suppose that these itch insects 
could fly, or were capable of being wafted through the air — they would then 
represent what is conceivable enough of the subtle exciting cause of cholera. 
Between the two epidemic distempers, influenza and cholera, there were numerous 
and striking points of similitude or analogy. They have observed the same, or 
very nearly the same, geographical route. Both, issuing from their cradle in the 
east, have traversed the northern countries of Europe, till, arriving at its western 
boundary, they have divided into two great branches ; the one proceeding onwards, 
across the Atlantic, the other turning in a retrograde direction, towards the south 
and east. The main differences between them have been, that whereas the poison 
of influenza spared very few of the community, inflicting a disease which, of itself, 
was seldom fatal — the poison of cholera, on the contrary, smote very few, but 
with so deadly a stroke that as many sank beneath it, probably, as recovered. 
Both were general disorders, affecting the whole system, but in both the most 
prominent of the symptoms had reference, in the majority of cases, to the mucous 
membranes ; to those of the air-passages in the influenza ; to those of the aliment- 
ary passages in the cholera. 

Now this strong analogy has been made use of as an argument that the cholera 
was not contagious. 44 The influenza (say the objectors) had no contagious 
properties; therefore it is, a priori, likely that the cholera had none." But I 
demur to the major proposition. Cullen thought the influenza was contagious, 
and I adverted, in a former lecture, to some facts which favour that belief. Sup- 
posing it, however, to be so, the proof of its contagious property must, from the 
very nature of the case, be extremely difficult. Its visitations are so rapid, widely 
spread, and multitudinous, that there is no time for its transference from house tQ 



826 



EPIDEMIC CHOLERA. 



house, or from person to person ; yet it may be nevertheless transferable. Its 
inherent rate of locomotion outstrips and precludes the tardier conveyance of the 
poison by man. Its contagious qualities (granting- them to exist) are hidden in 
its universality, and can seldom be traced but by accident. I therefore esteem 
this argument from analogy as worthless ; and my own creed respecting the 
cholera is, that it was contagious, in the limited sense already explained; but that 
its contagious power was not very great; that a comparatively small part of the 
population, of this country at least, was susceptible of its operation; and that few 
were in much danger of suffering from exposure to the physical cause of the dis- 
ease, except under circumstances of predisposition. At the same time I believe 
that a great majority of the cases of cholera were not attributable to direct conta- 
gion, but to the poison diffused through the atmosphere. There is nothing incon- 
sistent in the supposition that this noxious matter traveled sometimes by its own 
peculiar powers, sometimes made use of vehicles.* 

This, I say, is my creed upon the vexed question of contagion. Respecting 
the special nature of the poison I can only guess ; and my guessing, as you may 
have perceived, takes the same direction as before. I adverted, when speaking 
of the influenza, to what Dr. Holland has called " the hypothesis of insect life as 
a cause of disease." I shall not repeat the observations I then made ; but I would 
refer you, for much curious thought and information upon the subject, to Dr. Hol- 
land's very interesting essay. The hypothesis in question squares more readily 
than any other that I know of, with the ascertained history of the disorder: with 
its origin, after an unusually wet season, in the low marshy country, and hot 
atmosphere of Bengal : with its irregular but continuous migrations : with its dying 
away after a while, and its occasional and partial revivals. But still, remember 
that we are dealing merely with an hypothesis. 

"Whatever obscurity may overhang the exciting causes of the epidemic cholera, 
we are quite sure that eertain circumstances exercised a strong predisposing influ- 
ence upon the human body, to render it more than usually susceptible of the dis- 
ease. The predisposing causes, as might well be imagined, were such as tended 
to debilitate the system : and therefore poverty, which implies scanty nourishment, 
and frequently also the confinement of several persons to a narrow space, and 
want of fresh air; poverty which includes these and other evils, was found to 
predispose the body to a ready reception of the malady. But to intemperance, 
more than to any other single cause, may the proclivity to become affected by 
this species of cholera be ascribed ; and especially to the intemperate and habitual 
use of distilled spirits. This fact was peculiarly manifested in the selection, by 
the disease, of its victims in this country ; and it has been remarked almost every- 
where else. 

I have all along spoken of the visitation of epidemic cholera in the past tense, 
because, for the last eleven or twelve years, we have heard but little of it. Yet 
we can scarcely venture to hope that the stranger pest has altogether forsaken us, 
for we have had slight sprinklings of the disease in and near London, every sum- 
mer, I believe, since 1832; but it has never again been extensively prevalent or 
epidemic. Certainly it dealt lightly, upon the whole, with our country. It was 
much more general, and more widely fatal, in France, which it visited subse- 
quently to its arriving here : it was very destructive also in its subsequent course, 
both westward and toward the south-east. 

The epidemic cholera made its attack in two different modes. In one it seized 
upon the patient suddenly, and without warning. This was comparatively rare. 
Much more commonly the specific symptoms were preceded, for some little time, 

* [During the prevalence of the cholera in Philadelphia, in 1832, we closely investigated 
every fact calculated to throw light upon the' question of its contagious or non-contagious 
character, and for this investigation, our position in the Board of Health and as chief of a 
large hospital, afforded us ample opportunities — but we were unable to discover the slightest 
evidence of the disease having been in any one instance communicated from the sick to the 
weU—C.J 



EPIDEMIC CHOLERA. 



827 



even for some days perhaps, by diarrhoea. And this I take to be the most import- 
ant practical fact that was ascertained during its prevalence among us. When 
the disease was once fairly formed, medicine had very little power over it ; but 
in the preliminary stage of diarrhoea it was easily manageable. Unfortunately 
people are inclined (especially those classes of the community among whom the 
cholera most raged), to regard a loose state of the bowels as salutary ; and to make 
no complaint of it, and to do nothing for it: or, in other cases, they conceive it to 
proceed from some peccant matter within, which requires to be carried off, and 
they take purgative medicines to get rid of it. Both of these are serious and often 
fatal mistakes. Mere neglect of the diarrhoea frequently permitted it to run into 
well-marked and uncontrollable cholera; and the employment of purgatives has- 
tened or insured that catastrophe. The proper plan of proceeding, I am con- 
vinced, was, to arrest the diarrhoea as soon as possible after its commencement, 
by astringents, aromatics, and opiates. You may object, perhaps, that the cases 
that were cured in this way were not cases of cholera at all, and never would 
have been ; but simple ordinary diarrhoea. It is impossible to prove the contrary, 
no doubt; but the presumption is strong that the diarrhoea would, in many, and, 
perhaps in most instances, have run on, if not checked, into the more perilous 
form of the disease. In many places, when, taught by experience, the authori- 
ties established diarrhoea dispensaries, to which those attacked by looseness of 
the bowels were warned and invited to apply, that the looseness might forthwith 
be corrected ; in many such places the cholera, which had before been cutting the 
inhabitants off by scores, and hundreds, began instantly to decline in frequency. 
I venture to advise you, supposing the disease should reappear, or whenever in 
the autumn a suspicion arises that this form of cholera is present in the commu- 
nity, not to try, in cases of diarrhoea, to carry off the presumed offending matter, 
but to quiet the irritation, and stop the flux as soon as you can. 

But when the regular symptoms, peculiar to the severe form of cholera, had 
set in, medicine, I repeat, had very little influence upon it: and accordingly, as 
might have been expected, a hundred different cures of the disease were an- 
nounced, most of them all but infallible. Some persons held that timely bleeding 
would save the patient; others relied confidently upon mustard emetics. Hot air 
baths were manufactured, and sold to a great extent, to meet the apprehended 
attack in that manner without delay. Certain practitioners maintained that the 
disease was to be remedied by introducing into the system a large quantity of 
neutral salts, which were to liquefy and redden the blood, and to restore the func- 
tions of the circulation. But of this practice it was said in a sorry but true jest, 
that, however it might be with pigs or herrings, salting a patient in cholera was 
not always the same thing as curing him. In a great number of the sick the 
blood was mechanically diluted by pouring warm water, or salt and water, into 
their veins. Some physicians put their trust in brandy, some in opium, some in 
cajeput oil, which rose to I know not what price in the market ; some again, in 
calomel alone. 

Now, I would not willingly mislead or deceive you on this point, by speaking 
with a confidence which I really have no warrant for, of the success or propriety 
of any of these expedients. I believe that each in some cases did good, ox seemed 
to do so ; but I cannot doubt that some of them did sometimes also harm. I 
had not more than six severe cases under my own charge : and I congratulated 
myself that the mortality among them was not greater than the average mortality. 
Three died, and three (I will not say were cured, but) recovered. The three that 
died I was called in to see when the disorder was at its height: in each case it 
went on with frightful rapidity, in spite of all the means adopted, and proved fatal 
a few hours afterwards. The three that recovered I saw somewhat earlier, but 
still not till the specific symptoms were present : one was a girl in the hospital. 
They all recovered under large and repeated doses of calomel. Yet (as I said 
before) I do not venture to affirm that the calomel cured them. In the first case 
which was treated in that way, I merely followed up the plan that had been begun 



828 



EPIDEMIC CHOLERA. 



by Dr. Latham, who had visited the patient for me when I was accidentally ab- 
sent. I found that he had felt better, less sick and less faint, after taking half a 
drachm of calomel at a dose ; and I repeated the same dose many times, for after 
every dose his pulse rose somewhat, and he appeared to rally. This was the 
.same man whom I mentioned before as having made no urine from the Sunday to 
the Wednesday : all that time he kept discharging rice-water stools. At last, on 
the fourth day he passed a little water, and his alvine evacuations became rather 
more consistent, and began to look green: and from that time he gradually got 
well. Afterwards I treated my hospital patient in the same way, and with the 
same event. Yet I will not pretend to say that these persons might not have done 
quite as well if they had been left entirely to themselves. 

Some of the expedients recommended had certainly a very marked and imme- 
diate effect upon the condition of the patients, especially the injection of warm 
water into the veins. Many instances of this were related at the time. One 
I myself saw. The patient was a young man, who was nearly moribund appa- 
rently. His pulse had almost, if not quite disappeared from the wrist; he was 
very blue, and his visage was ghastly and cadaverous: in one word, he was in an 
extreme state of collapse. Out of this he was brought in a few minutes by in- 
jecting warm water into one of the veins in the arm. The pulse again became 
distinct and full ; and he sat up, and looked once more like one alive, and spoke 
in a strong voice. But he soon relapsed ; and a repetition of the injection again 
rallied him, but not so thoroughly: and in the end he sunk irretrievably. Dr. 
Babington told me of a patient whom he saw speechless, and all but dead, and 
whose veins were injected. He then recovered so as to sit up, and talk, and even 
joke, with the bystanders: but this amendment did not last either. Yet even 
this temporary recovery might sometimes be of great importance : might allow 
a dying man to execute a will, for example. And some of the persons thus re- 
vived got ultimately well. We had for some time a woman in the Middlesex 
Hospital acting as nurse, who had been rescued, when at the verge of death in 
cholera, by the injection of warm water into her veins. 

It was remarked of those who recovered that some got well rapidly, and at 
once ; while others fell into a state of continued fever, which frequently proved 
fatal some time after the violent and peculiar symptoms had ceased. Some, after 
the vomiting and purging and cramps had departed, died comatose ; over-drugged 
sometimes, it is to be feared, by opium. The rude discipline to which they were 
subjected might account for some of the cases of fever. And the process of arti- 
ficially replenishing the veins was certainly attended with much danger. The 
injection of air with the water — inflammation of the vein from the violence done 
to it — an over-repletion and distension of the vessels by the liquid — might, any 
one of them, and sometimes, I suppose, did, occasion the death of the patient. 
Never, certainly, was the artillery of medicine more vigorously plied — never 
were her troops, regular and volunteer, more meritoriously active. To many 
patients, no doubt, this busy interference made all the difference between life and 
death. But if the balance could be fairly struck, and the exact truth ascertained, 
I question whether we should find that the aggregate mortality from cholera in this 
country, was any way disturbed by our craft. Excepting always the cases in 
which preliminary diarrhoea was checked, just as many, though not, perhaps, the 
very same individuals, would, probably, have survived had no medication what- 
ever been practised. 

I do not know that I have any thing more to say that could be of any use to 
yon, in respect to the epidemic cholera.* 

* [Soon after the appearance of the cholera in Philadelphia, we were persuaded that had 
we a remedy capable of arresting the inordinate serous discharge, which in this disease is 
poured out by the mucous membrane of the alimentary canal, we should very readily 
succeed in its cure. We were, therefore, induced to try the effects of the acetate of lead, 
with the remedial powers of which in a somewhat analogous disease, the cholera of infants, 
we were familiar. We administered it in pills, combined with opium and camphor, or 



DYSENTERY. 



829 



LECTURE LXXIIL 

Dysentery. Diarrhoea Miposa. Intestinal Concretions. Worms. 

Another of the morbid fluxes from the alimentary tube, of which I have yet 
to speak, is dysentery. 

Its characteristic symptoms are, griping pains in the abdomen, followed by 
frequent, mucous or bloody stools, straining and tenesmus. In chronic cases pus 
is sometimes discharged from the bowels. The acute form or stage of the disease 
is attended with fever. 

The differences between dysentery and diarrhoea are obvious enough. Both of 
them may be accompanied by griping pains : in both the stools are frequent and 
loose : but in diarrhoea they are fecal ; in dysentery there is retention of the natural 
feces, or they are expelled from time to time, in small, hard, separate lumps, termed 
scybala. Again, straining, and tenesmus, and the excretion of mucus, which is 
often tinged with blood, form no necessary features in diarrhoea ; whereas in 
dysentery these symptoms are prominent and constant. These nosological dis- 
tinctions are true and useful, although in our actual intercourse with the sick we 
do not find them always or strictly observed. Some of the worst forms of dysen- 
tery commence with the ordinary symptoms of diarrhoea. 

Dysentery consists, essentially, in inflammation of the mucous membrane of 
the large intestines ; yet not, I apprehend, of the whole of that long surface indis- 
criminately. Observation of the course of the disorder, during life, and of the 
morbid appearances visible after death, leads to the conclusion that in simple 
dysentery, marked by tormina and tenesmus, and frequent dejections of sanguino- 
lent mucus without fecal matter, the inflammation chiefly affects the rectum and 
the descending colon. When the earlier portions of the large intestines are involved 
in the diseased process, the stools at the outset are often composed in great measure 
of excrement in an unnaturally fluid state, and mingled with blood and slime. 
We generally speak of these circumstances as constituting dysenteric diarrhoea. 

Slight and simple dysentery may occur and run its course with very little or no 
disturbance of the circulation. When it is acute and severe, it is attended with 
more or less pyrexia. The acute disease may terminate in recovery; or in early 
death ; or in chronic dysentery, which usually, in the end, is fatal. 

The wards of our metropolitan hospitals place frequently under our notice 
severe cases of chronic dysentery in the persons of soldiers and sailors, who bring 
the disease home with them from hot climates. With these exceptions, dysentery 
is, now-a-days, neither a very common nor a very serious disorder in this country. 
I say now-a-days, for the time was when it raged in London like a plague. The 

when the stomach rejected it in this form, in solution with the acetate of morphia, and at 
the same time, by the rectum, in injections composed of a strong solution with the addition 
of laudanum. Under this plan of treatment, the discharges were in numerous instances, 
promptly arrested, and the patients recovered, even after the stage of collapse had ensued. 
From our subsequent experience with this plan of treatment, we are convinced that had the 
remedy been generally resorted to from the commencement of the epidemic, the mortality 
of the disease would have been materially reduced. Since 1832 many cases of the cholera 
have occurred every year; all that have fallen under our notice were treated by the acetate 
of lead, and we have lost none. — Dr. Graves has subsequently recommended the same 
remedy, and speaks of its effects in the highest terms. — We usually administer the acetate 
of lead in the dose of one grain, combined with one of opium and the same quantity of 
camphor, every hour, or two, or three, according to the violence of the attack. The thirst 
of the patient was assuaged by small portions of ice held in the mouth and allowed slowly 
to dissolve — large and frequent draughts of cold water we always found to be injurious. — 
Cups to the abdomen were frequently employed, and we have reason to believe always with 
advantage. — From warm bathing, dry heat to the surface, sinapisms, stimulating pediluvia, 
we never saw any good effects result. — C] 



830 



DYSENTERY. 



present Dr. Heberden, in his valuable essay, On the Increase and Decrease of 
different Diseases, shows, that in the seventeenth century the number of deaths 
set down, in the weekly bills of mortality under the titles bloody flux, and griping 
in the guts f was never less than 1,000 annually, and in some years exceeded 
4,000. For five-and-twenty years together, viz., from 1657 to 1692, they every 
year amounted to above 2,000. During the last century, the number gradually 
dwindled down to twenty. Dysentery is one of the pests of hot climates. In all 
tropical regions at certain seasons of the year it is very prevalent and destructive. 
But it is in fleets and armies, and especially among troops in actual service, that 
the distemper most displays its terrible power. There is no single malady which 
is so crippling to an army in the field as this. Sir James M'Grigor, to whom 
was entrusted the superintendence of the medical department of the army on " the 
two greatest services on which the military force of this country has, of late years, 
been employed, namely, that in Waicheren, and that in the Peninsula," calls 
dysentery " the scourge of armies," and the " most fatal of all" their diseases. 
In two years and a half, the British army in Spain lost no less than 4,717 men 
by this complaint. 

How are these facts to be explained? Wherefore is dysentery, which was so 
familiar to our ancestors, so happily rare among us ? Why does it thus wait 
upon and afflict the march of armies ? Upon what depends its frequency in hot 
climates ? We may expect to obtain some answer to these questions by searching 
into the causes of the disorder. 

It has been ascribed to exposure to wet and cold ; to the use of unwholesome 
food ; to the agency of malaria; to contagion. 

Weather and season have a manifest influence in the production of dysentery. 
In temperate climates, like our own, it is an autumnal disorder. In tropical coun- 
tries it is observed to be more common and more severe when rains succeed to 
long-continued drought. In respect to this, as to other bowel affections, a high 
diurnal temperature of the air appears to be the predisposing, and exposure to 
cold the exciting cause. I stated, on a former occasion, that great vicissitudes of 
temperature are very frequent and very pernicious, even under the torrid zone. 
Scorching days are followed by extremely cold nights. The dysentery which 
arises under these circumstances is apt to run on into the ensuing winter. Sol- 
diers in the field against an enemy are peculiarly obnoxious to the agencies which 
favour or generate the complaint. Marching, or engaged in actual conflict, during 
the day; bivouacking at night, often in the open air, and under every variety of 
weather; ill-provided too often with clothes and bedding; their food scanty, pre- 
carious, or of bad quality ; seizing the many opportunities which their dreadful 
trade supplies of license and intemperance; depressed, it may be, by disaster or 
defeat; we need not wonder either at the prevalence of dysentery among them, 
or at its untractableness while they remain subject to the same morbid influences. 
Neither can the causes be warded off from the patient, nor, in general, can the 
patient be removed from the causes. Yet occasions do arise which show dis- 
tinctly enough this alleged relation of cause and effect. Prsesens morbum facit — 
subluta tollit. Take, on the one side, the following facts from Sir John Pringle's 
book On the Diseases of the Army. The men who had fought at Dettingen 
lay that night on the field of battle, without tents, exposed to a heavy rain. 
For the next night or two they encamped on better, but still wet ground ; and 
they wanted straw. Nearly half of these troops were soon after affected with 
dysentery ; while three companies which had not been engaged in the battle, nor 
exposed to rain, nor lain wet, escaped the complaint entirely. Take this converse 
fact, related by Desgenettes. Four hundred of the French " army of Egypt," 
reduced to a state of extreme weakness and emaciation by dysentery there con- 
tracted, embarked at Alexandria on their return towards France ; were carried 
away, in short, from the alleged causes of their disorder. Nineteen died at the 
very outset of the voyage ; which had, however, so good an effect upon all the 
rest, that before they reached Malta they were thoroughly convalescent. 



DYSENTERY. 



831 



The very frequent coincidence or alternation, in some places, of dysentery with 
intermittent fever, has given rise to the opinion that both these diseases are alike 
attributable to the malarious poison. But dysentery prevails where there is no 
other evidence of the presence of malaria. You may recollect that when we were 
upon the subject of ague, I showed you that its repeated paroxysms were attended 
with extreme and increasing congestion of blood in the internal organs ; of which 
congestion the tumid spleen, the ague-cake, was an effect and a token. Now 
whatever gorges the splenic vein, gorges its tributary, the inferior mesenteric, 
which carries the blood from the rectum and the descending colon. Upon such 
congestion of the mucous membrane inflammation is readily engrafted ; and in 
this indirect way dysentery may be said to result from the marsh effluvia. Ague 
is an effect of malaria; and dysentery is, sometimes, a sequela of ague. In pre- 
cisely the same manner, dysentery is apt to supervene, in hot climates especially, 
upon hepatic congestion and disease. 

That dysentery is, in itself, a contagious malady, we have no satisfactory 
evidence. In its sporadic form, in this country, we never see it spread from per- 
son to person. But it is a prominent symptom in some epidemic visitations of 
continued fever, which undoubtedly is contagious. To this fact I am inclined to 
attribute the notion, formerly much more common than it now is, that simple 
dysentery is catching. 

The remarkable decline of dysentery in this metropolis, has been cotemporary 
with that of other severe disorders ; and is due to the same combination of causes. 
For nearly two centuries we have had no plague among us. Agues, formerly 
very rife in London, have almost disappeared. Continued fevers, which used to 
break out annually in hot weather, are comparatively unfrequent. I believe that 
we may trace these great blessings to an event which was regarded, at the time, 
as a national judgment ; I mean the great fire that, in 1666, consumed every thing 
between Temple Bar and the Tower. The streets and houses thus destroyed had 
been filthy in the extreme, close, densely crowded, and consequently most un- 
healthy. The impurity of the air excited, perhaps, some maladies; and it 
certainly predisposed those who dwelt in it to various kinds of disease, " the 
seeds of which (says Dr. Heberden) like those of vegetables, will only spring up 
and thrive when they fall upon a soil convenient for their growth." To the better 
construction of the houses and of the streets in the rebuilt city ; to the increased 
means of ventilation; to the general formation of drains and sewers; to the more 
copious supply of water; and to the more temperate and cleanly habits of the 
people; we may fairly ascribe our present exemption from dysentery, from ague 
and continued fever, which are often the parents of dysentery, and from the plague 
itself. In too many parts of this over-grown place there is still much room for 
improvement. 

The pyrexia that accompanies dysentery sometimes begins before the local 
symptoms declare themselves; more frequently it succeeds their manifestation. 
Occasionally the fever runs high, the pulse is hard and frequent, the skin hot, the 
face flushed, and the tongue furred; and the patient complains of headache and 
thirst. But in this, as in other abdominal diseases, the pulse soon becomes small 
and weak, the strength rapidly declines, and the temperature of the body sinks. 

In acute cases the pain is often severe ; but it is subject to remissions and 
exacerbations. It occupies the hypogastrium, or some part of the course of the 
colon, where there is usually more or less tenderness on pressure. The patient 
is tormented by a sensation as if there were some excrement ready to be dislodged, 
goes perpetually to the night-chair, and is irresistibly impelled to strain violently 
to get rid of the irritation. But the efforts are ineffectual ; he discharges but 
little ; and what is voided is either altogether a jelly-like mucus (in which case the 
complaint has been called the dysenteria alba, and the 7norhus mucosus), or more 
commonly it is mucous and bloody (the bloody flux of our old authors), mixed 
with films, and membranous shreds, and morsels that resemble flesh. In many 
of the dejections there is no genuine fecal matter at all ; or the small indurated 



832 



DYSENTERY. 



balls which I just now mentioned come away occasionally. Frequently the 
ejected mucus is variegated in colour, green, or black, or reddish, like the wash- 
ings of meat, and horribly fetid. Sometimes pain and difficulty in making water 
are added ; there is dysuria, the irritation of the rectum being reflected upon the 
bladder through the lower portion of the spinal cord. Sometimes the stomach 
sympathizes, and nausea and vomiting ensue. With all this local suffering there 
is a continuance of febrile distress ; the patient passes sleepless, or dreamy and 
disturbed nights, and is low-spirited and desponding. In the fatal cases the pulse 
becomes very small and rapid, the features sharpen, and the surface grows cold. 
Death begins at the heart. 

Inspection of the dead body discloses more or less ulceration, chiefly of the 
large intestine. The glands that are scattered over its surface are enlarged and 
prominent, looking somewhat like small-pox pustules, for which indeed they have 
been mistaken. They probably form the foci of most of the ulcers, which are 
sometimes narrow and oblong, lying across the gut; sometimes very large and 
irregular, with here and there islands or ridges of thickened mucous membrane. 
In the worst cases the whole extent and circumference of the bowel present, 
internally, one irregular, confused, and tattered mass of disorganization.* 

* [la the ordinary cases of dysentery, the morbid appearances detected after death are, 
inflammation with thickening of the mucous membrane of the colon and rectum; oc- 
casionally, mortification and sloughing of this membrane, but more generally, in pro- 
tracted cases, deep and extensive ulcerations, in the course of the transverse bands of the 
colon, or enlargement and ulceration of the follicles of the large intestines. In the more 
violent forms of the disease, especially those which occur in hot and intertropical climates, 
in addition to the inflammation, ulceration, mortification or sloughing of the inner coat of 
the large intestines, there is often morbid vascularity of the mesocolon, mesentery and omen- 
tum, with adhesions of the omentum to the adjacent viscera, and of contiguous portions of 
the intestines to each other. The latter usually happen only when ulcers have perforated 
nearly all the coats of the bowels. The glands of the mesocolon and mesentery are often 
enlarged, sometimes inflamed, and more rarely in a state of suppuration ; the corresponding 
portion of the intestine being usually the seat of a deep and extensive ulcer. The omen- 
tum occasionally adheres to these diseased glands, forming a band by which a portion of 
intestine may become strangulated and be the cause of death. 

The ulcerations of the large intestines are commonly most numerous and extensive in 
the caecum and upper portion of the colon. The ileo-caecal valve has, in some cases, been 
found entirely destroyed by the ulceration ; the lower portion of the ileum forming then an 
intussusception into the caecum, and becoming there strangulated has caused death. In a 
few more fortunate instances, the strangulated portion of the ileum sloughs off, after 
adhesion has taken place between the adjacent parts, so as to maintain the continuity of 
the canal, when the patient may recover. The right portion of the omentum is not unfre- 
quently found adhering to the caecum, and this morbid attachment gives rise to symptoms 
which may be mistaken for hepatic abscess. Sometimes, in the whole course of the colon, we 
find not more than eight or ten deep ulcerations, with sloughing, thick, abrupt, raised edges, 
surrounded by an extensive thickened base, into which sinuses and undermining cavities 
are seen to penetrate. These appearances, Mr. Twining states, {opera citat.) have reminded 
him of the foul ulceration at the centre of a small carbuncle; he has seen several patients 
die with only six or eight of these ulcers in the colon. The patients had a flushed face, rest- 
lessness, and symptoms of continued fever, which were with difficulty controlled by any 
course of treatment. 

The last three or four inches of the ileum are generally studded with superficial ulcera- 
tions and have a rough appearance from the enlarged follicles and glandular bodies ; with 
this exception we rarely meet with any traces of disease in the small intestines in those 
who die of dysentery — excepting in those cases in which the dysenteric symptoms occur 
towards the termination of protracted fevers. 

In a few instances, the coats of the colon are so much thickened, that when a transverse 
section is made, its canal stands open like a thick leathern tube, the interior of the intes- 
tine being covered with numerous large ragged ulcers, in the intervals of which the mu- 
cous membrane is partly destroyed, and hangs in shreds. In several of these cases-, Mr. 
Twining (on the Diseases of Bengal), has observed the caecum and lower portion of the 
ascending colon, to be nearly covered with a thick layer of coagulable lymph, deposited 
beneath the peritoneal coat, and extending a considerable distance along the iliacus mus- 
cle ; in some instances, an unusual amount of fat is found at the same part mixed with 
the lymph. In other cases, when the disease has been more protracted, the whole of the 



DYSENTERY. 



833 



When submitted to early treatment, and when its exciting causes can be averted, 
or avoided, dysentery is not an intractable disorder. Sir James M'Grigor remarks 
of the camp dysentery in the Peninsula, that it had two stages, which it was of 
consequence to note, because they required different and almost opposite modes 
of treatment: the inflammatory stage, and the stage of ulceration. A plan pro- 
posed by Dr. Somers appeared to Sir James so judicious, and proved so success- 
ful, in the first attacks of the pure unmixed disease, that he recommended its 
general adoption in the army. It was this : 

First, the patient was freely bled. Immediately afterwards twelve grains of 
Dover's powder were administered. This dose was repeated three times, at in- 
tervals of one hour. Plenty of warm barley-water was at the same time given, 
and profuse sweating encouraged for six or eight hours. A pill, containing three 
grains of calomel and one of opium, was exhibited every second night; and in 
the intervening days two drachms of Epsom salts dissolved in a quart of light 
broth. The venesection was repeated, while the strength and the pulse permitted 
it, until the stools were free or nearly free from blood ; and Dover's powder as a 
sudorific, was always given after the blood-letting. When the pains were great, 
and attended with much tenesmus, the warm bath gave instantaneous relief. " This 
plan being steadily persevered in for a few days, the inflammatory diathesis of 
the intestinal canal, which had excited symptomatic fever throughout the general 
system, was found gradually to yield, and make way for returning health." 

If the disease was not cut short by this method, but advanced into the second 
stage, and became chronic, the most effectual remedies appeared to be laxatives, 
and opiates, given alternately ; and combined with such medicines as promote per- 
spiration. The abdomen should be swathed with flannel, or covered by a warm 
adhesive plaster. Much benefit may be obtained from the employment of clysters, 
if there be not too much tenesmus to admit of the introduction of the pipe of the 
injecting syringe. Warm starch, with laudanum in it — not exceeding in quantity 
a couple of ounces, lest the irritable bowel should expel it again — will sometimes 
afford signal relief. Or if the pain and tenesmus are so great that a clyster-pipe 
cannot be used — or the enema is not retained — a grain or two of solid opium 
inserted into the rectum beyond the sphincter ani, will often allay the distress. 
The food should be farinaceous and simple; and great care must be taken during 
the convalescence to prevent a return to improper diet, and a fresh exposure to cold. 

There is one important point in the treatment of dysentery, concerning which 
a striking discrepancy of opinion exists, even amongst practitioners who have had 
large experience of the disease : I allude to the employment of mercury as a re- 
medy. I have no data for settling the question: but the amount of evidence 
appears to be against its indiscriminate use. It seems (as we might expect) to 
be powerful both for good and for evil. Sir James M'Grigor has probably hit 
the distinction which should guide us to prescribe or to withhold this drug. It 
was, he tells us, when the dysentery was complicated with disease or disorder of 
the liver, that mercury proved so highly useful : when along with the dysenteric 

great intestines are contracted in diameter, resembling- a cord, their mucous coat being at 
the same time covered with numerous small superficial ulcers. In such cases, also, the 
internal surface of the csecum and of four or five inches of the colon, will now and then be 
of a livid red colour inclining to brown, having a fleshy appearance, as if from a growth of 
granulations. Mr. Twining (opera citat.) has met with this condition but seldom, but when 
it has existed, he has found it to extend also to a small part of the sigmoid flexure of the 
colon. The patients in these cases had become much emaciated, with flat contracted abdo- 
men, dry skin, tongue of a slate colour, glossy and morbidly clean as if skinned ; the stools 
consisted of an opaque dirty-brown water. 

When death takes place after protracted suffering from dysentery, we often find the cel- 
lular structure at the root of the mesentery and mesocolon, and across the bodies of the 
lower lumbar vertebree deprived of its usual elasticity and pliability, and to a certain degree 
indurated; and in many cases, entirely devoid of fat. This change is probably the result 
of a previous inflammation at this part — giving rise to an exudation of coagulable lymph 
into the interstices of the cellular substance. — C.l 
53 



834 



DYSENTERY. 



symptoms there were present a dull pain in the hepatic region, and in the right 
shoulder, a yellowish-brown colour of the skin, and of the conjunctiva, and un 
easiness when the patient lay in any other posture than on the right side. He 
adds : " In the early stage of the acute and unmixed disease, and before vene- 
section has been performed, mercury will aggravate the symptoms. In the more 
advanced stage of the disease, particularly when there is hectic fever, with exten- 
sive erosion or ulceration of the intestine, it is invariably found to hurry it on to a • 
fatal termination." 

The sporadic dysentery which we chiefly see in this country seldom requires 
the lancet. Leeches, however, are to be applied, in the track of the colon, wher- 
ever there is much tenderness on pressure. A full dose of castor oil may then be 
given ; and after that an opiate. It is the practice of some physicians to prescribe 
laxatives and opium together; but in this complaint it is better to alternate them. 
Opiate enemata are of service for relieving tenesmus. These remedies will be 
much assisted by the warm bath ; by hot fomentations to the abdomen; and by 
such means as promote the natural secretions of the skin. If there be any reason 
to suspect that the portal system is gorged with blood, complete relief to the 
dysenteric symptoms may often be obtained by the practice which I recommended 
as proper in melaena; viz., the exhibition of five grains of calomel at bed-time, 
and of a senna draught the next morning, for two or three days in succession. 
Should the symptoms still drag on, it may be necessary to give mercury, even to 
the extent of making the gums tender; but it should be introduced gradually. 
Equal parts of hydrargyrum cum cr eta. and of Dover's poivder, constitute a very 
good combination either in pill or powder for such forms of the complaint. But 
in the milder cases of simple sporadic dysentery there is no occasion, I had 
almost said there is no excuse, for giving your patient a sore mouth by the lavish 
employment of mercurial remedies.* 

* [There are few cases of dysentery in which the lancet, or the application of leeches or 
cups to the abdomen can be dispensed wilh, without endangering ulceration, thickening or 
other structural changes in the mucous membrane of the intestines — by which the sufferings 
of the patient are prolonged and his life endangered. When we consider that the disease 
consists in fact in an inflammation of the lining membrane of the great intestines, proceeding 
on. more or less rapidly, to ulceration, and in the more violent cases to gangrene and slough- 
ing, but little doubt can be entertained of the propriety of blood-letting in its early stage — 
even in the mildest cases, the application of leeches or cups to the abdomen will very 
generally be attended with marked relief, and will materially shorten the duration of the 
attack. The more violent forms of the disease can be successfully managed only by the 
prompt, free and even repeated use of the lancet, and the application at the same time, of 
leeches upon that portion of the abdomen where pressure causes the most pain; and this 
system of active depletion must be continued, so long as fever or tenderness of the abdomen 
continues, more especially if the stools continue to be bloody. The use of the warm bath, in 
a few hours after the bleeding, and its daily repetition, will always be attended with benefit; 
or when there is no convenience for the employment of the warm bath, the abdomen may 
be enveloped with cloths wrung out of warm water and repeated as they lose their heat, 
or covered with a light, soft and warm poultice. A large number of cases, if treated at 
their commencement by bleeding, and the warm bath or fomentations, with perhaps a dose 
of Dover's powder at night, to ensure repose, will be very readily and speedily cured by" 
these means alone. 

There exists much discrepancy of opinion in regard to the employment of purgatives in 
dysentery. — Some practitioners insisting that they should be early commenced with and 
repeated at .short intervals until natural stools are procured. While we cannot perceive 
any indication that purgatives are calculated to fulfil, which cannot be as effectually met 
by other less exceptionable remedies, we are convinced that the operation of purgatives 
cannot fail to increase, in most cases, the irritation of the bowels, and to augment consider- 
ably the sufferings of the patient. In cases where ulceratien of the intestines is suspected 
to exist, we consider that purgatives are altogether inadmissible. 

Subsequent to bleeding, the internal remedy from which we have derived the most ad- 
vantage in nearly all the forms of dysentery that have fallen under our notice, is the ipe-- 
cacuanha; we usually administer it in doses of half a grain, combined with the blue mass 
and extract of hyoscyamus, of each one grain, repeated every three hours — ten grains of the 
Dover's powder being given at night. After the discharges from the bowels have lost in 
some measure their slimy, bloody appearance, and though still small, liquid, and frequent, 



DYSENTERY. 



835 



The fluxes of which I have hitherto spoken have all consisted in an immoderate 
discharge of some of the usual contents or secretions of the alimentary tube, in an 
altered and unnatural state. But matters are sometimes voided from the bowels 

have acquired more of a fecal character, combining the ipecacuanha with acetate of lead 
and a small portion of opium, will be found in general to quickly diminish the tormina and 
tenesmus, and to afford marked and often very great relief to the patient. 

Blisters are not a remedy from which any advantage can be anticipated until after the 
more acute symptoms of the disease have been reduced by bleeding — previously they will 
often do harm, but at this period they will be often serviceable. We have repeatedly ob- 
served very great relief to follow their application. 

To remove the painful affection of the bladder, with suppression of urine, that so fre- 
quently attends violent cases of dysentery, Mr. Twining recommends injections of cold 
water into the rectum as a remedy the most prompt and certain in its effects. These injec- 
tions will also be found an excellent remedy for the copious discharges of blood which 
frequently occur ; these discharges will in general, however, be promptly arrested by an 
injection of ten grains of acetate of lead in six ounces of water. 

In cases where the tenesmus is severe during the night, an injection of sixty drops of 
laudanum in two ounces of cold water will usually remain in the rectum until morning, 
and promote greatly the comfort of the patient. 

The intense sufferings which the patients often experience from the severe tormina and 
almost constant and distressing tenesmus attendant upon many cases of the disease, tempt 
the inexperienced practitioner to resort at once to opiates for their relief. But the use of 
opium in dysentery requires the utmost caution; until the violence of the inflammation, in the 
more severe forms of the disease, is reduced by active depletion, they are, in general, inad- 
missible; they are apt to mask the more prominent symptoms, and by the calm they thus 
produce may lead the physician into a false security as to the condition of his patient 
while a fatal disorganization is taking place in the intestines. After, however, bleeding, either 
general or local, or both, according to the violence of the case, has been carried to a proper 
extent, an opiate at night in the form of Dover's powder, or during the day time opium 
combined with ipecacuanha and the blue mass, will often be demanded to quiet the tor- 
mina and tenesmus, and in this manner will give great relief to the patient and contri- 
bute materially in shortening the duration of the most distressing symptoms of the disease. 
Opiate injections are certainly one of the most prompt and efficacious means we possess 
of relieving the distressing tenesmus, which often continues to torment the patient after the 
violence of the attack has been reduced. As an injection, we prefer the solid opium rubbed 
up with olive oil, flaxseed tea or thin starch. The tenesmus is usually dependent on ulcera- 
tions low down in the rectum; and may frequently be relieved by introducing within the 
anus, three times a day, a portion of the size of an hazelnut of an ointment composed of thirty 
grains of acetate of lead, mixed with an ounce and a half of fresh lard. When tenes- 
mus remains after the more prominent symptoms of the disease have been removed, an 
injection of one drachm of acetate of lead dissolved in eight ounces of tepid water was a 
favourite prescription with Mosely, and in many cases it will afford prompt relief. 

The utmost caution should be observed in regard to the nature and amount of the food 
and drinks allowed to the patient as well during the disease, as in the stage of conva- 
lescence. It is all important to keep the colon as nearly as possible empty so long as any 
degree of inflammation exists. — The practice followed by some practitioners of exhibiting 
to the patient large quantities, daily, of flaxseed tea and other mucilaginous fluids, under 
the notion that by so doing we soothe the inflamed intestine, is productive of far more in- 
jury than good. Whilst the disease continues the mildest diluents only should be allowed, 
and these only in moderate portions at a time. Even after convalescence has been fully 
established, the patient should be restricted to the blandest and most unirritating food, and 
this in very moderate quantity. Errors in diet, as Mr. Twining very properly remarks, are 
among the principal causes of a tardy recovery and frequent relapses. 

In describing the post-mortem appearances in fatal cases of dysentery, we noticed various 
morbid conditions of the caecum as of occasional occurrence; to these Mr. Twining, in his 
work on the Diseases of Bengal, (page 69,) directs especial attention. No particular 
change in the general treatment of the case, however, is demanded. All that is necessary 
is for the practitioner to bear in mind the possibility of the occurrence of more or less 
violent inflammation of the caecUm, and by the most undeviating perseverance in the em- 
ployment of the remedies demanded for its removal, especially the local application of 
leeches, to prevent the disorganization of the intestine, and the death of the patient. "When," 
remarks Mr. T., " a considerable enlargement of the caecum takes place, during dysen- 
tery, it is usually first noticed about ten or fourteen days after the commencement of the 
attack. There is not usually so much pain as to make the patient complain, particu- 
larly of the part affected, and unless the practitioner habitually examines the abdomen of 
those he is treating for dysentery, he will be, occasionally, told of the swelling at a period 



836 



DIARRHOEA ADIPOSA. 



totally unlike any of the healthy discharges. Jldeps is not an intestinal excretion ; 
yet it is sometimes passed in great abundance by stool. Many unquestionable in- 
stances of this are on record, both in ancient and in modern literature. I have not 
seen more than one, and therefore have but little to say upon the subject ; yet I must 
not pass it over altogether. A certain quantity, sometimes it has been a large quan- 
tity, of oil, of liquid fat, has been poured forth, in a sort of diarrhoea. Sauvages 
was aware of the disorder, and calls it, in his Nosology, diarrhoea adiposa. *In a 
paper in the Medico- Chirurgical Transactions upon this affection, Dr. Elliotson re- 
fers to an example of it described by Tulpius in which a woman discharged every 
day, for fourteen months, a considerable quantity of yellow fat, thatlay upon the feces 
like melted butter. When voided into a vessel of water it floated, like oil, upon 

of the disease when the patient is past recovery: or he will find, upon dissection, such a 
mass of disease and inflammation, with induration, in the right iliac region, that he will be 
surprised how it could have escaped his notice during life. Excepting in fat persons, the 
rounded, doughy, inelastic tumefaction of the ceecum is easily detected by examination 
with the hand; and, in fact, is often visible on inspection. 

The inflammation of the caecum is to be treated by the daily application of leeches to the 
right iliac region ; the discharge of blood being promoted by warm fomentations or poul- 
tices. When by this means the morbid sensibility is removed and the tumefaction con- 
siderably reduced, a blister should be applied and kept open by some stimulating dressing. 
Mr. Twining recommends as a means of reducing the remaining induration, " a course of 
Plummer's pill, and extract of colocynth, at night, followed by the compound powder of 
jalap, in the morning." " We must remember," he adds, " that no part of the disease can 
be left unsubdued without hazard to the patient's life." 

In chronic dysentery, there is frequent watery purging, attended often with tormina, and 
very generally with tenesmus, by which the patients are much distressed and soon greatly 
exhausted. The discharges are mostly of a pale gray colour, often mixed with more or 
less of a mucous, or white slimy substance, and not unfrequently portions of undigested 
food. They sometimes consist of a copious paste-like brown mass, in a state of fermenta- 
tion ; occasionally, they are frothy, with a whitish or pale gray sediment like a mixture of 
chalk and beer; in a few very protracted cases, the discharges are very frequent and copi- 
ous, quite watery, and varying in colour, from a dark-brown to a bright-orange, or from a 
dirty yellow to a pale straw. They are in some cases inodorous, or nearly so, in others they 
have a peculiar sickening odour, and in others again they are more or less fetid. Blood 
is rarely present in the stools, and the patients suffer from fever only in those cases in 
which there is extensive disease of the mesenteric gland — when they occasionally presented 
a well-marked fever of a hectic character. The abdomen is, generally, flat, inelastic, and 
somewhat retracted; occasionally, however, tympanitis is a troublesome symptom. The 
skin is usually dry, shriveled and desquamating, and of a dirty-brown or sallow hue. 

The treatment of chronic dysentery differs but little from that proper in cases of chronic 
diarrhoea. During the continuance of the disease, and for some period after it has been 
removed, the patient is to be strictly confined to a mild, unirritating diet, taken in very 
moderate quantity, and, for drink, to some bland mucilaginous fluid, as toast or rice water 
— and even this only in such portions as are necessary to allay his thirst. He should be 
shielded from the influence of cold and damp and all sudden atmospherical changes, by 
flannel next his skin and appropriate clothing, and by a careful attention to the temperature 
of the chamber he occupies. 

Leeches or cups to the abdomen will frequently be found of service — but their use will 
require judgment, and a close scrutiny of each case in order that any latent or chronic in- 
flammation may be at once detected. Whenever indurations within the abdomen can be felt, 
and they are attended by morbid sensibility on pressure or the least degree of febrile excite- 
ment, the application of leeches or cups should not be neglected. When the indurations are 
without sensibility, or after this has been removed, blisters are generally very important 
remedies. The daily use of the warm bath and warm fomentations to the abdomen assidu- 
ously employed, are means from which, in cases of chronic dysentery, the most decided 
advantage will invariably result. Small doses of ipecacuanha combined with extract of 
hyoscyaraus and the blue mass, and repeated every three hours, with a dose of Dover's 
powder at night, will generally be found to aid veiy effectually in restoring the capillary 
circulation to its healthy state, in quieting the morbid irritability of the mucous membrane of 
the intestines, in moderating the profuse morbid discharges, and in rendering the stools less 
frequent and of a more natural character. The balsam of copaiba and turpentine will often 
be found of equal advantage in many cases of the present affection, as in chronic diarrhoea. 
In regard to the period proper for the employment of astringents, and the articles of this 
kind that are best adapted to the disease, the same remarks may be repeated as were made 
in our note on chronic diarrhoea. — C] 



INTESTINAL CONCRETIONS. 



837 



the surface ; and when cold it assumed the consistence and appearance of fat. 
Like fat, it was very inflammable, and burned with a bright flame. With all this 
there was no kind of distress, nor any wasting of the body ; and the patient was 
in excellent health sixteen years afterwards. Dr. Elliotson had a case of this 
kind under his own care. The man had also diabetes and phthisis. The symp- 
toms were precisely the same as those described by Tulpius. Dr. Prout and Dr. 
Faraday analyzed portions of the adipose matter, and they pronounced it to be 
genuine fat. Mr. Lloyd, of St. Bartholomew's Hospital, has given us the details 
of a case in which the evacuation of grease was associated with jaundice. The 
excretion looked like melted fat, but when cool had the consistence of butter. 
It swam on the surface of water, melted at a moderate heat, and burned readily. 
In this instance the head of the pancreas, and the duodenum, were involved in a 
mass of scirrhous disease. And this is a very curious fact: for Dr. Bright also 
states that in three different persons, each of whom he had known to pass fat from 
the bowels during life, and whose bodies he had the opportunity of examining 
after death, he found scirrhous disease of the pancreas, and fungous disorganization 
of the duodenum. 

The remarkable coincidence, occurring so often, of these fatty discharges with 
cancerous disease of the pancreas and duodenum, is well worthy of being borne 
in mind ; although it may noi, as yet, afford any explanation of the phenomenon. 

The single case of which I have had any cognizance is that of a tradesman now 
living in my neighbourhood, who from October 1843 to August 1844, suffered 
frequent attacks of this kind. First, he had severe pain in the epigastrium and 
right 'hypochondrium, with little or no fever, nor acceleration of pulse. Occa- 
sionally, when the pain was extreme, it was accompanied by nausea and vomiting. 
After the pain came jaundice and white stools; and, lastly, a discharge from the 
bowels of a quantity of white fragments, looking exactly like coarse chewings of 
walnuts. Sometimes much larger lumps of the same sort were voided. These 
lumps and fragments were found to be composed of adeps. They floated, many 
of them at least, and for a while, upon the surface of water. They felt greasy ; 
and burned, like fat, with a flame. 

After this series of symptoms the patient would recover perfectly, save that the 
attacks reduced his strength somewhat. They occurred about once a fortnight, 
so that he had about a score of them in ten months. 

The symptoms resembled those which declare the passage of gall-stones : and 
upon one occasion two concretions were detected among the fragments of fat. 
One of these was yellowish ; the other black, like a cinder. Once also, a con- 
siderable portion of what seemed membrane came away. My neighbour, Mr. 
Francis E. Hicks, (to whose kindness I am indebted for the opportunity of seeing 
this patient,) is of opinion that a cyst, which secreted the fat, existed in the liver, 
and discharged its contents periodically ; and that the membranous fragment was 
a part of this cyst. 

Projecting a little into the epigastric notch, I could feel what appeared to be the 
edge of the left lobe of the liver. This spot was slightly tender, and dull under 
percussion. 

I had previously been consulted by the same patient for a chronic and obstinate 
cough, which, after harassing him for three or four years, ceased suddenly, upon 
the occurrence of the first of these strange seizures. On that occasion, he voided 
at least a quart of the fat. Since August, 1844, he has experienced only two or 
three slight threatenings of an attack ; but lo, his old cough has returned. 

Mr. Hicks tells me that a female relative of his own laboured for four or five 
years under a perpetual dry cough, which was most distressing to herself, and 
very irksome to the hearers of it. A pint of fatty matter was then passed by stool 
and the cough ceased at once, entirely and permanently. This happened more 
than ten years ago. 

All that we know of the disease seems to amount to this: that it is not a com- 
mon complaint ; and that it is not necessarily a fatal complaint. Persons who 



838 



INTESTINAL CONCRETIONS. 



have passed great quantities of fat in that way have lived in good health for many 
years afterwards. Yet though not necessarily fatal, it has frequently been found 
associated with incurable malignant disease in the duodenum and pancreas. Dr. 
Prout informs us also that in cases in which a similar oily fluid has been passed 
through the urethra, the kidneys have been found in a state of organic malignant 
disease. 

With respect to the treatment of such cases, all the hints I can give you are 
such as are furnished by the two following facts : — 

Mr. Howship, in his book on morbid anatomy, mentions the instance of a lady 
who was affected with this diarrhoea adiposa, and parted with vast quantities of 
fat; and who was cured upon the principle of similia similibus curantur, for she 
recovered after swallowing a pint of sweet oil. And Dr. Elliotson, acting on this 
hint, gave Ms patient, who was labouring at the same time under diabetes, a quar- 
ter of a pint of olive oil ; and the voiding of fat greatly diminished from that time, 
and soon ceased entirely. 

Whether these were really cures, or whether they were coincidences, is a ques- 
tion which we want larger experience to help us to determine. 

When I was speaking of the causes of enteritis, I adverted to the presence o 
foreign substances, as they are called, in the bowels, and to intestinal concre- 
tions. 

There are some points connected with these subjects which I had not then lei- 
sure to pursue, but which you ought not to be ignorant of. 

Intestinal concretions are very common in some of the lower animals — in horses 
and oxen especially. Most of you have seen, I dare say, immense intestinal cal- 
culi of this kind, and great numbers of them, in the Museum of the College of 
Surgeons. The old remedies called bezoars were of the same nature. 

They occur, also, these intestinal calculi, in the human entrails, and in various 
parts of them ; chiefly, however, in the cascum and large intestines, but sometimes 
in the stomach : indeed, very large ones have occasionally been met with in the 
latter organ. Bonelus describes one which weighed nine ounces, and was as big 
as a hen's egg. Generally they are few in number in the same person : one only, 
perhaps, exists ; or two, or three. Yet as many as thirty have been found toge- 
ther in the stomach in one case ; and in another case nine. One of the Monros 
of Edinburgh (Monro primus) detected twelve in the colon of a boy, during life, 
by the touch. Monro secundus took a concretion that weighed four pounds from 
the colon of a woman. They have been known to measure as much as eight 
inches in circumference. In the twenty-fourth volume of the Edinburgh Medical 
and Surgical Journal is an account of one long one, or, perhaps, of three that 
had become united together, weighing twelve ounces. Mr. Turner, of Keith, 
has very lately published the case of a man who passed fourteen large intestinal 
concretions. 

Now, what are these substances, and how do they get there? What is the 
pathology of the malady 1 Why, they seem to be formed, in many instances, by 
the deposit of saline particles, intermixed with animal matter, upon and around 
some accidental nucleus which has entered the alimentary canal, and there stopped. 
Sometimes a gall-stone forms the nucleus: the centre of the calculus has several 
times been found to consist of pure cholesterine. Those matters over which the 
gastric juice has no power, and which pass the pylorus unchanged — such as the 
stones of fruit, husks of grain, many unbroken seeds, portions of bone, and the 
like. Other of these intestinal concretions are evidently composed of a mass of 
short fibres, matted, or interwoven together, after the manner of felt. These 
calculi have a somewhat soft and velvety feel, yet are too hard to be much com- 
pressed. Sometimes they involve a nucleus, and sometimes they do not. Their 
composition has been discovered in rather a curious manner. Mr. Clift, who, as 
you know, has long had the main charge of the Hunterian Museum, after atten- 
tively examining some of the specimens there collected, fancied that they might 



INTESTINAL CONCRETIONS. 



839 



be formed somehow of the beard of oats ; and the late Dr. Wollaston, at Mr. Clift's 
suggestion, I believe, undertook to analyze them somewhat more rigidly ; and he 
found that Mr. Clift's conjecture was well-founded. If you have ever looked 
closely into the structure of an oat which has been separated from its husk, you 
may have noticed that one end of it is formed somewhat like a tiny brush ; made 
up of very minute needles or beards. Dr. Wollaston found that these ends were 
identical in their shape and composition with the fibres of the intestinal concre- 
tions. 

The accuracy of the result of this analysis is singularly confirmed by the fact 
that this particular kind of intestinal calculus is almost peculiar to the bowels of 
Scottish people ; among whom, as you know, oats form a very common article of 
diet, in the shape of oat-meal. 

Concretions of the same species have also been found in the intestines of Lan- 
cashire persons; and they also use oatmeal a good deal as food. Mr. Children 
gives an account of some in the Philosophical Transactions for 1822. The fibres 
were cemented together by mucus ; and the concretions contained also albumen, 
phosphate of lime and soda, and common salt. 

I mentioned formerly the danger which attends the incautious or excessive use 
of magnesia, whether for stomach complaints or for urinary disorders. When 
this substance is taken habitually, and when due care is not used to ensure its 
habitual expulsion from the intestines, it is liable to accumulate and concrete there, 
especially in the caecum and colon. Large masses of this kind have been met 
with, composed almost entirely of carbonate of magnesia. 

And the habitual use of any other indigestible substance may have the same 
ill consequence. The seeds of figs ; unbruised mustard seeds, which (as I men- 
tioned before) are taken daily by some persons ; the woody knots found in certain 
pears ; all these have been known to form the material of concretions, or of hard 
injurious masses in the bowels. 

Now concretions of this kind come at length to produce symptoms by the 
pressure and distension they occasion, by the ulceration to which they sometimes 
give rise, and, above all, by the obstacle they oppose to the passage of the contents 
of the intestines. They generally cut the patient off by exciting inflammation. 

But they may exist for a long time without producing any definite symptoms. 
And when symptoms do arise, or when we ascertain that such concretions have 
formed, we are often at a loss for a remedy. From t,he colon we may hope at 
last to dislodge them: by mechanical means when they are near the outlet; by 
frequent injections of warm water, or soap and water, whereby they may be 
softened or broken down, and washed out, when they are beyond the reach of 
the finger, or of instruments passed into the rectum. 

We have an illustration of the patience of the alimentary canal under the pre- 
sence of these masses, in what often happens when foreign bodies of some mag- 
nitude are swallowed and remain in the tube. 

In one of the earlier volumes of the Medico- Chirurgical Transactions you 
may read the history of a celebrated knife-eater. A sailor, in a drunken bravado, 
swallowed a clasp-knife. This was followed by no immediate bad consequences, 
and he used to brag of the feat he had performed. And afterwards, either to satisfy 
the scruples of those who did not believe his assertions, or for the sake of rewards 
which some people were thoughtless and cruel enough to offer, or to win wagers, 
he stupidly repeated his folly, till he had swallowed (I think) thirteen knives of 
various kinds and sizes. They killed him at last ; and their remains were found 
in various parts of the alimentary tract. But he had no serious symptoms for 
some time. 

Mr. Wakefield has given us an account of a culprit, confined in the Cold Bath 
Fields Prison, who had swallowed seven half-crowns before his incarceration. 
One day out they all clattered into the pan of his night-chair. 

I saw a prisoner myself, last autumn, in the Penitentiary, who, after some 
sickness, and tenderness of the belly, voided a half-crown from the rectum. This 



840 



WORMS. 



was in November, 1839. He had swallowed the piece of money two years and 
a half before — viz., in March, 1837; and, until within a week of his passing it, 
he had enjoyed excellent health. 

Before I proceed to any of the other viscera of the abdomen, I may as well take 
such notice as the nature and limits of these lectures admit and require, of the 
subject of worms; in which subject the intestinal canal is more concerned than 
any other part of the body. It seems a strange, as it is a somewhat humiliating 
fact, that the human body should furnish food and a habitation for many of the 
inferior creatures ; not only after death, but while it is yet alive. The parasitic 
animals which thus prey upon man have been much studied from time to time, 
and especially of late, in their relations to natural history : and some of the facts 
that have been ascertained respecting them you ought to be acquainted with. 
But I shall pursue the subject no further in this place than it concerns us as patho- 
logists and physicians. Its natural history will, no doubt, be fully taught you by 
the professor of comparative anatomy. 

First, then, it is a notorious fact that numerous parasites do crawl over our 
surface, burrow beneath our skin, nestle in our entrails, and riot, and propagate 
their kind, in every corner of our frame: producing oftentimes such molestation 
and disturbance as require the interference of medicine. Nearly a score of animals 
belonging to the interior of the human body have been already discovered and 
described : and scarcely a tissue or an organ but is occasionally profaned by their 
inroads. Each, also, has its special or its favourite domicile. One species of 
strongle chooses the heart for its dwelling-place, another inhabits the arteries, a 
third the kidney. Myriads of minute worms lie coiled up in the voluntary mus- 
cles, or in the areolar tissue that connects the fleshy fibres. The guinea-worm 
and the chigoe bore through the skin, and reside in the subjacent reticular mem- 
brane. Hydatids infest various parts of the body, but especially the liver and 
the brain. A little fluke, in general appearance much like a miniature flounder, 
lives, steeped in gall, in the biliary vessels. If you squeeze from the skin of 
your nose what is vulgarly called a maggot — the contents, namely, of one of the 
hair-follicles, — it is ten to one that you find, in that small sebaceous cylinder, 
several animalcules, extremely minute, yet exhibiting under the microscope a 
curious and complicated structure. Even the eye has its living inmates. But it 
is, I repeat, in the alimentary tube that we are most apt to be plagued with these 
vermin. 

Independently of minute scientific divisions into genera and species, there are 
some broad lines of distinction between these creatures. Thus some kind of 
worms occupy, as I have said, the interior of our bodies ; these are called, accord- 
ingly, entozoa : some dwell externally, and are named ectozoa ; or, more properly, 
perhaps, epizoa. 

There are five sorts of intestinal worms, sufficiently common to make it likely 
that you will meet with some or most of them in your future practice. I shall, 
on that account, direct your attention first of all to them. 

1. A frequent tenant of the human intestines is the round worm, so like in 
shape, size, and general appearance to the common earthworm. It is from this 
species, no doubt, that the whole class are called worms. This round worm is 
often denominated a lumbricus ; but that is erroneous: it is a species of ascaris, 
and it has been named by naturalists the ascaris lumbricbides — the ascaris that is 
like a lumbricus. 

2. The ascaris vermicularis ; or the oxyuris vermicularis. These animals 
resemble slender maggots rather than worms. They are often called simply asca- 
rides : or, in the vernacular, thread-wonns : and they are very much like bits of 
white thread. 

3. The tricocephalus dispar ; also a small worm, but longer than the last ; its 
vulgar denomination is accordingly the long thread-worm. 

4 and 5. Two species ottaenict; long, flat, articulated animals, resembling pieces 



ROUND WORMS. 



of tape. The taenia solium, or common tape-worm of this country ; and the 
taenia lata, or broad tape-worm. 

Of all these I proceed to mention a few more particulars. 

The ascarides lumbricoides, or round worm, is, I say, very like the common 
earth-worm, and used to be thought identical with it. It runs from five or six 
inches to about a foot in length, and it is of a reddish-brown colour, with a tinge 
of yellow. The female worm (for they are of both sexes) is much more common 
than the male, which is smaller also, and may be distinguished by a curved state 
of its tail, and by the genital organs. Sometimes young ones are met with, about 
an inch and a half long. 

I shall not go into any minute description of the anatomy of these worms. You 
cannot mistake them, except for earth-worms ; and the points of distinction between 
the two, when known, are easily perceived. The earthworm, then, is redder than 
the intestinal worm, and less pointed at its two ends. The mouths of the two 
differ much. That of the earth-worm is a short longitudinal fissure, or slit, placed 
on the under surface of its small rounded head. In the ascaris lumbricoides, the 
mouth is situated at the extremity of the worm, is of triangular shape, and is sur- 
rounded by three tubercles. 

It is curious that similar differences, only reversed, exist in respect to the other 
aperture of the alimentary canal, the anus. In the earth-worm this is terminal, at 
the very end of the cylinder : in the ascaris it is a transverse slit near the ex- 
tremity, and on the under surface of the animal. 

Again, the earth-worm has rows of little projections, like bristles, upon its under 
surface ; feet they may be called, for they appear to serve the purposes of locomo- 
tion. In the parasite there is nothing resembling this. 

By attending to these plain marks, you may avoid being deceived by impostors, 
who pretend that they are afflicted with worms, and to prove their case bring you 
an earth-worm or two in a bottle. 

The habitat of these worms is in the small intestines. They may, and do, pass 
upwards into the stomach, or downwards into the large bowel : in either case they 
are generally soon voided. Sometimes they are vomited up : but they have been 
known to creep into the oesophagus, and thence into the nostrils. Andral states 
that he saw a case in which a child was strangled by one of these worms, which 
had turned back and become entangled in the larynx. They have been found also 
in the excretory ducts of the liver. This Andral has witnessed ; as has also Dr. 
Baron in this country. 

It was formerly thought that these animals were capable of perforating the coats 
of the intestine : but that opinion is now generally exploded. They do not ap- 
pear to have the means, if they possess the inclination, to bore through. What 
gave rise to this notion was the circumstance of their sometimes passing out of 
the bowel, through ulcerated or other openings, into the peritoneal sac; or into 
the vagina or bladder ; or outwards through hernial apertures. 

The number of these worms existing at the same time in the same person is 
very variable. The late Dr. Hooper mentions a girl, eight years old, who voided 
upwards of 200 in the course of one week. An instance is recorded of a soldier 
who passed 367 in six days. Another patient got rid of 460 in a fortnight. 

Fifty or sixty have been found in the same dead body. They often lie in 
packets. The corresponding portion of mucous membrane has in some cases 
been red, in others quite natural. Sometimes two are met with ; sometimes one 
only. So that we cannot infer with certainty that because one such worm has 
been voided, more remain behind ; although that is always probable. 

This worm is more common in the early periods of life than afterwards. 

The other species of ascaris, the ascaris vermicularis or threadworm, resembles 
the former in some respects, but differs from it remarkably in size. Here also 
the female is longer and larger than the male ; the one being perhaps half an inch 
in length, the other not two lines, and very slender. 



842 



THREAD-WORMS— TAPE-WORMS. 



The thread-worms live principally in the rectum, and sometimes exist there in 
vast numbers; thousands: and they pass out, or are ejected, matted together with 
mucus in the shape of balls, or entangled in portions of excrement. Sometimes 
they emerge of their own accord, and crawl about the neighbourhood, getting into 
the vagina in females, and even into the urethra, and causing intolerable irritation, 
itching, and distress. 

They are seen when recently expelled, to be very lively ; moving their anterior 
extremity about continually. To this restlessness and activity the animal owes its 
name, which is derived from the Greek word aexapiZaiv, to leap. The Germans 
call it springwurm. 

This worm also belongs chiefly to infancy and childhood. It does sometimes 
infest adults ; but generally as the patient grows older the animals cease to trouble 
him, whether curative means are employed or not.* Bremser, however, knew a 
person eighty years old, who was nearly killed by them. 

The third kind of these round worms is the long thread-worm ; the tricocephalus 
dispar. It is from an inch and a half to two inches in length. One extremity, that 
to which the head belongs, is extremely fine and small ; and then suddenly bulges 
out into a thicker body. The thinner portion is about twice as long as the thicker. 
Its name is derived from this variation of size. 0p t |, a hair, and xsq>a^, the head ; 
the portion to which the head is appended being as fine as a hair. At one time 
the head was mistaken for the tail, and then the animal was called tricuris, from 
0ptf|, and ovpa, the tail. The thicker or body part is rolled up in a spiral form, 
especially in the male, the female being straighter. This worm is of a white 
colour, unless tinged by its food. It also affects the large intestine as its place of 
abode; but the opposite end of that gut, the caecum, is its favourite spot. It is 
sometimes met with in great numbers, attached to the mucous membrane by its 
head ; the body hanging loose. 

Although generally overlooked, it is said to be extremely common, and to occur 
in most bodies. I have seldom seen it; but then I have never hunted for it. It 
infests the dog, the fox, the monkey, and other mammalia. 

This species of entozoon attracted a good deal of attention about seventy or 
eighty years ago ; it being then first observed in Germany during the prevalence 
of an epidemic fever, which was characterized by profuse mucous diarrhoea. 
Rcederer and Wagler have given an excellent account of this disorder, under the 
title of morbus mucosus. It was thought to have been excited by these worms, 
which were found in abundance in the caecum after death. This opinion must 
have been erroneous, for the animals were known in other places, long before ; 
and they produce, in general, no inconvenience. 

The two taeniae are more formidable beasts. With a general resemblance between 
them, there are strong particular distinctions. 

The taenia solium, or common tape-worm, has a minute hemispherical head, and 
a long flat body, of a whitish colour, composed of many pieces curiously articu- 
lated together. The articulated pieces are quadrilateral, very short and small in 
the creature's neck ; they become gradually square as the distance from its head 
increases ; and at length are longitudinally oblong. These portions, or joints as 
they are called, have foramina on their margins, leading to ovaries within. The 
foramina, which are very conspicuous, are placed alternately on the one side of 
the animal and on the other: on the right edge of one joint, on the left of that 
next to it. This arrangement is, however, subject to occasional irregularities. 
Each joint is let in, as it were, to that immediately in front of it; and the connec- 
tion between them is not very firm. It is less firm in proportion as the animal 
is older, and as we approach its posterior extremity : so that the segments are apt 

* [We have met with these worms nearly as often in the adult as in the child. — Accord- 
ing to our experience, the female adult is much more liable to them than the male. — C] 



TAPE-WORMS. 



843 



to come away, by stool, separately. They have somewhat the appearance of the 
seeds of cucumbers or gourds ; and the parasites, for that reason, are sometimes 
called cucurbitine worms. Blumenbach and others have supposed that each arti- 
culated piece was a distinct worm : but that is not the case. The head of the ani- 
mal, and its peculiar terminal segment, forbid this belief. 

The common tape-worm is very .narrow and thin towards its anterior extremity ; 
one-third or one-quarter of a line perhaps in breadth. At its broadest part it may 
be from three to six lines wide. 

The young taeniae seem to be merely wrinkled ; but they are really articulated. 
The question has been started, whether the lost joints are ever reproduced. It is 
believed that no new joints are formed, but that the original ones are gradually 
more and more developed. The animal is hermaphrodite. 

Specimens of this worm are preserved, upwards of twenty feet in length. 
Much exaggeration seems to have existed formerly about its size. It has been 
said to measure 150, and even 300 feet. In all probability separate portions of 
several have been estimated as forming parts of one and the same worm. There 
is one case well-authenticated (it is cited by Bremser from Robin) in which a 
tape-worm was found to extend from the pylorus to within seven inches of the 
anus; adhering firmly to the mucous membrane all the way. The animal has the 
power of motion. Its movements are felt by the patients, within them. When 
recently expelled, and placed in tepid water, it may be seen to shorten itself; nay, 
portions protruding many feet from the anus have been known to draw themselves 
back again. 

This kind of worm is more frequent in adults than in children : yet it is some- 
times met with even in the foetus. It is exceedingly common in dogs. It has 
been badly named ver solitaire, for it is not always single. It is not only found 
in company with different worms, but also with others of its own species. Its 
natural place of abode is the small intestines : but it extends sometimes into the 
large, and sometimes into the stomach. Vandoverer declares that after an emetic 
one of his patients vomited forty Dutch ells of the worm, and might have got rid 
of more " if he had not been afraid of puking out all his guts, and for that reason 
bit the worm off." 

The taenia lata, or broad tape-worm, has often been confounded with the taenia 
solium ; yet there are striking differences between them ; respecting which, for 
all practical purposes, it is enough to say that 4he heads (as viewed through a 
microscope) are very dissimilar; that the joints of the taenia lata are shorter and 
broader, and adhere together in a different manner; and that the pores leading to 
the oviducts are situated not on the edg*e of each joint, but in the centre of its flat 
surface. This variety is not so easily broken across as the former ; and therefore 
its segments are less liable to be voided in a separate form. It is probably shorter 
also than the taenia solium. Fifteen feet have been supposed its average length. 
Marvelous stories, however, are told on this head. Boerhaave declares that he 
effected the expulsion of one, which was 300 ells long, from the bowels of a 
Russian. 

The geographical distribution of these two species of taenia forms a curious 
part of their history, and throws some light upon the doubtful question of their 
origin. In England, Holland, and Germany, the taenia solium is common, and 
the taenia lata very rare. In Russia, Poland, and Switzerland, it is just the 
reverse : the taenia lata prevails ; the taenia solium is seldom seen ; while in France 
the one species is nearly as frequent as the other. 



844 



HYDATIDS. 



LECTURE LXXIV. 

Entozoa continued. Hydatids. Trichina Spiralis . The Guinea- Worm. Stron- 
gulus Gigas. Origin of Entozoa. Question of Spontaneous Generation. 
General symptoms of the presence of Intestinal Worms. Particular symp- 
toms, and remedies, of the common Round Worm, of Thread-worms, of 
Tape- Worms. 

At our last meeting I gave a summary description, sufficient, however, for our 
purposes as medical practitioners, of the five kinds of vermes which are most 
common in the human intestinal canal. There are yet a few more of these entozoa 
which are curious and interesting enough to deserve a brief notice. 

Hydatids — animals like bags or bladders of water — are of very frequent occur- 
rence in various parts of the body. They are also called acephalocysts, headless 
bags. These are not to be confounded with enlarged Graafian or other vesicles, 
nor with morbid serous cysts in general. They look like, or rather they are, 
spherical sacs having one aperture only, and containing a thin colourless liquid. 
They are usually found congregated, sometimes in vast numbers, within a large 
cavity or cyst, to which they are not attached. This is a consequence of the 
peculiar manner in which the animals are propagated. The wall of the cyst is 
laminated, and the young hydatids bud forth from between its layers. In the 
species which most commonly infests the human frame, they are born into the 
cavity of the parent : in some other species they are detached externally. We 
find therefore a parent bag, full of other smaller bags ; which, again, are pregnant, 
as it were, with their own offspring, the grandchildren of the primary cyst: and 
so on, somewhat after the manner of a nest of pill-boxes. Minute in their origin, 
these parasites may thus increase and multiply till the original cyst attains an 
immense size, and at length destroys life by its bulk and pressure. Of course 
the immediate consequences of such pressure will depend greatly upon the parts 
occupied by the hydatids. You may readily imagine what kind of symptoms are 
likely to ensue, when they are lodged within the abdomen, within the less yielding 
thorax, within the unyielding skull. They are more common in the liver than 
in any other single organ. I lately mentioned the case of a woman, Harriet 
Baldwin, who died in the Middlesex Hospital, and whose liver contained thou- 
sands of these globular bodies. The enlarged gland had completely sealed up, 
by its pressure, a portion of the inferior cava. 

We can seldom tell that hydatids exist in the body until we see them ; nor, if 
we knew of their presence, could we propose any rational method of cure. It 
has been fancied that a galvanic current, or an electric shock, passed through the 
organ containing these creatures, might kill them, and so at least prevent their 
increase; or that they might be poisoned by drugs that are not seriously preju- 
dicial to man, such as mercury or iodine. But these are mere dreams of our 
baffled art. They sometimes open a way for themselves to the surface, and es- 
cape through an ulcerated outlet : and sometimes they are let out, to the surprise 
perhaps of the operator, who only knew that he was dealing with an abscess 
which required puncturing, Mr. Arnott put a lancet into a fluctuating tumour in 
the epigastrium of one of my patients ; very offensive pus issued, with the 
shriveled skins of sundry defunct hydatids. The cyst was situated, I believe, 
in the liver. Although the orifice was slow to heal, the patient ultimately got 
well. 

There are single cyst-like bodies, with short retractile necks, bearing the gene- 
ric name of cysticercus. One species of this kind, the cysticercus cellulosus, 
inhabits the interfascicular areolar tissue of the muscles. It is rare in the human 
subject, but frequent in the pig ; giving rise to that condition of the muscles which 



TRICHINA SPIRALIS. 



845 



is familiarly known as measly pork. This is one of the internal parasites with 
which the organ of vision is liable to be infested. A most remarkable instance 
occurred a few years ago, in Glasgow. In the eye of a child, who had suffered 
repeated attacks of ophthalmia, Mr. Logan discovered one day, to his extreme 
astonishment, a semi-transparent body, about two lines in diameter, floating unat- 
tached in the anterior chamber. It seemed almost perfectly spherical, except that 
from its lower edge there proceeded a slender process, of a white colour, with a 
slightly bulbous extremity, which appeared to be heavier than the globular part, 
for it was always turned downwards. This head or neck was seen to project or 
elongate itself from time to time ; and occasionally it was drawn up and completely 
hidden in the cystic portion. When the patient sat still, in a moderate light, the 
animal covered the two lower thirds of the pupil. " Watching it carefully (says 
the gentleman who has recorded the case), its cystic portion was seen to become 
more or less spherical, and then to assume a flattened form ; while its head I saw 
at one moment thrust suddenly down to the bottom of the anterior chamber, and 
at the next drawn up so completely as to be scarcely visible." The child's head 
was now turned gently back, and instantly the hydatid revolved through the 
aqueous humour, so that its head fell to the upper edge of the cornea, now the 
more depending part. Upon the child again leaning forwards, it settled, like a 
little balloon, in its former position ; preventing the patient from seeing objects 
directly before her. 

The animal was carefully watched for three weeks ; and no other change was 
noticed than a slight increase in the bulk of its cystic portion. In six weeks it 
had evidently grown bigger, the eye became injected, and the iris less free in its 
movements ; and pain ensued. Extraction of the hydatid was attempted ; but the 
patient was unruly ; the lens was forced out, and the animal ruptured and expelled 
in shreds : the iris became entangled in the wound of the cornea, and vision in 
that eye was spoiled. 

There is a very singular microscopic parasite, the trichina spiralis, dwelling in 
myriads, sometimes in the muscles of the living human body. It was first 
described, I believe, by Mr. Hilton, of Guy's Hospital, and afterwards more 
fully by Professor Owen, in 1835. Mr. Wormald, the Demonstrator of Anatomy 
at St. Bartholomew's Hospital, sent to that gentleman a portion of human muscle, 
which presented a singular speckled appearance, as if it were mouldy. Mr. Owen 
found that each speck was a shuttle-shaped cyst, containing a very minute cylin- 
drical worm, coiled up in two, or two and a half, spiral turns. The worm mea- 
sures, when unrolled, no more than ^ih of an inch in length, and T ^th of an 
inch in diameter ; and of course requires, for a satisfactory examination, to be seen 
through a microscope. The longer axis of the containing cyst lies between, and 
parallel to, the fibres of the muscle. Fourteen similar instances have since come 
to Mr. Owen's knowledge. 

This is a very strange kind of parasite. One would imagine that the presence 
of innumerable living beings, in or between the muscular fibres, would be likely 
to give rise to symptoms. We might expect pain, or muscular debility, or em- 
barrassed movements ; yet no indication of the presence of these worms seems 
to have been afforded in those instances in which the condition of the subject in 
whom they were found was known, during life. The principal points that have 
hitherto been made out appear to be the following: — 

1. The muscles thus beset with parasites are the voluntary muscles : and those 
which lie superficially are fuller of the worm than the deeper seated. The pecto- 
ralis major, latissimus dorsi, and other large flat muscles, usually present them in 
great abundance. They have been detected in the muscles of the eye : and even 
in those belonging to the little bones of the ear, and of whose action we are wholly 
unconscious. They occur also in the diaphragm, in the muscles of the tongue 
and of the larynx, in those of the soft palate, in the constrictors of the pharynx, 
in the levator ani, in the external sphincter ani, and in the muscles of the urethra. 



846 



THE GUINEA-WORM. 



They have not yet been seen in the muscular tunic of the stomach and intestines, 
in the detrusor urinas, or in the heart. Mr. Owen makes this interesting remark 
— that all the muscles infested by the trichina are characterized by the striated 
appearance of their ultimate fasciculi : whereas the muscles of organic life, which 
the animal does not inhabit, have, with the exception of the heart, smooth fibres, 
not grouped into fasciculi, but united reticularly. 

2. It appears, also, from what has been hitherto observed of these entozoa, that 
their presence in the body is unconnected with age, sex, or any particular form 
of disease. They have been concomitant with cancer of the penis; tubercles of 
the lungs ; exhaustion of the vital powers by extensive ulceration of the leg ; fever, 
combined with pulmonary phthisis: aneurism of the aorta; sudden depression or 
collapse after a comminuted fracture of the humerus; diarrhoea. They have also 
been met with in the muscles of a man who, while in the apparent enjoyment of 
robust health, was killed by a fracture of the skull. 

The Filaria Medinensis — Dracunculus — or Guinea-worm — has its residence 
in the subcutaneous areolar tissue. It is a long, slender, round, uniform animal, 
like a fiddle-string, or a piece of bobbin ; as you may see in the specimens before 
you. Its length varies from five or six inches to twice as many feet. Men's lower 
limbs, their feet and legs, are the parts most commonly possessed by this worm ; 
but it occurs also in the scrotum, in the parietes of the belly, in the arms, beneath 
the conjunctiva of the eye, and in almost every superficial situation. It is some- 
times solitary ; but several may co-exist or succeed each other in the same indi- 
vidual ; nine or ten perhaps. A Dr. Marrudri, a friend of the celebrated Clot Bey, 
had suffered from twenty-eight of them in succession. 

This entozoon is endemic in the hot intertropical regions; in Asia and Africa; 
upon the coast of Guinea, whence its trivial name. It sometimes abounds after 
the manner of an epidemic. Sir James M'Grigor tells us that the 86ih and 88th 
regiments, stationed at Bombay, were much plagued by this pest. The 86th was 
free from it upon entering the fort, in September, 1799 ; and so continued till the 
setting in of the monsoon in 1800. In the course of the monsoon nearly 300 
of the men were attacked. The 88th regiment relieved the 86th. No case of . 
Guinea-worm appeared among them for nearly a month after their coming into 
the barracks at Bombay, in October, 1800. In the latter end of November, they 
embarked for the Egyptian expedition ; and in the course of the voyage in one 
ship alone 199 men out of 360 were crippled and laid up with this loathsome 
disease. It was thought to be infectious. The artillery-men, who were kept 
separate, escaped. Of 181 instances, of which Sir James M'Grigor gives a 
tabular account, the feet were the parts affected in 124. 

These animals sometimes remain for a long while in the areolar tissue without 
producing inconvenience, and therefore without betraying their presence. Hence 
they are sometimes brought over to this country. The great navigator, Dampier, 
had no symptom of a Guinea-worm which he carried about with him, until about 
half a year after he left the place in which he contracted it. Sometimes the 
parasite is quiet and harmless for a still longer period ; in one recorded instance 
it was latent and dormant for three years. 

The symptoms which do at length arise are the following : — itching of the part 
affected ; a sensation as if there were something creeping under the skin ; some- 
times a cord-like ridge can be felt in the track of the worm ; at length a vesicle, 
or a pustule, or a little boil forms, from which, when it breaks, the head of the 
animal protrudes. This process is often attended with fever; and in certain parts 
of the body the local suffering is considerable: the areolar tissue sloughs; and 
sometimes dangerous hemorrhage occurs. 

The only treatment which these cases appear to admit of, is the gradual and 
careful extraction of the worm. Lest that part of it which already protrudes 
should recede, or be broken, it is gently wound, day by day, round a small stick, 
or a little roll of adhesive plaster; pains being taken not to pull upon it so much 



STRONGULUS GIGAS. 



847 



as to risk its being torn asunder. The roll is protected by a bandage. When- 
ever, by accident, the animal is broken, very serious consequences are said to 
ensue; violent inflammation of the part, abscesses and sinuses, and high irritative 
fever. This mischief is ascribed by some to the presence of dead animal matter, 
by others, of young filariae, in the subcutaneous tissue: for I should have men- 
tioned that the Guinea-worm is viviparous; and although neither digestive organs 
nor generative organs have yet been discovered in its structure, it is sometimes 
found stuffed internally with a countless offspring. The extraction is tedious 
work. Where, indeed, the areolar tissue is very loose, as in the scrotum, the 
worm is occasionally drawn out at the first attempt : but the process sometimes 
occupies weeks; and its average period appears to be not less than ten days. 
When the course of the animal is quite superficial and obvious, the natives are 
accustomed to make an incision in the skin, at about the middle point, and to pull 
the worm through from both ends. When once it is out, the parts presently 
heal. All other medication (and much has been tried) has been found useless; 
except, perhaps, the administration of assafetida; and that not as a means of cure, 
but of prevention. It is said that the Brahmins in India, who are in the constant 
habit of using this drug, are exempt from attacks of the dracunculus. Cleanliness 
was also found, in the army, to be a considerable protection. 

There is a species of filaria peculiar to the eye ; and another to the bronchial 
glands : but these are extremely rare. 

The urinary organs have their parasites also : of which I shall specify but one, and 
that chiefly on account of its strange lurking-place, and remarkable size. I alluded 
to a species of strongle which sometimes occupies the human kidney, and which 
is no uncommon tenant of the same organ in various animals ; the horse, the bull, 
the dog, the wolf, the polecat, and the otter. In the human subject its length 
varies between five inches and a yard, and it is sometimes half an inch in diameter. 
There is a specimen nearly of that size in the Hunterian museum. It may well 
be called the giant strongle, strongulus gigas. Fancy a creature as big as a snake 
coiled up in one's kidney. It gives rise to no distinctive symptoms, although, as 
you may suppose, it causes much renal distress; hematuria, retention of urine, 
and great suffering in its passage out of the body, either through the natural uri- 
nary channels, or by abscess and ulceration through the back. 

With respect to some, at least, of the parasitic animals that I have been describ- 
ing, those I mean which are found shut up in close chambers, our first feeling is 
that of wonder how they came there. Into all parts, from which a road is open 
to the external surface, we can conceive that living creatures may enter, or their 
eggs be carried. But how can either animals or ova find their way, unperceived, 
into the substance of the liver and of the voluntary muscles, into the eye, into the 
brain? The whole matter is obscure, yet interesting. 

With respect to the common hydatids, it has been conjectured — and the con- 
jecture does not seem improbable — that they are not parasites, nor distinct animals 
in any sense; but merely certain of those primitive nucleated cells — from which 
the microscope asserts that all the varied tissues of the body are originally formed 
— rendered gigantic and monstrous by some erring or morbid action of the vital 
forces. Except in size, the cell and the hydatid are declared to be alike : alike 
in shape, alike in the mode of their growth and multiplication. But this view of 
the matter, granting it to be the true one, does not relieve our difficulty ; for within 
these very hydatids, distinct living animals have been found : parasites of the 
second order, entozoa of an entozoon, if the hydatid be itself a separate animal — 
tenants of a formation-cell, if the hydatid be only an extravagant development of 
the primary corporeal structure. 

Within several of the transparent hydatids which were taken from the liver of 
the woman Baldwin, a number of small, opaque, white grains were visible. These 
were examined by Mr. Tomes and myself, under the lens of his powerful micro- 



848 



ORIGIN OF ENTOZOA. 



scope. They were plainly minute animals : baglike, with an orifice or mouth 
which, in some instances, protruded a little from the bag, in others was evidently 
contracted and drawn inwards. Around this orifice was arranged a circlet of 
small, flat, spear-shaped rays, somewhat like a Vandyke collar. Many of these 
rays, or spines as they have been called, were detached, and lying loose in the 
surrounding liquid. Being very ill-informed in this department of natural history, 
I paid less attention to these creatures than they deserved ; — fancying indeed that 
they might be common and well-known, or rather that they were juvenile hydatids. 
I have become aware of my mistake, through perusing a paper, by Mr. Curling, in 
the twenty-third volume of the Medico- Chirurgical Transactions ; where he more 
minutely describes precisely similar phenomena. Mr. Curling shows that these 
included animalcules are parasitic vermin which infest a peculiar species of hy- 
datid, called the Echinocuccus Hominis. Later opinions assert that what we call 
the hydatids, is nothing more than a nest, or habitation, formed by or for the 
small indwellers. 

Now whatever hypothesis we may adopt respecting the nature of hydatids 
themselves, the puzzling question still remains, whence originated the living beings 
inclosed within them 1 How got they thither ? 

It was the opinion of Linnaeus, and of other natural philosophers of his time, 
that the intestinal worms were really terrestrial or aquatic animals which had been 
accidentally swallowed, either while young and small, or in the antecedent state 
of ova. It was even pretended that these animals had been recognized and de- 
tected out of the body, in stagnant waters. But later inquirers, especially Brem- 
ser and Rudolphi, have completely disproved this notion. After dedicating twelve 
years of his life to the observation and study of entozoa, Bremser was satisfied 
that no creatures identical in structure with the intestinal worms are ever met with 
out of the body, except such as have come from the intestines of man, or of some 
other animal; and conversely, that no terrestrial or aquatic worms are ever found 
living within the bodies of men or of animals, unless they have been directly or 
plainly received from without. 

But, then, is it not possible that, as Boerhaave supposed, aquatic or terrestrial 
reptiles, casually entering the body from without, being placed under entirely 
new and unnatural conditions, may have attained a monstrous growth, and under- 
gone metamorphoses such as we know that some of the lower animals, by change 
of circumstance, do undergo; as the tadpole becomes a frog, the maggot a but- 
terfly ? 

To this theory there are strong grounds" of objection. First, there is no ascer- 
tained relation (as in the other cases) between the structure of intestinal worms, 
and of animals having an independent existence out of the body : and they are 
never caught (as they would surely sometimes be) in the transition state — the 
intermediate condition. Secondly, opposed to this " accidental" hypothesis are 
also the facts that certain species of worms infest certain species of animals only : 
that in the same animal different species of worms occupy (as we have seen) 
special parts of the alimentary canal; have each their peculiar habitat: that 
worms and animals of external origin mostly die as soon as they are received 
into the digestive organs ; while the true intestinal worms perish whenever they 
are delivered therefrom. Thirdly, the circumstances that these worms not only 
live but breed within the human bowels, and that they are met with even in the 
intestines of the unborn foetus, are very adverse to this theory of an accidental 
error loci. 

But, to give up the notion of a metamorphosis, may not intestinal worms 
spring from specific germs or ova introduced from without, not casually, but in 
accordance with a natural law : germs or ova which find in the interior of living 
bodies the only conditions that admit of their development, the only soil in 
which they are capable of germinating, the only nest in which they can be 
hatched ? I confess that such is my own belief. We have something like this 
at least in that common affection of horses called the " bots." A species of 



SPONTANEOUS GENERATION. 



849 



oestrus or gadfly deposits its eggs upon the animal's hide, where they cause, I 
presume, some irritation, which induces the horse to lick that part with his 
tongue. The eggs are thus conveyed into the mouth, whence they reach the 
stomach. There they are converted into larvae, and affix themselves to the 
parietes of the stomach. At length, when they are ready to undergo their final 
metamorphosis, they are detached from the interior of the stomach, pass along 
with the food and feces through the intestines, and are ejected from the rectum 
with the dung. 

Why, it is asked, may not similar phenomena take place in the human body ? 
There can be no doubt that we every day swallow, inadvertently, numerous ova, 
of various kinds. It is supposable enough that sometimes the digestive organs 
may, and sometimes they may not, have the power of decomposing or expelling 
these ova. 

It is quite certain that what are generally called spurious worms may have 
that mode of origin in the body. Thus, Dr. Elliotson states that he had once a 
patient, an infant, who discharged from the bowels a dozen live larvae, or mag- 
gots, of the common fly. The child had eaten part of a high pheasant some 
months before. There was, in that case, this instructive circumstance. The 
infant had been suffering under a chronic cough, but as soon as those larvae were 
got rid of, the cough ceased. Dr. Elliotson says that he saw them in the napkin, 
moving about in the fecal matter, just as they might have done if they had never 
been in the child's body. The same physician tells us that he has twice known, 
in two different patients of his, a living caterpillar to be discharged from the in- 
testines. One of the patients was a woman who had been in the habit of eating 
cabbage stalks while she was washing them for the pot. The moth lays its eggs 
on cabbages, and she no doubt had swallowed some of them, and one had hatched 
within her. In the ninth volume of Dr. Duncan's Medical Commentaries is a 
precisely similar case. A boy, after a dose or two of calomel and jalap, discharged 
from the rectum very many caterpillars, all alive, and full of activity. He had been 
in the habit, when in the garden, of eating young cabbage leaves. Till this habit 
began he had enjoyed good health. While the animals were within his bowels 
he suffered severely; had locked jaw; and fell into a state resembling coma. 
Upon their expulsion he recovered perfectly. Centipedes have in like manner 
been vomited, and voided from the bowels. But the most wonderful instance of 
this kind that ever was heard of, is related by Dr. Pickells in the Transactions 
of the King and Queen'' s College of Physicians in Ireland. A young woman 
of melancholic disposition and chlorotic appearance, had been in the daily habit, 
from some superstitious motive, of drinking water mixed with clay taken from 
the graves of two priests who lived and died in the odour of sanctity. In this 
way she probably imbibed the ova of the insects which subsequently issued from 
her body. In the course of about three years and a quarter, she discharged, 
partly by vomiting, but chiefly per anum, upwards of 2000 beetles, and their 
larvae, most of them alive. Dr. Pickells counted more than 1300. Larvae, and 
pupae, and perfect insects, all came forth simultaneously. Some of them ran 
off, as soon as they were vomited, into holes in the floor; and two large winged 
insects were so lively and vigorous as immediately to fly away. These strange 
births were preceded and attended by a complicated and distressing train of symp- 
toms ; a gnawing, and sense of something creeping at the pit of the stomach, 
vomiting of blood, amenorrheca, hysterical convulsions, headache, retention of 
urine, and sometimes a degree of mental derangement. She was at length freec| 
from this disgusting malady by large doses of the oil of turpentine. 

These spurious worms differ from the true intestinal parasites in this — that the 
human alimentary canal is not their only, but their accidental and unusual nidus. 
Nevertheless, their occasional presence, alive, in that place, adds to the probability 
that some of the entozoa may be originally ectozoa. 

The main difficulty, however, respects those animals which occupy shut cavi- 
ties wiihin us, or are embedded in our solid organs: and this difficulty forms one 
54 



850 



INTESTINAL WORMS. 



avowed ground of the theory of equivocal generation: which means the sponta- 
neous production of living creatures, independently of any germ, or egg, or parent. 
The vulgar suppose that dirt engenders fleas, that maggots result from the putre- 
faction of flesh, that eels arise, of themselves, in and out of mud. In other words, 
they infer the spontaneous origin of those creatures, of which they cannot or do 
not trace the procreation by pre-existing parents : and philosophers and men of 
science have done the same. They will not believe that which they cannot see. 
Now this doctrine of equivocal generation shocks, I confess, my mind, and offends 
my reason. If well founded, it strikes at the root of that great argument of Natu- 
ral Theology, which deduces the existence of a First Intelligent Cause, from the 
marks of adaptation, design, and contrivance, so manifest throughout the visible 
universe. Observe the demand which this doctrine makes upon our faith. In defi- 
ance of all experience and analogy in respect to creatures which our finite senses 
are competent to examine, it calls upon us to believe that living beings, of complex 
and intricate, yet definite and harmonious structure ; provided with a digestive 
apparatus, with instruments of locomotion, with generative organs; of various 
species ; in many instances of separate yet answering sexes ; that not one or two 
of these beings, nor a pair or two, but beings and pairs innumerable, are daily 
formed by the casual concourse of " organic molecules." The obscurity that 
hangs over the origin of the entozoa is not indeed the only nor, I think, the chief 
ground upon which the notion of spontaneous generation rests. You are probably 
aware that minute animalcules, so minute that most of them cannot be seen with- 
out a microscope, soon become abundant in water wherein vegetable or animal 
matters have been dissolved by infusion. Such animalcules are therefore called 
Infusoria. How do they come there ? There are two suppositions open to us. 
One is, that they are formed by the fortuitous union of organic atoms contained 
in the infusion. The other is, that they proceed from ova or germs existing in 
the liquid, or floating always in the atmosphere, and ready to quicken whenever 
they light upon their proper element. That the ova of animals which are them- 
selves visible only by the aid of a microscope, should be absolutely invisible by 
us, is not surprising. We may conclude that the latter supposition is the most 
true, if we can show that when these ova or germs are excluded, all ihe other 
conditions of the production of infusoria being present, no animalcules appear. 
Now Spallanzani long ago found, by careful trials, that no animalcules were dis- 
coverable when the access of air to the infusion was completely prevented. But 
it has been objected to his experiments, that the presence of atmospheric air may 
be one of the essential conditions upon which the requisite combination of the 
organic molecules depends. Air, solar light and heat, and organic matters in solu- 
tion being given — does animal (or even vegetable) life ever result? That is the 
question. The experimentum crucis lias been made, and has answered " No," 
as I lately learned from one of Professor Owen's admirable introductory lectures; 
by whom, I am glad to find, this uncomfortable doctrine of equivocal generation 
is strongly discountenanced. The experiment to which I refer was conducted by 
M. Schulze, of Berlin. I will read you his own account of it, as I find it recorded 
in the Edinburgh New Philosophical Journal. 

" The difficulty to overcome consisted in the necessity of being assured, first, 
that at the beginning of the experiment there was no animal or germ capable of 
development in the infusion; and secondly, that the admitted air contained nothing 
of the kind. For this purpose I filled a glass flask half full of distilled water, in 
which I mixed various animal and vegetable substances ; I then closed it with a 
good cork, through which I passed two glass tubes bent at right angles, the whole 
being air tight. It was next placed in a sand-bath, and heated until the water 
boiled violently, and thus all parts had reached a temperature of 212°. While 
the watery vapour was escaping by the glass tubes, I fastened at each end an appa- 
ratus which chemists employ for collecting carbonic acid ; that to the left was filled 
with concentrated sulphuric acid, and the other with a solution of potash. By 
means of the boiling heat, everything living, and all germs in the flasks or in the 



SPONTANEOUS GENERATION. 



851 



tubes, were destroyed ; and all access was cut off by the sulphuric acid on the one 
side, and by the potash on the other. I placed this easily moved apparatus before 
my window, where it was exposed to the action of light, and also (as I performed 
my experiment during the summer) to that of heat. At the same time I placed 
near it an open vessel, with the same substances that had been introduced into 
the flask, and also after having subjected them to a boiling temperature. In order 
now to renew constantly the air within the flask, I sucked with my mouth, several 
times a day, the open end of the apparatus filled with solution of potash ; by which 
process the air entered my mouth from the flask through the caustic liquid, and the 
atmospheric air from without entered the flask through the sulphuric acid. The 
air was of course not at all altered in its composition by passing through the sul- 
phuric acid in the flask, but if sufficient time was allowed for the passage, all the 
portions of living matter, or of matter capable of becoming animated, were taken 
up by the sulphuric acid and destroyed. From the 28th of May till the beginning 
of August, I continued uninterruptedly the renewal of the air in the flask, without 
being able, by the aid of the microscope, to perceive any living animal or vegetable 
substance, although during the whole of the time I made my observations almost 
daily on the edge of the liquid: and when at last I separated the different parts 
of the apparatus, I could not find in the whole liquid the slightest trace of infusoria, 
of confervae, or of mould. But all three presented themselves in great abundance 
a few days after I had left the flask standing open. The vessel which I planed 
near the apparatus contained on the following day, vibriones and monads, to which 
were soon added larger polygastric infusoria, and afterwards rotatoria. " 

This experiment confirms the belief which various other facts had suggested — 
that the different kinds of entozoa are not parentless animals, and that they some- 
how find their way into the body they inhabit, from without. The lowest of the 
infusoria are of fixed and determinate species ; and Ehrenberg states that even the 
minutest monads possess a complicated organization. It may be asked, concerning 
both them and the entozoa, why, if they ever arise spontaneously, should they be 
furnished with a generative apparatus ? Again, some of the entozoa abound in 
certain places, and strangers coming to those places appear to contract them there. 
The dracunculus was thought by the soldiers in India to be communicable from 
person to person, as the itch insect, and the chigoe, to both of which it has some 
analogy, certainly are. The infant filaria probably creeps in through the skin 
without causing any noticeable pain. Even that monster among the entozoa, the 
tape- worm, invades the bodies of those persons who visit the countries to which 
it belongs. I told you before that, when tape-worm occurs in Germany, it is 
always the taenia solium; when in Switzerland, almost always the taenia lata. 
Now the celebrated Soemmering was afflicted by one of these beasts ; and he was 
by birth a German : yet the worm that he voided was of the foreign species, the 
taenia lata. He had resided, however, for some time in Switzerland ; and there, 
we can scarcely doubt, he caught the ovum, or the young one, of the parasitic 
animal. Mr. Abernethy once told me the following curious story : — A shepherd 
had to drive a flock of healthy sheep to a distant part of the country. The journey 
occupied two or three days. On the road one of the animals broke its leg, and 
was carried the rest of the way on horseback. All the flock, except this hurt 
individual, was turned for one night into a marshy pasture. The broken limb 
was set, and the patient got well; and was the only one of the whole flock that 
did not subsequently become affected with the rot ; the only one that escaped 
having flukes in its liver. Is it not presumable that the ova of these parasites 
were swallowed with the herbage cropped by the sheep in the damp meadow? 
The germs of the entozoa which dwell in closed chambers, and within the' solid 
viscera of the body, are probably carried thither by the blood. 

Upon the whole, we may reject the hypothesis of equivocal generation, and 
fall back upon the Harveian axiom, taken in its most extended sense, of omne 
vivum ex ovo. If I have digressed somewhat in order to set before you the 



852 



INTESTINAL WORMS. 



grounds of my own belief in this matter, the interest and importance of the sub- 
ject must be my excuse. 

What I have further to say will relate exclusively to the intestinal worms of the 
human body : their predisposing causes ; the symptoms they occasion ; and the 
modes of getting rid of them. 

However much we may be in the dark as to the exact mode in which these 
parasites reach their habitations, we do know something of the circumstances 
that appear to favour their production and multiplication. They certainly prevail 
most in persons who, from whatever cause, are weak and unhealthy; and par- 
ticularly in scrofulous children. There are, however, many exceptions to this : 
they are not uncommon in individuals who are robust and vigorous. Intestinal 
worms, of all kinds, are more abundant in some situations than in others ; espe- 
cially in places that are low and moist. They are accordingly very frequent in 
Holland, and in some parts of Switzerland. Wherever there is much debility of 
the digestive organs — in leucophlegmatic habits — in persons who secrete habit- 
ually a large quantity of mucus — worms are apt to congregate. The children of 
the Negroes in the West Indies are wonderfully infested by them. 

It more concerns us to inquire into the general symptoms, through which the 
existence of worms in the alimentary canal may be ascertained, or suspected. 

Those symptoms are very multifarious; and, for the most part, very equivo- 
cal. I know of none that can be reckoned certain or pathognomonic, except the 
actual appearance of one or more of the animals, or of portions of them, in the 
excrements of the body. Yet that they do give rise to a variety of morbid phe- 
nomena — which morbid phenomena are, however, liable to be produced by other 
causes also — there can be no question. 

The most common of these are well known to all nurses and old women ; 
such as colicky pains, and swelling of the belly ; picking of the nose, in conse- 
quence of itching and irritation there ; itching of the fundament ; a foul breath ; 
grinding of the teeth during sleep ; a variable and capricious appetite, sometimes 
voracious and insatiable, sometimes none at all ; and irregular bowels. 

Worms sometimes occasion strange, and even severe, nervous symptoms, 
explainable upon the principle of the reflex office of the spinal cord. We con- 
clude that the symptoms are owing to worms in such cases, because they cease 
when the creatures are got rid of. Some examples of this I have already noticed. 
Tims Dr. Elliotson's infant patient lost a chronic cough upon the expulsion of 
the live larvae of the common fly. Bremser gives a very similar case. A child 
of eleven, afflicted with taenia, had a troublesome dry cough. It was observed 
that the cough was suspended for two months, just after a very large portion of 
the worm had been brought away by anthelmintic medicines. This kind of coin- 
cidence happened, not once only, but three or- four times; and at length, when 
the whole of the worm had come away, the cough was permanently cured. I 
mentioned, some time ago, the frequent association of intestinal worms with epi- 
lepsy, which is then of the eccentric form : and I stated that a certain nobleman 
voided some kind of worm (a tape-worm, I think) from his bowels, and was 
thenceforward free from epileptic fits, under which he had long laboured. A 
curious circumstance, illustrating the fact that irritation of the mucous membrane 
of the alimentary tube may affect distant parts, is quoted by Dr. Joy from Albinus. 
A soldier received a wound, which led to the formation of an unnatural anus, in 
front of the abdomen, and in the track of the colon. Through this opening the 
mucous membrane of the bowel sometimes protruded; and whenever it was out, 
and exposed to the contact of cool air, the patient began to cough; and continued 
to do so till the mucous surface was warm again. Partial palsy, amaurosis, 
aphonia, and other nervous symptoms, occasionally depend upon the presence of 
worms in the intestines.* 

* [Dr. Schleifer, in the Austrian Weekly Journal of Medicine, relates the case of a child, 
nine years of age, who became dumb, after suffering in early life from cutaneous eruptions, 
engorgement of the glands, &c. The loss of hearing was attributed chiefly to a fall, and 



THREAD -WORMS. 



853 



But let us examine into the symptoms which are more or less proper to par- 
ticular species of intestinal entozoa; and into the treatment which they severally 
require. 

A variety of symptoms are ascribed to the ascaris lumbricoides. Dr. Bailiie 
says that the most characteristic are a tumid belly, emaciated extremities, offen- 
sive breath, and a deranged appetite. To these may be added colicky pains of the 
abdomen. When these animals get out of the small intestines, and ascend into 
the stomach or oesophagus, they may occasion pain, nausea, vomiting, even con- 
vulsions. They have caused death, as I mentioned before, by crawling into the 
biliary ducts, and into the chink of the glottis. Sometimes, on the other hand, 
they emerge, unexpectedly, from persons who had received no previous notice of 
their presence within. 

This, the commonest parasitic tenant of the human bowels, is also a trouble- 
some one to eject. A great variety of anthelmintics have been cried up as suc- 
cessful against it; but brisk purgatives, and bitter medicines in the intervals, have 
the best evidence in their favour. These animals seem not to like steel ; and my 
own plan of assailing them is that of purging the patient from time to time by 
calomel and jalap, and administering, three times a day, some preparation of iron ; 
the sulphate, or the muriated tincture. I believe that most of the patent worm- 
meclicines consist of mercury, jalap, and scammony, given in strong doses. The 
fetid drugs, assafetida, galbanum, valerian, are often used. Cowhage, also, the 
dolichos pruriens, which is supposed to tease the skin of the parasite no less than 
that of the human worm ; and tin-filings, which are thought to bruise or lacerate 
the offenders, are favourite remedies with some persons. I have never tried them. 
The oil of turpentine I have not found so successful in expelling this species of 
ascaris as I shall presently show you that it is against the tape-worm. Croton 
oil has been much commended, either given by the mouth or rubbed upon the 
abdomen. Common salt, coloured by cochineal, and exhibited every morning in 
half-drachni doses, was found by Dr. Rush to be very successful. 

The symptoms produced by the ascaris vermicidaris are itching and irritation 
about the anus, especially in the evening, and aggravated by the warmth of the 
bed, and by whatever overheats the body. I would refer you to a paper by Dr. 
Heberden on this subject, in the first volume of the Medical Transactions. The 
case he describes is the more valuable, as it was related to him by a physician 
who was all his life plagued by these thread-worms. Generally, however, they 
infest children ; and become fewer, and at length disappear, as childhood passes 
into youth. When they do accompany life through its several stages, although 
they are a source of serious annoyance and suffering, they do not appear to shorten 
the duration of the patient's existence. 

To introduce at one end of a tube, several yards long, substances which are 
intended to act upon animals that live quite at its other end, would be a very 
round-about course. Whether a purgative effect, or a specific destructive effect, 
be the object, enemata are preferable to medicines given by the mouth. Bitters 
offend and destroy these little worms. I have relieved many patients from their 

treated accordingly. The child became emaciated, pale, with a dark-leaden appearance of 
the contour of the eyes. The tongue was white and loaded, the breath offensive, and the 
abdomen tumid and hard. The museles of the face were in constant motion, and the pa- 
tient moaned incessantly. Dr. S. suspected the presence of worms, and treated the patient 
accordingly. In three weeks, eighty-seven lumbrici were discharged, and, during five 
weeks, immense quantities of ascarides. At the end of the sixth week, the child had re- 
covered his hearing and speech. 

In the Journal of Medicine and Surgery of Paris, for April, 1844, a case is quoted, from 
the Gazette Medicales of Dijon, of a young man, nineteen years of age, who was attacked 
with all the symptoms of acute pleurisy: chil!, followed by fever; severe pain in the left 
side; difficult, jerking respiration ; paroxysms of dry cough, which occasioned the patienl 
to scream out, &c; all of which symptoms promptly disappeared after the discharge of 
seventy-five lumbrici.-— C] 



854 



TAPE-WORMS. 



tormentors by prescribing simply the infusion of quassia as an injection. To- 
bacco clysters are praised; but the remedy is a hazardous one. Dr. Darvvall 
says of an enema composed of half an ounce of the muriated tincture of iron 
mixed with half-a-pint of water, " there are few cases so obstinate that this will 
not suffice to overcome." Lime-water, injected into the rectum, forms another 
effectual remedy for ascarides, and (as pharmacologists love to speak) a rather 
elegant one. 

Thread- worms may be scooped out of the rectum with the finger. Old women 
fish for them with a piece of fat meat, or a candle, wherewith the entangled worms 
are drawn out of the bowel. Perhaps, in troublesome cases, the plan laid down 
by Martinet is as good as any. He recommends three successive injections: the 
first merely purgative; the second specific (common salt in solution, cold vinegar 
and water, lime-water, some bitter infusion); the third, oleaginous and soothing. 
Oil often allays the itching. This teasing symptom may sometimes be quieted 
by applying a towel, wetted with cold water, to the fundament, while in bed. 

With some means of this kind for expelling the worms, appropriate measures 
should be combined for improving the general health. 

I know of no signs by which the presence of the tricocepkalus dispar is 
revealed ; and I am equally ignorant of any remedies for it. 

That a tape-worm is within, we know when the joints of it are voided. 
Numberless symptoms have been ascribed to this huge internal parasite. The 
following are probably the most distinctive. Uneasy feelings in the epigastrium, 
which often abate or are removed by eating ; the appetite generally craving, but 
sometimes bad ; itching of the nose and of the anus ; nausea ; colic : giddiness ; a 
sour breath. Less frequently loud borborigmi occur ; and sometimes convulsions. 

Louis has watched and recorded, with his accustomed minuteness, the symp- 
toms of ten cases, in the wards of La Charite. Seven of the patients were males, 
and three females. The youngest was a boy of twelve, the son of another of the 
patients; the oldest was seventy-four. Most of them were in comfortable cir- 
cumstances, and had been habitually well fed. The greater number of them had 
for some time been passing fragments of tape-worm, with their stools, in their 
clothes, and in their beds. In one of the cases the articulations had been twice 
only detected in the stools, and each time upon the operation of a purgative. 

In all the patients but two, the other symptoms commenced when the evacua- 
tion of the fragments commenced. This renders it probable that the worms begin 
to give annoyance when they get into the large intestine. The temporary relief 
that results from the expulsion of portions of the animal strengthens that supposi- 
tion. The case is mentioned in the Medico- Chirurgical Journal of a man who 
was in the habit of freeing himself from large fragments of tape-worm by intro- 
ducing a stick into his rectum, and twisting the worm round till it broke. 

The chief symptoms observed in Louis's cases were colicky pains of the abdo- 
men ; itching of the anus, and of the end of the nose ; uneasiness in the epigas- 
trium ; and deranged digestion and appetite. 

Pain in the abdomen occured in all the instances: but it differed in different 
cases, both in degree and in kind. It was intermittent; and mostly felt towards 
the flanks. 

There was itching at the margin of the anus in seven of the ten cases ; itching 
of the nose in four. With one exception, only, itching was present in one or the 
other, or in both of these situations. 

The appetite was craving in one patient; unaffected in four; variable or bad in 
all the rest. In all, slight emaciation was observed. In all, the pupil of the eye 
was of its natural dimensions. This is noticed, because dilatation of the pupil 
has been set down as one of the symptoms of taenia. 

Louis thinks that the following combination of symptoms indicates with tole- 
rable certainty the presence of some kind of worm in the intestines. Pain in the 



TAPE-WORMS. 



855 



belly ; colic of various degrees of intensity, unaccompanied by diarrhoea ; itching 
about the anus, and at the end of the nose. If pains in the limbs, lassitude, and 
nervous symptoms exist also, the diagnosis is strengthened. 

We have a very effectual remedy for taenia — at any rate for the tape-worm of 
this country — in oil of turpentine, given in large doses. The anthelmintic virtues 
of this substance were not generally known till a paper on the subject, by Dr. 
Fenwick, of Durham, was published, in 1811, in the Medico- Chirurgical Trans- 
actions. A sailor, plagued by this parasite, had noticed that large fragments of 
the worm were passed whenever he had swallowed an unusual quantity of raw 
gin. Thinking that a stronger spirit might have a stronger effect upon his inter- 
nal enemy, he tried a glass of turpentine, which completely cured him. This 
practice was then taken up by some unprofessional persons who gave turpentine, 
with similar success, in several cases. At last Dr. Fenwick, in conjunction I 
believe with my friend Dr. Southey, investigated the subject; and when they had 
satisfied themselves of the value of the remedy, the result of their inquiries was 
communicated by Dr. Fenwick to the late Dr. Baillie, in a letter which was read 
before the Medical and Chirurgical Society. But there is nothing new under the 
sun. Fifty years ago, Mr. Maiden, in the Memoirs of the London Medical 
Society, recommended the same remedy, in the same doses, for the same purpose. 
But his recommendation had been neglected, or forgotten. 

The dose of turpentine is from half an ounce to two ounces. It may be given 
in combination with castor oil ; or castor oil may be administered afterwards to 
assist its purgative effect. It should be taken in the morning, fasting : and no 
drink should be admitted into the stomach until the medicine begins to operate, 
lest sickness and vomiting should be provoked. The worm generally is voided, 
dead, within an hour or two. 

The inconveniences of turpentine as a remedy are its nasty taste, the sort of 
intoxication it is apt to produce, the distressing sickness it excites in some per- 
sons, and the strangury it sometimes occasions. This effect of it, however, is 
less common from large than from small doses of the oil. The bowels should be 
kept open with castor oil, so long as the urine retains the violet smell, which 
indicates the presence of the turpentine in the circulation. 

Upon the continent a celebrated empyreumatic oil, called Chabert's, is in great 
repute. It contains turpentine ; but is still more nauseous than it. One part of 
the empyreumatic oil of hartshorn is mixed with three parts of oil of turpentine. 
After the mixture has stood for three days, three-fourths of it are to be distilled over, 
in glass vessels, by means of a sand bath. Chabert was a veterinary surgeon, 
and had used this remedy with remarkable success upon domestic animals, cows, 
dogs, and sheep. Bremser, after testing its safety by taking it himself, adminis- 
tered it, he tells us, to no less than 500 individuals troubled with taenia. Among 
these were two children, a year and a half old. He found it both a powerful and 
a permanent cure. Of the whole number treated there were but four who required 
a second course of the remedy. It seems to kill both the worms and their ova. 
The dose is two teaspoonfuls, night and morning, until four or six ounces r^ave 
been taken ; a purgative being from time to time interposed. If that dose pro- 
duces any confusion of head, it must be diminished. 

Bremser admits that this curative process is tedious, but affirms that, on the 
other hand, it is safe, and but little inconvenient. When the patient has continued 
free from any symptoms of tape-worm for three months, he concludes that the 
cure is absolute. Other practitioners agree with him in attesting the efficacy of 
this oil ; but are not so confident about its perfect safety and convenience. 

Another great remedy is the bark of the pomegranate-root. This is at least as 
old as the time of Celsus. It has long been employed in India. Its value has 
only been recently appreciated in France ; and in this country it is not much used, 
I believe, even yet. You may read a very instructive account of its effects in a 
paper communicated to the Medical and Chirurgical Society by Mr. Breton. He 
boiled two ounces of the fresh bark of the root in a pint and a half of water, till 



856 



TAPE-WORMS. 



the decoction was reduced to three quarters of a pint. Two ounces of this, cold, 
he gave to a patient who had tape-worm, and repeated the dose every half hour 
until four doses had been swallowed. About an hour after the last dose, an entire 
taenia was voided alive. 

The bark dried in the sun he found still more active. A stout man forty years 
old, took a decoction prepared in the same way as the former, only with the dried 
instead of the fresh bark. Three hours after the first dose, a live tape-worm 
came away, nineteen feet two inches long. The medicine thus prepared seemed 
to be too strong; the patient was sick, giddy, and trembling for several hours. 
He, also, had taken four doses. 

To two boys, of seven and ten years of age, he began early in the morning to 
administer one ounce of a decoction made of half the previous strength, every 
half hour, for six times ; and then stopped. In the middle of the day he resumed 
the medicine in half-ounce doses. Giddiness and faintness soon came on ; and, 
about five o'clock, each of the patients passed a taenia of the solium kind. 

A scruple of the powder was given, mixed with water, every hour for five suc- 
cessive hours, to a boy of nine. Forty minutes after the last dose a living taenia 
was expelled. 

The same quantity was given to a girl, ten years of age ; beginning at eight, 
and repeating the dose hourly till twelve o'clock. At twenty-four minutes past 
one she voided a living taenia lata; and the next morning, at nine o'clock, a dead 
taenia solium. This curious case shows that the two species may exist in the same 
person at the same time. 

Mr. Breton relates other examples, but those which I have cited are quite suffi- 
cient to demonstrate the power of this substance. The bark appears to act upon 
the worm as a poison. In tepid water taeniae will live for several hours. When 
they are plunged into the aforesaid decoction, they writhe and manifest great un- 
easiness. Between the first dose of the medicine and the expulsion of the worm, 
the shortest period appears to have been three hours, the longest twenty-five. 

Louis's ten cases, before referred to, were all treated by a nostrum called the 
potion of M. Darbon. It proved successful in all. Eight or ten ounces of it were 
taken in the morning, before breakfast ; and the cure was accomplished by that 
single dose. It is said to be quite safe, to have no very decided taste, and to cause 
no further inconvenience than a slight colicky feeling, and uneasiness in the epi- 
gastrium, less than is produced by many a purgative: and even these sensations 
were probably owing to the movements of the worm ; for when, after the lapse 
of four months, the dose was repeated, it was followed by no inconvenience at all. 
The medicine is not strongly cathartic, and sometimes requires the aid of a lave- 
ment. In each of these cases the expelled taeniae were apparently dead. Their 
heads were detected in the evacuations : in one instance seven heads were seen. 
Louis says that within a few days at furthest after the discharge of the worms, all 
the previous symptoms of their presence ceased ; and the patients improved in 
respect to appetite, digestion, complexion, flesh, and strength. They all remained 
well four months afterwards, and then the potion was again administered ; but it 
brought away no more worms. Some of the patients, who had previously tried 
other modes of cure, had never enjoyed so long an interval of freedom. 

Various other remedies have been employed, and employed with' more or less 
success. One of them, the root of the male fern, formed the basis of a nostrum, 
called Madame Nouffer's, which was so highly thought of, that in 1776 the King 
of France gave that lady some hundred pounds sterling for the secret of its com- 
position. I think, however, you will find the oil of turpentine equal to the cure 
of tape-worm in most instances. Should it fail, or should circumstances forbid its 
use, I would advise you to resort to the bark of the pomegranate root. It seems 
probable that M. Darbon's remedy, if its nature were divulged, would supersede 
all others. 



INFLAMMATION OF THE LIVER. 



857 



LECTURE LXXV. 

Diseases of the Liver. Acute Inflammation. Jibs cess of the Liver. Causes and 
Treatment of Acute Hepatitis. Chronic Hepatitis, Jaundice. Its Symptoms, 
Causes, and Species. 

From the alimentary canal I go to the other organs directly or indirectly con- 
cerned in the digestion and assimilation of our food. And, first, let us look at that 
large gland, the liver, of which the main office, so far as we can perceive, is the 
secretion of bile. 

The liver is liable to various forms of disease : but it is not so frequently in 
fault as many would have us believe. It is often blamed most gratuitously and 
unjustly. 

The researches of Mr. Kiernan, recently published in the Philosophical Trans- 
actions, have paved the way for a better understanding in future of. its pathology. 
If I did not feel myself too much circumscribed by the remaining limits of this 
course of lectures, I should be glad to attempt to assist you in construing Mr. 
Kiernan's somewhat difficult and very valuable paper. But doubtless you are 
made familiar with the anatomy of the organ, as described by him, in other lec- 
tures : and I must content myself with noticing, as we go along, one or two points, 
in respect to its morbid appearances, concerning which, before Mr. Kiernan took 
the subject up, great mistakes prevailed, even among the most celebrated patho- 
logists. 

I shall follow the usual order, and consider first, inflammation of the liver, 
which may be either acute or chronic. 

These are, both of them, diseases that are much more common in warm climates 
than here. 

Of well-marked acute hepatitis the symptoms are fever, with pain and a sense 
of tension in the right hypochondrium, inability to lie on the left side, difficulty of 
breathing, a dry cough, vomiting, hiccup. 

You will not find all these symptoms present in every case : yet they are all 
worth attending to. 

, The pain is sometimes sharp and pricking, like a pleuritic stitch: sometimes 
dull and tensive. In the former case the peritoneal covering of the gland is sup- 
posed to be affected; in the latter its parenchyma. The pain sometimes extends 
to the right clavicle and to the top of the right shoulder. This circumstance was 
noticed by Hippocrates; and I have referred to it before as a good example of 
what are called sympathetic sensations. The existence of this pain makes it pro- 
bable that the inflammation affects the convex surface of the liver. Occasionally 
the left shoulder is painful : the left lobe of the liver being involved in the disease. 
The pain in the right side is aggravated, often, by the movements of the diaphragm 
in respiration ; and this explains the embarrassment of the breathing, and the short 
dry cough. Why the patient cannot well lie on the left side is obvious enough: 
all the connections of the inflamed organ are then put upon the stretch by its 
weight. There are, however, some exceptions to this rule. On the under or 
concave part of the liver lies the pyloric extremity of the stomach ; and thatviscus 
often sympathizes with the hepatic inflammation : nausea and vomiting occur; and 
hiccup. The thoracic symptoms on the one hand, or the stomach symptoms on 
the other, may be expected to predominate, according as the convex or the con- 
cave surface of the organ is chiefly the seat of the inflammation. 

The situation of the pain, the cough, the short and shallow breathing, used to 
puzzle the older observers : and they confess their occasional inability to deter- 
mine whether the inflammation was situated in the lower lobe of the right lung, 
or in the liver. But now-a-days we need have no difficulty in making the diag- 



858 



INFLAMMATION OF THE LIVER. 



nosis. The ear will tell us, if we employ auscultation and percussion, whether 
the contents of the chest or of the belly are suffering : and my own experience 
has taught me that sharp pain, with feverishness, occurring in the debateable 
ground of the right side, denotes pleuritic inflammation far more often than it 
denotes hepatic. 

Jaundice is an occasional, but by no means ^necessary effect or accompaniment 
of hepatitis, whether acute or chronic: and, therefore, what I have to say of that 
symptom I shall give under a separate head. 

Acute hepatitis may terminate in resolution; or it may terminate in diffused 
suppuration ; or, what is more usual, in the formation of a circumscribed abscess, 
or of abscesses, in the liver. In this climate we do not often meet with hepatic 
abscesses; but they are very common in hot countries: and some of the most 
interesting events of the disease have relation to the progress of these collections 
of matter. When they approach the surface of the liver, adhesions generally 
take place (in virtue of that conservative principle of which we so constantly dis- 
cern the working) between the diseased organ and the neighbouring parts. If no 
such adhesion occurred, the matter would at length burst into, the cavity of the 
peritoneum ; and this does sometimes happen. The peritonitis, which is thus 
suddenly set up, is almost fatal. I referred, however, in a former lecture, to one 
instance in which it was recovered from. Sometimes the adhesion is effected 
between the liver and the parietes of the abdomen, and the abscess points exter- 
nally, and may be opened by the surgeon. Such a case occurred in my neigh- 
bourhood last year. Sometimes the liver glues itself to the stomach, or to the 
intestines; and then the abscess breaks into the alimentary tube, the matter is 
evacuated by vomiting, or by stool : and all goes on tolerably well again. In 
other instances the agglutination is to the diaphragm, which is perforated, and the 
pus makes its way into the sac of the pleura, or through the lung to the bronchi, 
and so out by the mouth. I have seen three examples of this myself. In one 
the abscesses originated in the formation and degeneration of hydatids in the liver; 
and the patient (a woman, she was under Dr. Macmichael's care in the Middlesex 
Hospital) spat up quantities of yellow fluid, consisting partly I suppose of pus, 
but chiefly of pure bile. The examination of the dead body ultimately demon- 
strated the nature of that case. The second of the three patients got well : yet I 
cannot doubt that, bating the hydatids, the disease was essentially of the same 
kind. It also occurred in a woman, whom I admitted into the hospital. She 
was a kitchen-maid at the Thatched House Tavern in St. James's Street; and 
she had received a violent blow at the back part of the right hypochondrium. 
This was followed by pain there and by fever ; and at length she began to have 
cough, dyspnoea, and expectoration. She brought up an abundance of frothy 
mucus of a bright yellow colour: not at all resembling the rusty sputa of pneu- 
monia, but exactly of the tint which bile would give to it. At the same time 
large crepitation could be traced from the bottom to the top of the right lung. 
I fully expected that this woman would die : but by degrees the yellow expecto- 
ration ceased, all the auscultatory signs gradually disappeared, and she recovered 
perfectly. 

It is plain that in such instances as this, there must be adhesion of the lung 
to the diaphragm also: but cases have occurred in which the matter burst into the 
cavity of the pleura, and presently destroyed the patient by suffocation. 

The event of the third case is still sub judice. A gardener, forty-five years 
old, was attacked, four weeks before he came under my care in the hospital, with 
severe pain in the right loin. Just at the edge of the short ribs, and not far from 
the vertebral column, on the right side, I found a large elastic swelling, very 
tender, and of a bluish red colour. As the patient's urine was most remarkably 
loaded with amorphous deposits, my first suspicions turned towards the kidney. 
It soon, however, became evident that, although the tumour was below the dia- 
phragm, the parts above that muscle were involved in the disease. The right 
half of the thorax was dull to percussion ; no vesicular breathing was audible 



INFLAMMATION OF THE LIVER. 



859 



there, but some scattered crepitation and bronchophony. Four days subsequently 
to his admission the patient began, during an effort of coughing, to discharge 
almost in a stream, from his mouth, a considerable quantity of gray, pultaceous 
fluid, of the consistence of gruel, and horribly foetid. Altogether the amount of 
matter thus expectorated was estimated at two quarts. The pain then ceased ; 
and the swelling was observed to be less. After three days more, it was deemed 
proper to puncture the tumour, and matter was let out having precisely the quali- 
ties of that which he had ejected through the mouth. The patient remained 
eleven weeks in the hospital, the expectoration becoming' less unnatural, and the 
discharge from the abscess gradually diminishing. He then chose to depart. 
Some months afterwards he applied for re-admission, and again staid with us a 
week or two. His health had much improved during the interval: but the 
wound in his back was still open, and he still continued to expectorate somewhat : 
and yellow bile was frequently to be seen, both on the dressings which covered 
the puncture, and in the vessel into which he spat. I think it probable that this 
man may eventually recover, at the expense, however, of a permanently damaged 
lung. 

Rigors occurring during the progress of hepatitis should make us suspect that 
suppuration is taking place: if the pain is thenceforward mitigated, or exchanged 
for a sense of weight, and hectic fever sets in, we may be tolerably certain that 
pus has formed. 

Of the several courses taken by an hepatic abscess, that towards the surface of 
the body is the most common ; and it is the only one with which we are able to 
interfere. And the chief thing we have to look to, is not to interfere too soon. 
The adhesion of the inflamed organ to the wall of the abdomen is the indispensa- 
ble condition, not of success only, but of safety, where the question arises of 
puncturing the tumour. Without such adhesion the pus will be transferred from 
the cyst to the cavity of the peritoneum ; or if the abscess be not reached by the 
scalpel, that cavity will be laid open. Now it is not easy to ascertain whether 
there be adhesion or not. Certainly the operation ought not to be attempted until 
the parts above the abscess are very thin, and are verging to a point ; and even 
then, unless there were some distinct purpose, besides that of saving a little time, 
some urgent distress or danger to relieve, I think such abscesses might be more 
prudently left to themselves. Dr. Gregory, of Edinburgh, used to mention a case 
in which, as fluctuation was palpable, and the tumour pointed, it was proposed to 
open it; but the patient died, somewhat suddenly, before the operation could be 
performed ; and inspection of the dead body showed that no adhesion existed. 
Mr. Malcolmson has lately published, in the Medico-Chirurgical Transactions, 
two or three instances of a like kind. These are circumstances which teach us 
to be cautious about recommending the operation. 

A case is recorded of the bursting of an hepatic abscess into the pericardium ; 
another into the vena cava. Facts of this kind constitute mere medical curiosities, 
and have no practical bearing. 

It is clear, both from the size of the organ, and from its situation in the body, 
that an abscess in the liver can never be otherwise than gravely hazardous. Yet 
many recover from them. Much evidently depends upon the manner and direc- 
tion in which the pus seeks a vent. The most desirable road for its exit is one 
which it sometimes takes, but which I have not yet mentioned. It occasionally 
flows out into the duodenum through the excretory ducts of the liver, when these 
happen to have been laid open by the suppurating process. Next to this we 
may hope for its discharge through the adhering parietes of the abdomen ; next 
by a breaking of the abscess into the alimentary canal. The escape of the matter 
through the air-passages is fearfully perilous ; and its entrance into the shut serous 
sacs, or into the great blood-vessels, almost necessarily fatal. 

I have spoken of abscess in the liver, as an event of acute inflammation of that 
organ. Such inflammation is apt to arise, in tropical countries, after exposure to 
cold. In any climate it may be excited by a blow, or other mechanical injury. 



860 



ACUTE HEPATITIS. 



But abscess in the liver seems to be far more frequently the result of other remote 
causes. You will call to mind those collections of matter which form in the liver, 
as well as elsewhere, in consequence of suppurative phlebitis. There is, more- 
over, an acknowledged connection between hepatic suppuration and dysentery. In 
hot climates the two are often found coincident. It has commonly been thought 
that, in these cases, the affection of the liver happens first, in the order of time ; 
that the hepatic disease, interfering with the freedom of the portal circulation, 
occasions congestion of the submucous capillary blood-vessels, and so disposes 
the membrane to take on inflammation under the influence of any slight exciting 
cause. In some recent lectures, however, delivered before the College of Physi- 
cians, Dr. Budd has proved, by a careful collation of a large number of authentic 
instances, that the relation of these two morbid conditions to each other, is 
exactly the reverse: that the dysentery is the primary disorder, and the hepatic 
abscess the secondary; the link of connection between them being the same as . 
between suppurative inflammation of a vein, and the formation of pus in parts 
more or less remote. The blood, in its return through the veins which are tribu- 
taries of the vena porta, carries with it, if hot pus, yet some vitiating ingredient 
from the inflamed membrane: and this vitiating ingredient provokes inflammation 
in the capillary vessels of the liver. 

This, to the best of my knowledge, is a new, and certainly it is an important 
view of the pathology of hepatic abscess. I trust that, ere long, Dr. Budd will 
lay before the public the evidence upon which it is founded. 

Acute hepatitis, when it occurs, requires vigorous treatment in the outset. Our 
object is, if possible, to prevent suppuration. Blood should therefore be freely 
taken from the system by venesection, and from the neighbourhood of the in- 
flamed part by leeches. I will not weary you by going over the old ground that 
we have so often trodden already, nor repeat observations which have been many 
times made respecting the methods, and the requisite amount, of this great anti- 
phlogistic remedy. Depletion of the portal vessels may also be indirectly 
obtained by purgatives ; especially by such purgatives as produce copious and 
watery stools. The neutral salts are therefore proper in this disorder. It may 
be, as some suppose, that they operate beneficially, as counter-irritants, upon the 
duodenum; but their effect in draining the veins that feed the vena porta, and 
thereby relieving the hepatic congestion, is more obvious and more intelligible. 
These saline medicines should be much diluted ; and their action may be quick- 
ened, if that be necessary, by adding the infusion of senna. 

After blood-letting has been duly performed, and the force of the inflammatory 
action has been broken, blisters may be applied to the right hypochondrium : and 
I believe that repeated blistering is more serviceable than a single blister kept 
open by savine ointment. 

Some difference of opinion prevails among medical men in regard to the em- 
ployment of mercury in the outset of acute hepatitis. I cannot pretend to offer 
you the results of my own observation on this point, but I find that the best 
authorities, among those who have had to treat the disease in hot climates, are 
against its use at the very first, as being stimulating to the liver. I suspect that 
this is a piece of theory: but at all events, after the first violence of the inflam- 
mation has abated, that remedy is not to be omitted, either in the acute, or in the 
chronic form of the disorder, to be mentioned presently: only in the one case it 
should be so administered as to affect the system as speedily as possible; in the 
other it is to be introduced with a slowness which bears a proportion to the pace 
of the disease. 

When suppuration has taken place, or is unavoidable, when the patient ceases 
to complain of pain, but has in its stead a feeling of weight in the hypochon- 
drium, and becomes distinctly hectic, a corresponding change must be made in 
the treatment. Active depletion is no longer admissible ; you must sustain the 
strength by a more nourishing diet, and prescribe some tonic remedies; the sul- 
phate of quina, with sulphuric acid ; or the nitro-muriatic acid, which enjoys a 



CHRONIC HEPATITIS. 



861 



considerable repute, greater perhaps than it merits, for the relief of liver com- 
plaints. 

Acute inflammation of the liver is apt to degenerate into chronic. Chronic in- 
flammation may also arise under the circumstances that give birth to the acute 
form. Chronic hepatitis, again, is not unfrequently produced by the presence of 
specific disease in the liver; of carcinoma; of scrofulous tubercles. Melanosis 
and hydatids are both of them of common occurrence in the same part; and they 
may give rise to symptoms, or they may not: and when these morbid conditions 
do declare themselves by external signs, those external signs are very much the 
same as belong to chronic hepatitis. The precise diagnosis is exceedingly ob- 
scure ; the symptoms point distinctly to the liver as the seat of the disorder; but 
as to its exact nature, we must often be content with probabilities alone. 

The symptoms of chronic hepatitis — or of the chronic forms of disease to 
which I have alluded, when they show themselves by symptoms — are (I give 
you them in Cullen's words) "some fullness and some sense of weight in the 
right hypochondrium ; some shooting pains felt at times in that region ; some 
uneasiness or pain felt on pressure in that part; some discomfort from lying upon 
the left side; perhaps some degree of jaundice; and sometimes a certain amount 
of fever combining itself with more or fewer of these symptoms." In short, 
they are just the symptoms of acute hepatitis occurring in a minor degree. 

Chronic affections of the liver are sometimes attended with an increase, and 
sometimes with a diminution, of its size. When it is augmented in bulk, its 
place and enlargement may be ascertained by palpation and percussion ; nay, 
the magnified gland may sometimes be seen, extending beyond its proper situa- 
tion in the hypochondrium, and passing far down into the abdomen. I have 
known the liver reach to the right groin: and when its left lobe is affected, it 
will sometimes stretch across towards the lower part of the left side of the belly. 
On the other hand, the liver may shrink into a much smaller space than it natu- 
rally occupies. These small livers are usually hard. Interfering more with the 
portal circulation than many enlarged livers do, they are more frequently attended 
with dropsy of the peritoneum. 

The *« hobnail" liver, the cirrhose of modern French writers, is nodulated as 
well as hard. The irregularity of its surface may be so great as to be percepti- 
ble to the touch. I fully described this condition of the liver when I was upon 
the subject of passive ascites, of which it is the most common cause. 

I mentioned, also, some time ago, the " fatty" liver, so frequently found asso- 
ciated with pulmonary consumption. The liver in this state is soft, enlarged, 
smooth on its surface, and of a buff or tawny colour throughout. Mr. Bowman 
has lately shown that these changes are owing simply to the unwonted abundance 
of certain small granules of fat, of which, in the healthy organ, each lobule con- 
tains a few only. If in a phthisical "patient we find the liver palpably enlarged, 
we may guess that it is encumbered with this interstitial fat: but there are no 
symptoms peculiar to the fatty liver. As to its cure, we are quite helpless:' and 
the same may be said of the hobnail liver, as well as of all those forms of dis- 
ease in which the organ is loaded with specific deposits. 

Dark masses of extravasated blood are sometimes found interspersed through 
this gland, and then, by an absurd perversion of language, the patient is said to 
have had "apoplexy" of the liver. 

The same causes which produce acute hepatitis, acting in a less intense de- 
gree, will excite chronic inflammation of the same textures. Intemperance, also, 
and particularly the habitual and excessive use of alcoholic liquors, certainly tends 
to generate hepatic inflammation, especially in its more chronic form. We see 
this even here, and it is still more strikingly perceptible in warm climates, as you 
may learn by reading the works of those persons who have had experience of 
the diseases of India. Dr. William Ferguson, for example, who was for some 
time chief of the medical staff of the windward and leeward islands in the West 



862 



CHRONIC HEPATITIS. 



Indies, observed that there was a regular increase and aggravation of these chronic 
affections of the liver among the troops after they received their monthly pay, 
when they drank great quantities of ardent spirits ; arrack in the East Indies, and 
rum in the West. 

There has long been supposed to be what is called a gin-drinker' 's liver, in 
which a section of that gland presents an appearance very closely resembling the 
section of a nutmeg; and a good deal of useless speculation has been employed 
as to the nature of the change which has taken place in such cases. Mr. Kiernan 
has clearly shown that the nutmeg aspect of the liver is produced by mere con- 
gestion of blood. Congestion of the liver is, indeed, very likely to arise under 
he daily stimulus of distilled spirits, but it arises under various other circum- 
stances besides ; and therefore it is no safe test of the intemperate habits of the 
party. And of this we had sufficient evidence before Mr. Kiernan's observations 
were published. Again and again have I met with the nutmeggy liver, strongly 
marked, when there was reason to believe that the possessor of it had never trans- 
gressed the strictest rules of temperance in drinking: in young persons, for ex- 
ample, of both sexes, who certainly never had been dram-drinkers. Disease of 
the heart is a very obvious, and a very common cause of hepatic congestion. 

You are aware that the congestion occurs under two forms, according as the 
branches of the hepatic vein, or of the vena portae, are gorged. If both these sets 
of vessels are full, the liver is universally red. If the hepatic vein alone be the 
seat of the congestion, then in the centre of each lobule we see a red speck, sur- 
rounded by yellowish matter; the specks are isolated, the yellow colour is 
arranged in a sort of net- work. Whereas, if the portal system be greatly en- 
gorged, the red streaks will be continuous, and the yellow portions hemmed in 
by them, and isolated. I show you these distinctions in some specimens pre- 
pared by Mr. Kiernan himself. 

I should have stated, when speaking of the signs of chronic hepatitis, what is 
singularly true of chronic liver affections in general, that they are apt to be 
attended with much languor and lassitude, and a remarkable depression of spirits; 
and with that sort of dread, and apprehension of impending evil, which I men- 
tioned as being a striking feature of hypochondriasis: the very derivation of 
which term marks its frequent connection with hepatic disorder. There is sal- 
lowness of the complexion also; and sometimes emaciation. 

The same remedies are adapted to the chronic as are proper for the acute in- 
flammation of the liver: the comparative mode of their exhibition, however, 
differs somewhat. 

Blood-letting is not often necessary or advisable, except when more violent 
aggravations than usual of the inflammatory symptoms supervene. Topical 
bleeding, and blistering, are more expedient. 

But the two main remedies to be tried in this complaint are mercury, and the 
saline purgatives, given in small doses, and repeated for a long time together. 
Five grains of blue-pill every night, or every night and morning ; and as much 
of the sulphate of magnesia as will produce one or two watery stools every 
day, for weeks, perhaps, in succession. Patients are not so well content to bear 
this discipline when it is administered in boxes and phials, as physic; but they 
have more faith in the natural mineral waters : so that a residence at Cheltenham, 
or some such place, is exceedingly proper to be recommended in these cases ; 
where the daily use of the waters may keep up a continual drain on the system of 
the vena portae ; and where relaxation from business, the amusements that are 
constantly going on, with change of scene and of society, may contribute to dissi- 
pate the hypochondriacal feelings which are so apt to render the subjects of 
chronic hepatic disease supremely wretched. 

Moderate exercise, in the open air, on horseback and on foot, should be en- 
couraged. There is no doubt that hepatic as well as gastric derangements are 
fostered by sedentary habits. Tepid bathing is another expedient from which 



JAUNDICE. 



863 



benefit may be hoped. In many instances it will be proper to make trial of 
Scott's nitro-muriatic bath. 

Iodine has been thought of much use in certain kinds of hepatic disease ; in 
those kinds especially which are connected with enlargement of the viscus. The 
iodide of potassium; or a mixture of the iodide and of iodine; or some of the 
combinations of iodine and mercury, may be given in such cases : or the unguen- 
tum iodinii compositum, or the unguentum hydrargyri iodidi of the Pharmaco- 
poeia, may be rubbed night and morning upon the hypochondrium. I have not 
seen much benefit from these forms of medicine myself, in such cases ; but they 
are said, by persons of experience and credit, to have been successful in their 
hands. 

Taraxacum is also a drug which has been much employed in liver complaints 
since Dr. Pemberton's book on the diseases of the abdomen was published ; but 
it is very doubtful, in my mind, whether it ever does much good. The Germans 
are very fond of giving the muriate of ammonia in small and frequent doses. 
They have the same belief in the virtues of this salt, in various disorders, as the 
English practitioners have in those of mercury ; and what is curious, they attri- 
bute to it some specific agency upon the functions of the liver. 

In the account which I have now given of the principal diseased conditions of 
the liver, I have not included, nor dwelt upon, all the changes of structure and 
appearance to which that organ is liable. There are various conditions which 
disclose themselves by no intelligible symptoms during life, of which the nature 
has not yet been determined, and of which the cure still remains to be discovered. 
At this advanced period of the course, and with no time to spare, I do not think it 
necessary or right to trouble you with the unprofitable discussion of matters that 
are not strictly practical. 

I have mentioned jaundice as an occasional symptom both of acute and of 
chronic inflammation of the liver. But jaundice is spoken of, in general, as 
constituting, itself, a distinct form of disease. If we consider it in that light, its 
diagnosis is most easy. We have only to look upon our patient to know what is 
the matter with him. But jaundice depends upon various and very different 
morbid conditions ; and looking to those conditions as the true objects of diag- 
nosis, we find that the real nature of a given case of jaundice is often involved in 
very great obscurity. 

Let us first consider the constituent features of jaundice, whether it be regarded 
as a disease or as a sign of disease. They are, yellowness of the skin and of 
the eyes; whitish feces ; urine having the colour of saffron, and communicating 
a bright yellow tinge to while linen. 

The characteristic yellow hue is owing, no doubt, to the presence of bile, or at 
any rate of the colouring matter of the bile, in the circulating blood. And the 
deep tint of the urine is evidently derived from the same source. On the other 
hand, the paleness of the feces is to be ascribed to the want of bile, which always 
exists in healthy and natural excrement. This last symptom is not, however, a 
constant one ; there may be jaundice while bile appears in the stools. I shall 
explain how this is supposed to happen presently. 

It has been made a question how the bile, or its colouring matter, comes to be 
visibly present in the blood, or rather in many of the tissues supplied by the blood, 
and in several of the other fluids of the body. The general opinion, and proba- 
bly the true one, is, that the bile, after being secreted in the liver, is reabsorbed, 
and carried into the circulation, and so conveyed to the surface, and to the parts 
in which the change of colour is observed. This explanation is consistent with 
all the phenomena which we notice in the disorder. 

But another theory has been broached on this subject; first, I believe in this 
country, by Darwin. It has been more recently revived by M. Chevreul, who is 
followed by Mr. Mayo. These pathologists are of opinion that the bile is formed, 
not by the liver, but in the blood : that the office of the liver is to strain off or 



864 



JAUNDICE. 



withdraw the bile from the circulation, constantly, as fast as it is formed ; just as 
the perpetual elimination of urea from the blood appears to be one great purpose 
of the kidneys. They hold, therefore, that jaundice manifests itself whenever the 
due separation of the bile from the blood is suspended or imperfect. Failing of 
its natural vent, this peculiar substance accumulates in the blood, seeks other out- 
lets, is deposited in various places, and, in fact, partly escapes through unaccus- 
tomed channels. They speak of jaundice as a symptom of suppression of bile, 
while others consider it as a sign of retention; using these words, suppression 
and retention, in the sense in which they are applied to the secretion of urine. 
They maintain that the proper function of the liver, the abstraction of bile from 
the blood, may be arrested by alterations of the substance and structure of that 
gland ; or by the obliteration or obstruction of the gall-bladder or ducts, impeding 
or forbidding the removal of the bile already formed ; or by some obscure influ- 
ence of the nervous system upon these organs. They introduce the last kind of 
cause with the view of explaining those cases, which certainly occur, in which 
jaundice is the result of severe bodily pain or strong mental emotion. Nay, on 
their supposition, we might even suppose that the yellowness is sometimes due to 
a spontaneous and unwonted abundance of the elements of bile in the blood : in 
which case we need not wonder that jaundice should go along with perfect integ- 
rity of the biliary apparatus. 

The advocates of the first mentioned supposition are aware of the difficulties 
opposed to its reception, by the occasional absence, even in cases of well-marked 
jaundice, of all organic disease or apparent obstruction to the excretion of the bile. 
They show that in very many cases there is some obvious mechanical obstacle to 
the efflux of the secreted fluid : and in those instances in which none can be dis- 
covered after death, they conceive either that the ducts of the liver had been 
temporarily plugged up by inspissated bile, or a sort of biliary sand — or that they 
were closed for a time, by spasm — or by some morbid condition of the duodenum. 

Now of these two hypotheses, that which ascribes the yellowness to the reab- 
sorption of secreted bile, is, to my mind, the most probable and the simplest: and 
I cannot see that it is attended with more difficulty than the other. But you may 
choose for yourselves between them: and I pass from this digression to a some- 
what closer examination of the principal circumstances noticeable in the complaint. 
Its technical appellation, I should observe, is icterus, which is the Greek name 
for a bird with a yellow plumage, the galbula, or golden thrush ; the sight whereof, 
by a jaundiced person, was death (Pliny tells us) to the bird, and recovery to the 
patient. Various other terms have been applied to the disorder, most of them 
having reference, like jaundice itself (from the French jaune), to the unnatural 
colour. Morbus arquatus, from its exhibiting some of the bright hues of the 
rainbow ; aurigo, from its resembling gold ; and we hear the common people say, 
now-a-days, such a one is as yellow as a guinea. The Latins spoke of it also 
under the title of morbus regius ; why they so called it we learn from the follow- 
ing curious passage in Celsus, giving an account of the pleasant regimen, fit for 
royalty itself, to be adopted by those who labour under the malady. " Peromne 
vero tempus utendum est exercitatione, frictione : si hiems est, balneo; si aestas, 
frigidis natationibus ; lecto etiam et conclavi cultiore, lusu, joco, ludis lascivia, per 
quae mens exhilaretur: ob quae regius morbus dictus videtur." 

The whiteness of the stools I have mentioned as being a very common but not 
a constant appearance. It clearly depends upon the absence of bile. But some- 
times there is bile in the discharged feces, and at the same time the yellow colour 
of the skin and eyes. This probably depends upon the circumstance that some 
branches of the hepatic ducts are obstructed while the others are free ; and thus 
the bile that is secreted is, in part, reabsorbed into the blood, and in part carried 
off* into the intestines. In a former lecture I stated that one of the uses of the 
bile appeared to be that of stimulating the bowels to action ; it is the natural pur- 
gative. Accordingly, in most cases of jaundice, the bowels are costive. But 
neither- is this uniform. In some of the worst cases, wherein the jaundice depends 



JAUNDICE. 



865 



upon hepatic disease, which is connected with disease also of the mucous coat of 
the intestines, there is constant diarrhoea. 

In some instances the yellowness of the skin is at first attended with itching, 
which is occasionally so intolerable as to require the employment of opiates to 
allay it. In most cases there is no itching at all. The bile never fails to appear 
in the urine, which is in itself dark, and when collected in considerable quantity 
in a deep vessel, even black; and which tinges any white substance that is dip- 
ped into it of a bright yellow. The urine which thus sometimes seems black, 
may be proved to derive that appearance merely from concentration of the yellow- 
ness, by pouring a little of it into a shallow white dish, or by diluting it with 
water; when the brilliant yellow tint will become manifest. Bilious sweat 
sometimes occurs, staining the patient's linen yellow. The saliva, in some jaun- 
diced persons, has the same yellow tinge, and a distinctly bitter taste. It has 
been said that the milk of women who are nursing is made yellow in this disorder. 
Dr. Heberden, however, states that he never witnessed this ; and he had known 
a woman with a very deep jaundice upon her, suckle her infant for six weeks 
together with no apparent bad effects upon its health. One man assured him that 
his tears were yellow. You are aware of the vulgar notion, that to a jaundiced 
eye all things appear yellow. It is an old notion, for we find it expressed by 
Lucretius: — ♦* Lurida praeterea fiunt quaecunque tuentur Arquati." Heberden 
was disposed to regard this as a mere poetical fiction. But certainly it is some- 
times, though very rarely, indeed, a fact. Two women, whom he considered, 
however, to be of little credit, told Heberden that objects appeared yellow to 
them. I have been assured of the same thing by a medical man who experienced 
it in his own person. If I do not mistake, Dr. Mason Good saw all things yellow 
when he was jaundiced. Dr. Elliotson has had some very interesting cases of 
this phenomenon. One of his icteric patients declared that objects seemed yellow 
when looked at with one eye, but not with the other; and in the eye that per- 
ceived the yellow tint he observed two large red vessels running towards the 
cornea. And in one or two instances, which he met with afterwards, of yellow 
vision with both eyes in jaundiced patients, he found inflammation, or distended 
blood-vessels in both eyes. This very morning I saw in the hospital a patient of 
Dr. Wilson's, a middle-aged woman, affected with jaundice. She affirms that all 
objects seem yellow to her vision. In both eyes there are several varicose and 
singularly tortuous vessels, proceeding across the sclerotica towards the cornea*, 
and some of them reaching its margin. It seems probable therefore that the oph- 
thalmic vessels, in their natural state, do not permit the colouring matter of the 
bile to pass through them ; but that when they become enlarged by disease, so as 
to admit the colouring particles of the blood, they may also give a passage to the 
yellow colouring matter, which tinges the humours of the eye : and in that case 
the objects seen through the yellow fluids Would appear like those viewed through, 
a piece of yellow stained glass. This is a point which is w.o/fth your attention irb 
future. 

The shades of yellowness are different in different patients. Those who are 
pale and fair present a bright lemon colour. But in those who are florid, or 
whose cheeks and skin are flushed with fever, the tint will more resemble that 
of the Seville orange. Again, if the patient be naturally swarthy, or if his visage 
is livid or dusky through imperfect arterialization of his blood, the superaddition 
of jaundice will give him a greenish hue. These differences result from natural 
or acquired differences of complexion antecedent to the icterus. But sometimes 
the bile that is reabsorbed is vitiated and dark ; and we may have, for that reason, 
as Dr. Baillie has pointed out, cases of green or black jaundice. You will re- 
mark that from whichever cause the green or dark colour proceeds, whether from 
a mingling of the yellowness of the bile with the blueness of lividity, or from 
the circulation of green-coloured bile, such cases are especially unpromising 
cases. 

Icterus depends, as I have said, upon various and different internal causes ? and 
55 



866 



JAUNDICE. 



frequently we cannot determine at all, until death affords us the means of inspect- 
ing the parts concerned in its production, what the precise exciting cause may be; 
even when it is simply mechanical. Any kind of pressure made upon the ex- 
cretory ducts of the liver will produce it; and such pressure may be exercised 
by tumours seated in the liver itself ; or by a scirrhous pylorus; or by specific 
disease situated in the head of the pancreas, of which I have seen several ex- 
amples ; or by a diseased condition of the duodenum : and these possible causes 
of a detention of the bile in its receptacle should always be borne in mind when 
we are investigating an obscure case of jaundice. 

The impediment, in the cases just supposed, is external to the ducts; but tncy 
may be obstructed within, plugged up by inspissated bile, or by a biliary calculus. 
This forms one of Cullen's species of icterus — the icterus calculosus. The con- 
cretion is most commonly situated, I believe, in the ductus choledochus ; some- 
times, however, in the cystic, and sometimes in the hepatic duct. The pain that 
attends the passage of a gall-stone through these ducts is often dreadful. Per- 
haps there is no pain to which the body is subject that is more severe. You will 
not wonder at this, when you consider that through a tube, of which the natural 
size scarcely exceeds that of a goose-quill, there sometimes passes a stone as big 
as a walnut. The common duct has been found so dilated as* readily to admit 
one's finger. Cullen's definition of this species is "Icterus, cum dolore in re-* 
gione epigastrica, acuto, post pastum aucto, et cum dejectione concretionum bili- 
osarum." Now the last of these circumstances, the voiding of biliary calculi by 
stool, may happen over and over again, without its being noticed, and it does not 
help us at all to judge of the nature of the complaint at its commencement, while 
the gall-stone is still in the ducts. With the pain, which is not constant, but 
comes and goes, there are much nausea and vomiting ; and sometimes hiccup ; and 
the matters vomited are usually very sour. The patient is flatulent and dyspeptic; 
languid and gloomy. At length the concretion passes into the intestines; the 
pain suddenly ceases, and all is soon well again. Attacks of this kind, having 
happened once, are very apt to be repeated. 

Now this pain you might readily mistake for the pain of inflammation, were 
it not marked by these two circumstances-r-the absence of tenderness and the 
absence of fever. Pressure, instead of augmenting, usually mitigates it. The 
patient keeps his hand firmly applied to his epigastrium; or. rests, perhaps, the 
weight of his body upon some hard substance placed beneath his stomach. I 
speak now of the beginning of the attack, before there has been much retching; 
for a degree of tenderness of the abdominal muscles is often produced by repeated 
straining and vomiting. The pulse is unaffected, or I should rather say it is not 
accelerated, during the pain : occasionally it is even slower than natural, and the 
skin cold. Though there be no inflammation, rigors may occur; just as they 
sometimes happen when a solid substance — a bougie to wit — is passing through, 
and distending the urethra. 

Nevertheless, inflammation does sometimes arise, and then the pulse becomes 
frequent, and the skin hot, and thirst and headache are complained of, and the 
epigastrium is tender; and if blood be drawn it exhibits the buffy coat. Some- 
times the gall-stone makes , its way,. by ulceration, through the contiguous struc- 
tures, and so is dischargedxnitwardly, or into the bowels. In such cases there 
must have been inflammation. 

As jaundice often occurs wjthout any pain, so a gall-stone may enter and pass 
through the ducts, and produce pain, when there is no jaundice. The cystic 
duct alone may be blocked up, and that portion only of the bile be prevented from 
escaping which is accumulated in the gall-bladder. It is probable that re-absorp- 
tion of the contents of that cistern is not very active. Or a calculus of an angu- 
lar shape may stick in the common duct, and thus impede, without entirely stop- 
ping, the egress of the bile. Dr. Heberden thought that gastrodynia was not 
unfrequently owing to biliary concretions : founding his opinion upon the fact 
that many persons suffer, for months or years, under occasional attacks of epi- 



JAUNDICE. 



867 



gastric pain, which is at last associated with jaundice. But after all, this might 
happen from progressive disease in the stomach itself; and it is a pity that Dr. 
Heberden's views were not fortified by dissections. 

When once a large calculus has forced its way through the natural channels of 
the bile, they remain permanently dilated ; and smaller stones may be afterwards 
voided without pain or other notice of their passage. There are persons who get 
rid of scores of them in this way, during the course of their lives. 

Sometimes a large concretion, after its extrication from the biliary passages, 
lodges in the more capacious intestines, and gives rise to serious obstruction there. 
I mentioned, recently, one case of this kind which had fallen under my own notice. 
But in general the concretions are presently voided with the stools : and they 
should always be looked for. The patient is much gratified by seeing that his 
enemy has been expelled; and also by the proof he thus obtains of the sagacity 
and judgment of his physician. The feces should be mixed with water, upon 
the surface of which any gall-stones, since they are specifically lighter than that 
fluid, will float. I never but once succeeded in thus catching a concretion in the 
evacuations of a patient, whose symptoms had led me to search for it. 

We often find gall-stones, even in vast numbers, in the gall-bladders of persons 
who, during their lifetime, had never been known to suffer pain about the liver, or 
to have jaundice, or to exhibit any token of the presence of such concretions. We 
infer from this that, while they remain in the reservoir of the bile, they are harm- 
less ; and that the suffering and the hazard they occasion are mechanical conse- 
quences of their transit through the gall-ducts. I have heard of an instance in 
which upwards of 1,300 gall-slones were taken from a human gall-bladder after 
death. 

These gall-stones are not, as you might suppose, mere lumps of inspissated 
bile. There are, I believe, concretions of that kind, but they are very rarely met 
with in the human subject. The ordinary calculi consist, in a great measure, of 
a peculiar substance, cholesterine, which exists in a state of solution in healthy bile, 
but which, in some morbid conditions of that fluid, being released from its solvent, 
assumes its proper crystalline form. Very little is known respecting the circum- 
stances under which the change takes place. Cholesterine, Dr. Prout tells us, is 
the product of some modification of the oleaginous principle. Biliary concretions 
seldom form in children. They are much more common in women than in men. 
They occur most frequently in persons who are corpulent, lead sedentary lives, 
use generous fare, sleep much, and neglect their bowels : all which things foster 
or denote a torpid and congested state of the hepatic system. Cattle are said to 
be subject to biliary calculi when shut up in stalls during the winter, and to lose 
the complaint when they are again turned out into the pastures in the spring. 
Hence the absurd notion, countenanced even by Van Swieten, that grass is a good 
remedy for jaundice. 

Another variety of jaundice, also noticed by Cullen, is supposed to depend 
upon mere spasm of the gall-ducts. " Icterus spasmodicus, sine dolore, post 
morbos spasmodicos, et pathemata mentis." 

Now the existence of this cause is hypothetical. The gall-ducts, though not 
distinctly muscular, possess a vital power of contraction. I am not aware that 
the disease has ever been clearly traced to a connection with " morbi spasmodici." 
It is an alleged cause which we can neither prove nor disprove. Certainly the 
" pathemata mentis" play their assigned part: fits of anger, and of fear, and of 
alarm, have been presently followed by jaundice; and it has also been produced by 
great bodily suffering, by a severe surgical operation, or, perhaps, by the dread 
which attended it. Mr. North witnessed a case in which an unmarried female, 
on its being accidentally disclosed that she had borne children, became in a very 
short time yellow. A young medical friend of mine had a severe attack of intense 
jaundice, which could be traced to nothing else than his great and needless anxiety 
about an approaching examination before the Censor's Board at the College of 
Physicians. There are scores of instances on record to the same effect: and this 



868 



JAUNDICE. 



is observable of such cases, that they are often fatal, with head symptoms : con- 
vulsions, delirium, or coma, supervening upon the jaundice. But with respect to 
the immediate cause of the icteric symptoms, they may, I say, depend upon a 
spasmodic constriction of the gall-ducts. Mr. Mayo has suggested another cause, 
viz., the sudden formation of bile in unusually large quantity in the blood, by some 
influence propagated through the nerves. 

Jaundice sometimes supervenes upon violent and long-continued vomiting; in 
which case the extremity of the gall-ducts is supposed to have been compressed 
by the coats of the duodenum. 

Jaundice may also occur, as I stated before, as a symptom of acute or chronic 
inflammation of the liver ; and then its treatment will merge in that of the primitive 
disease which occasioned it. 

Icterus occasionally comes on during pregnancy ; and disappears after child- 
birth. The pressure of the gravid uterus may thrust other organs, a loaded colon 
for example, against the liver, and so impede the passage of the bile. The little 
exercise that pregnant women are apt to take, and the costiveness that frequently 
attends their condition, may have some influence in causing the icterus gravi- 
darum. 

All systematic writers follow Cullen in making jaundice a common disorder 
among newly-born children. The icterus neonatorum occurs, they say, a few 
days after birth; is not attended with any suffering, or obvious disturbance of the 
bodily functions ; and soon disappears. Now there seems reason to believe that 
this is not icterus at all; and has no relation to the biliary organs. The surface 
of the infant, at its birth, is frequently of a deep red, from hyperemia or conges- 
tion of blood ; presenting a condition which falls little short of a mild but universal 
bruise. By degrees the redness fades, as bruises fade, through shades of yellow 
into the genuine flesh-colour. Such, I am assured by those who are more con- 
versant with these matters than myself, is the pathology of the icterus infantum. 
Of course true jaundice may, as well as most other complaints, befall the earliest 
period of life ; but I conceive that it seldom does. 

The prognosis in jaundice is generally favourable ; except when it depends 
upon structural disease of the liver, or supervenes suddenly upon some great 
mental or bodily shock. In both these cases the prognosis is bad, or doubtful. 
It is better, in that variety connected with hepatic disease, if the disease proceeds 
from some known cause, by which a low degree of inflammation has been pro- 
duced ; and the cause is such as can be avoided for the future. Just, indeed, as 
in chronic hepatitis, of which the icterus is simply an occasional symptom. The 
prognosis is worst of«all in old persons, when the constitution is impaired, and 
there is no obvious cause for the disease ; and particularly when the colour of the 
skin is greenish, or approaching to black.* 

* [Mr. Twining, in his work on the Diseases of Bengal, has presented some very interest- 
ing and important views in relation to the pathology of jaundice. 

Mr. T. has found that jaundice, not only during its early stage, but for a long period sub- 
sequently, while the discoloration of the skin remains, is very generally attended with 
some morbid sensibility when pressure is made over the situation of the gall-bladder and 
capsule of Glisson, though the uneasiness, during the absence of pressure, is most gene- 
rally referred to the epigastrium. 

When the disease occurs in plethoric subjects, and the stools are of a pale-clay colour, 
Mr. T. has found it almost always attended with fever, and in some cases he has known 
robust patients to die, with symptoms of oppressed brain, within thirty-six hours after the 
sudden appearance of intense jaundice, for the accession of which no cause could be 
assigned. 

In consequence of the acknowledged obscurity which exists in regard to the true pa- 
thology of the disease, he was anxious to ascertain the exact condition of the liver and 
biliary ducts in persons labouring under jaundice. The almost invariable existence of 
pain, increased upon pressure, confined to a circumscribed spot on the right side, just 
below the centre of a line drawn from the right nipple to the umbilicus, led him early to 
suspect circumscribed inflammation of some part of the liver as the most frequent cause of 



JAUNDICE. 



869 



the disease. This opinion he believed to be confirmed by the good effects which, in the 
majority of cases, are produced by a systematic course of depletion : nevertheless, if cir- 
cumscribed inflammation be the efficient cause of jaundice, he found it difficult to ex- 
plain why the disease was so frequently absent during the progress of the most unequivo- 
cal and intense inflammations of large portions of that organ. The examination of in- 
dividuals who had recovered from jaundice only a short time before death occurred from 
other diseases, exhibited no appearances in the liver indicative of any circumscribed por- 
tion of it having been the seat of recent inflammation. In the course of his dissections, 
however, Mr. T. found that albuminous infiltration into the cellular structure of the capsule 
of Glisson was sometimes present. Within this capsule are situated two small bodies which, 
from their structure, appearance, and uniformity of situation, he is inclined to believe are 
absorbent glands: one of them is situated near the termination of the gall bladder in the 
cystic duct, the other, at the upper part of the ductus communis; the superior gland is 
sometimes very small, and occasionally, it is more closely attached to the side of the gall 
bladder than to the cystic duct; the lower one is more uniform in bulk, being usually half 
the size of a small bean ; it is always placed just at the commencement of the common 
biliary duct. Irritations affecting the absorbent vessels passing through this gland may, 
Mr. T. conceives, cause in it such a degree of swelling as would produce transient com- 
pression and closure of the common duct and thus prevent the passage of the bile into the 
intestines and give rise to the phenomena of jaundice. So long as the obstruction is com- 
plete the stools will be nearly white or of a very pale-gray colour ; when, however, the jaun- 
dice is attended with severe fever and symptoms of intense gastro-enteritis, the stools will 
very often be coloured by the blood which is poured out by the capillary vessels of the 
intestinal mucous membrane, as well as by other morbid secretions. 

When previous inflammatory disease of the capsule of Glisson has caused an infiltration 
of coagulable lymph into the cellular structure of that part, at a remote period, and its 
subsequent absorption has left a degree of induration and constriction, Mr. T. believes 
that a very slight enlargement of the lower gland will effectually compress the common 
biliary duct; he has seen its canal obliterated, from this cause, exactly at the point of con- 
tact with the swollen and indurated gland. He has, also, seen the cystic duct obliterated 
where it was in contact with the upper gland, in consequence of the enlarged and diseased 
condition of the latter ; but he does not believe that this could have any influence in the 
production of jaundice. 

Mr. T. does not deny the agency which biliary calculi — tumours of the pancreas, liver or 
spleen, or scirrhous pylorus may occasionally have in the production of the phenomena of 
jaundice, nor, that, in some rare cases, the disease may have been excited simply by mental 
emotion; nor is he willing to place undue importance on the observations upon which his 
views of the most frequent cause of the disease are based. Should these, upon more ample 
investigation, be found to be correct, they will have an important influence upon the treat- 
ment of the disease. 

According to Mr. T., the most successful plan of treatment in those cases of jaundice 
accompanied with pain, augmented upon pressure, of the right side of the abdomen, is 
by depletion by the lancet and leeches— active purgation — the daily use of the warm bath 
— and sudorifics, aided by low diet and perfect rest, in the commencement of the disease; 
followed by milder purgatives, and a small blister over the region of the gall-bladder, kept 
open for a long time. Subsequently, a- course of Cheltenham salts, or small doses of rhubarb 
and sal. polychrest, with gentle exercise, and frictions with camphorated liniment over the 
right hypochondrium are advisable: at the same time, it may be proper to allow a mild 
unirritating diet, in such quantities as shall improve the patient's strength. The disease 
may sometimes occur under circumstances that forbid depletion. This Mr. T. considers an 
unfortunate circumstance, as he has but little confidence in other modes of treatment. 

In those cases in which the stools indicate the entire absence of bile from the intestines, 
Mr. T. considers the use of mercurials to be of doubtful propriety; but, when bile does pass 
into the duodenum, he admits that calomel may be useful, in conjunction with the remedies 
already detailed. Excepting in cases where there is pretty positive evidence of the exist- 
ence of biliary calculi, which he believes to be less frequently a cause of jaundice than 
is generally imagined, he doubts the propriety of having recourse to opiates. 

Whether the views of Mr. Twining in regard to the pathology of jaundice be or be not 
correct, must be determined by the result of future and more extended observations; they 
are sufficiently plausible and important, however, to demand the attention of the physician 
and to influence him in his treatment of the disease. In respect to the plan of treatment re- 
commended by Mr. T. we believe it will be found, with one exception only, to be, in a large 
number of cases, the only proper and successful one. The exception to which we allude, 
is the indiscriminate administration of active purgatives : jaundice is, not unfrequently, 
connected with more or less extensive inflammation of the stomach and small intestines, 
and in these cases, the employment of active purgatives to the extent recommended by Mr. 
T. would unquestionably be decidedly injurious.— C] 



870 JAUNDICE, 



LECTURE LXXVI, 

Treatment of the various Species of Jaundice. Diseases of the Gallbladder ; 
of the Spleen; of the Pancreas. Diseases of the Kidneys. Nephritis and 
Nephralgia. Phenomena constituting a "Jit of the Gravel." Different kinds 
of Gravel. Diseased slates of the Urine. Description and remedies of the 
Lithic, Phosphatic and Oxalic Diatheses. 

In the last lecture, after describing the symptoms, causes and treatment of 
acute and chronic inflammation of the liver, and after pointing out various other 
forms of chronic disease to which that organ is obnoxious, 1 spoke of jaundice. 
I offered you some comments upon its phenomena; and I indicated several differ- 
ent internal conditions upon which it may, in different cases, depend : and the 
lecture was closed with some brief hints respecting the prognosis of icterus. I 
have yet to consider the plans of treatment best adapted to the several varieties of 
the complaint. 

Some kinds of jaundice are obviously and absolutely irremediable. From 
others the patients recover, whatever treatment may be adopted, or without any 
treatment at all. Hence, as is customary in such circumstances, remedies the 
most worthless and absurd are extolled for their efficacy against jaundice. The 
patient gets well, and the drug last tried is held to have cured him. Post hoc, 
ergo propter hoc, is an argument more often applied I believe to the variations of 
disease, than to any other class of events. 

In that species of icterus which occurs, sometimes, in connection with acute 
or chronic inflammation of the liver, the treatment must be such as I yesterday 
recommended for acute and chronic hepatitis. Mercury forms an essential part 
of that treatment; and, unless the disease yielded sooner, I should urge the 
remedy until its effect upon the gums, and, therefore, its presence in the circu- 
lating blood, was apparent. 

But to the icterus calculosus, mercury is not so well adapted. What we want 
is, not a more plentiful or a more healthful secretion of bile, but to get rid of the 
mechanical impediment to its excretion: or, at any rate, if that cannot be accom- 
plished, to ease the acute sufferings of the patient. Should fever attend the passage 
of a gall-stone, or should the epigastric pain become epigastric tenderness, leeches 
may be applied, or a vein may be opened. The abstraction of blood may prevent 
any thickening of the distended gall-ducts ; or it may perhaps relax their spasmo- 
dic closure around the calculus. But, in general, blood-letting is not of service 
nor requisite in this variety of jaundice. Our great resource, for relieving the pain, 
and for loosening the presumed spasms, is opium, given in full doses: and I can 
add but little, with any advantage, to the directions laid down, on this head, by 
Dr. Heberden. " This pain (says he) can only be assuaged by giving and repeat- 
ing opium and its preparations, as often as the continuance of the pain requires 
them ; and because this pain is very apt to return, the patient should always be 
advised to keep by him, as long as the distemper lasts, pills of pure opium, each 
weighing one grain — or what is equivalent to them — that no time may be lost in 
quieting a sensation which is so difficult to endure. One of these pills may be 
taken as soon as the pain comes on, and it may be repeated once or twice in the 
course of two hours, if the pain require it ; and I have often found it both safe and 
necessary to give much more." 

This plan, of giving opium in the form of pills, is the more judicious, because, 
from their small bulk, they are more likely to be retained than draughts would 
be. Sometimes the stomach is so irritable as to reject even a pill. I would add, 
therefore, to Dr. Heberden's recommendations, that of throwing an opiate injec- 
tion into the rectum; half a drachm or a drachm of laudanum, mixed with a small 



THE GALL-BLADDER. 



871 



quantity of warm gruel. Another very useful expedient is the warm bath. If 
this cannot be readily procured, hot fomentations to the epigastrium, the mustard- 
poultice, the turpentine stupe, are valuable substitutes for it. Dr. Prout states 
that he has seen more alleviation afforded by large draughts of hot water, contain- 
ing the carbonate of soda in solution (one or two drachms to a pint), than by any 
other means. " The alkali counteracts the distressing symptoms produced by 
the acidity of the stomach ; while the hot water acts like a fomentation to the seat 
of the pain. The first portions of water are commonly rejected almost imme- 
diately ; but others may be repeatedly taken ; and after some time it will usually 
be found that the pain becomes less, and the water is retained. Another advan- 
tage of this plan of treatment is, that the water abates the severity of the retching, 
which is usually most severe and dangerous where there is nothing present upon 
which the stomach can react. This plan does not supersede the use of opium, 
which may be given in any way deemed most desirable; and in some instances a 
few drops of laudanum may be advantageously conjoined with the alkaline solu- 
tion, after it has been once or twice rejected." The pain having been quelled, the 
bowels should be swept out by a brisk purgative. 

When the jaundice appears to have been suddenly engendered, by moral 
causes, the rationale of its production is obscure ; and the treatment has a corre- 
sponding uncertainty. The bile, retained or readmitted into the blood, is supposed 
to operate as a poison upon the nervous system. But the mental state which 
precedes and seems to occasion the jaundice, may possibly be itself the cause 
of the nervous symptoms that follow. In other forms of the malady patients 
remain intensely yellow, often for a long time together, without becoming coma- 
tose, delirious, or convulsed. Not that this is conclusive. We know that a given 
poison may influence different persons very differently. The same dose of opium 
that will put one man to sleep, will stimulate a second to madness, and will have 
no sensible effect upon a third. In the very complaint before us, one patient is 
tormented with a universal itching, which we attribute to bile in his blood ; and 
ten others remain free from that disagreeable feeling. If we were sure that the 
bile was the material cause of all the cerebral symptoms, we might hope to draw 
some of the poison off by blood-letting: but we are not sure of this ; and reason- 
ing upon the matter helps us not much towards the cure. The lesson which 
experience has furnished amounts to no more than this: that active purging is 
sometimes followed by evident amendment, and ultimate recovery. I would 
bleed also, if the pulse warranted venesection, but not otherwise. In all the vari- 
eties of what, from its intensity and rapid accession, I may call acute jaundice, 
purging is strongly indicated : and we sometimes succeed in rectifying the whole 
morbid condition by thus applying a sudden wrench (so to speak) to the biliary 
organs ; by giving, for instance, half a scruple or a scruple of calomel, and, a few 
hours afterwards, half an ounce of castor oil, with half an ounce of spirit of tur- 
pentine. 

When green jaundice arises from hepatic disease, we can only palliate. Mild 
laxatives and anodynes comprise all that such a state admits of. For the icterus 
gravidarum, delivery is the natural cure: it may sometimes be removed by the 
careful employment of aperients. 

» The gall-bladder has its own diseases, which I do not stop to investigate, for 
they seldom become the objects of specific treatment. Sometimes it is found 
shriveled up, and nearly empty: sometimes enormously distended; sometimes 
ruptured. Of these conditions, the distension of the gall-bladder is the only one 
that we can never expect to recognize in the living body. The bag then projects 
beyond the edge of the liver, and is palpable externally, forming an elastic tumour 
in the right side. Authors lay down marks for distinguishing a distended gall- 
bladder from abscesses of the liver, and from an hydatid cyst; but they are not 
much to be trusted to; nor is the precise diagnosis of any great moment. The 
practical rule seems to be that, when the swelling is adherent to the parietes of 



872 



THE SPLEEN — NEPHRITIS AND NEPHRALGIA. 



the abdomen, we may puncture it, whatever is its nature : but under no other cir- 
cumstances. 

I have already, incidentally, described most of the morbid states of the spleen 
which are susceptible of relief from medicine: especially the enlargement of that 
body constituting the ague-cake of the fens, and occurring in connection with inter- 
mittent fever; and that other kind of enlargement which sometimes goes along 
with haematemesis and melsena. The spleen is liable to tubercles also ; to depo- 
sits of other specific tumours, and of bone ; and to softening of its substance. 

The best remedy for the ague-cake is the remedy for intermitfent fever, quina. 
Purgatives also have the effect of reducing hypertrophy of that curious organ. 
One caution enforced by Dr. Abercrombie, is that in splenic disease, mercury 
should be sedulously avoided, or rather such an employment of mercury as would 
risk tenderness of the gums. Dr. Williams, of St. Thomas's Hospital, states in 
a recent publication, that he has made many trials of the bromide of potassium as 
a remedy in various disorders : but that he has satisfied himself of its utility only 
in cases of diseased spleen. Of this I know nothing. 

Again, it may seem a slight to the pancreas to pass it over without noticing the 
diseases to which it is subject. But really those diseases appear to be but few ; 
and they do not signify their existence by any plain or intelligible signs. I have, 
nine or ten times perhaps in my life, met with carcinomatous deposits in the pan- 
creas. In every instance the head of the gland, that extremity which lies next to 
the bowel, has been the exclusive or the principal seat of the disease. I have 
known this change in the pancreas to cause jaundice, by obstructing the bile- 
ducts: I have known it in the same way to occasion very great enlargement of 
the liver itself ; and I have known it to produce enormous and slowly fatal dis- 
tension of the stomach by compressing the duodenum, and so preventing the free 
passage of the aliment, through that gut. As to remedies for pancreatic diseases 
or disorders, I do not know of any. 

Diseases of the kidneys — and disorders of their function — and alterations in the 
fluid they secrete — require more consideration. And I proceed at once to the 
subject of their inflammation; to nephritis: and it will be practically convenient 
to take nephralgia, or pain of the kidney, into the account at the same time. Ne- 
phralgia is commonly, but not always, produced by the transit of a urinary calculus 
from the pelvis of the kidney, through the ureter, towards the bladder. This 
constitutes what is called, in common parlance, a Jit of the gravel. The symp- 
toms are these: — pain, sometimes dull, but more frequently very severe, in the 
loins, usually on one side, and descending often along the track of the ureter of 
the same side ; numbness of the corresponding thigh ; in the male, retraction, and 
perhaps pain, of the testicle ; a frequent desire to make water, which is generally 
high coloured ; nausea and vomiting. 

If to these symptoms there be added pyrexia, we learn the important fact that 
inflammation is present : we have the symptoms of acute nephritis. The passage 
of gravel from the kidney sometimes does, and sometimes does not, provoke 
inflammation of the gland. Nephritis is very seldom idiopathic. It may some- 
times arise under the influence of cold : more frequently it is excited by calculous 
matter lodged in the kidney; by a blow or fall upon the loins; by the internal 
administration of cantharides, or of turpentine. It is to the presence of fever that 
we look, to establish the inflammatory character of the renal affection. 

Nephralgic pains require to be distinguished on the one hand from rheumatic, 
and on the other from colic pains. In lumbago there is pain in the back, and it 
may or may not be attended with fever; but the pain usually affects both sides, 
and is aggravated by such movements of the body as call the muscles of the loins 
into action, particularly by stooping. It originates, frequently, in some strain or 
effort, of which the patient is made painfully conscious at the time. It is seldom 
accompanied by any notable trouble of the urinary functions. When rheumatic 



NEPHRITIS AND NEPHRALGIA. 



873 



pain extends from the back into the thigh, it mostly follows the course of the 
great sciatic nerve, and is felt down the outer part of the limb ; whereas the pain 
that accompanies nephritis or nephralgia shoots rather along the track of the ante- 
rior crural nerve. Lastly, lumbar pain, depending upon rheumatism, is not 
attended with nausea and vomiting. 

The pain of colic is often associated with sickness and retching: and it may 
occupy those parts of the abdomen which correspond to the place of the ureters. 
The urinary functions are undisturbed ; and this is a capital point of distinction. 
The numbness of the thigh, and drawing up of the testicle, are sufficiently cha- 
racteristic, when they happen ; but they are frequently altogether absent. 

Some years ago I was sent for by an exceedingly intelligent surgeon, who had 
been one of the house-surgeons at the Middlesex Hospital. I found him in bed. 
He told me he had pain in the abdomen. It had begun in the morning in the 
situation of the right kidney, and soon extended round to the right side of the 
abdomen and the groin. Two days before, he had experienced a similar attack 
of pain in the renal region, stretching round into the hypogaslrium. When I saw 
him he described the pain as lying more round the umbilicus than elsewhere; and 
he expressed a strong persuasion, from the feelings which attended it, that it 
would be removed by free action of the bowels. But he felt nausea j and had 
vomited some medicine which he had taken. He had no fever, no retraction of 
the testicle or numbness of the thigh, and the pain was not increased by pressure. 
Neither had there been any marked irritation of the bladder. He said, indeed, 
when I questioned him on that point, that he thought he had made water rather 
more frequently than usual the day before. I mention this ease to show you the 
occasional obscurity of the symptoms. Here a well-instructed medical man be- 
lieved that nephralgia, existing in his own person, was colic. To my judgment, 
however, it seemed most probable that a small calculus had been passing from his 
kidneys towards and perhaps into his bladder. I may as well tell you the event 
of the case, which interested me a good deal ; for it exhibits the train of symptoms 
that are apt to ensue after nephritic attacks; although in this instance they were 
but slightly pronounced. His bowels were well acted on by a purgative, and the 
next day he was free from pain, and apparently well. 

Two days after this, he had more frequent calls to pass urine than were usual 
with him, and having done so on one occasion, he presently felt the want again, and 
then passed a little blood. The urine had been of a clear amber colour throughout. 
At the expiration of two or three days more he called upon me to say that after 
making water he had perceived in the vessel a small crystallized mass, which he 
took out, supposing it to be (what it very much resembled) a fragment of sugar 
candy. In fact he had been eating sugar candy, and thought some portions of it 
had fallen down between his waistcoat and shirt, and afterwards into the chamber- 
pot. He had the curiosity, he said (some misgiving he must have had, too, for I 
had told him my own opinion of the nature of his attack), to put a small crystal 
from this fragment into his mouth; and as it neither tasted sweet nor dissolved, 
he suspected it might be a urinary concretion, and brought it to me. And sure 
enough it was so ; a piece of very pure oxalate of lime, which he had been for- 
tunate enough thus to get rid of. It was a quarter of an inch in length, and less 
than one-eighth of an inch broad, consisting of an aggregation of small crystals. 
It was exactly similar in appearance and colour to a piece of brown sugar-candy 
of the same size. It would pass, longways, into a large crow-quill. 

That it was oxalate of lime was proved in this manner. A little separate crys- 
tal was heated to redness on a piece of platinum foil, by means of a spirit-lamp 
and blow-pipe. By these means the oxalic acid was destroyed, and quick-lime 
left. This residue, moistened, and pressed into a pov/der on a piece of turmeric 
paper, gave the characteristic brown colour. 

You see, then, that a nephritic affection may be mistaken for an attack of colic. 
In reference to practice, it would indeed be a mistake of no great importance, since 
the remedies that are proper in the one case are generally proper, or not improper, 



874 



NEPHRITIS AND NEPHRALGIA. 



ra the other. If the pain be attended with fever, antiphlogistic measures are alike 
indicated in each of the two diseases. 

The numbness of the thigh, and the drawing up of the testicle, are analogous 
phenomena to the pain which affects the shoulders in hepatic disorders. Irrita- 
tion of one extremity of a nerve, situated internally, and belonging to an organ 
which is not endowed with a high degree of sensibility, causes sympathetic sen- 
sations in the sentient extremities of other branches of the same nerve, or of com- 
municating nerves. 

And this sympathetic affection of distant parts is sometimes attended (as I for- 
merly observed) not merely with pain, but with some degree of inflammation 
also. The testicle occasionally swells, and becomes tender during a nephritic 
attack. On the other hand, as the nerves which communicate with those of the 
testicle or thigh, may or may not be implicated in the renal disorder, so we see 
how it happens that these curious symptoms so instructive when they do occur, 
may frequently be wanting; as they were in the example I just now detailed 
to you. 

When the symptoms I specified in the outset are attended with fever, we con- 
clude that we have to deal with nephritis ; and when inflammation of the kidney, 
however produced, lasts for a certain period, without abatement, suppuration is 
to be dreaded. Such suppuration is marked, sometimes, by the supervention of 
rigors, by throbbing, perhaps, and it may be by a remission of the pain : but I 
believe it may take place without throwing out any such signals. Nay, I think 
it probable that inflammation, confined to the parenchymatous substance of the 
kidney, may arise, and run through all its stages, without denoting its presence 
or progress by any noticeable local signs; and that the sharp and peculiar symp- 
toms ascribed by authors to acute nephritis manifest themselves only when the 
investing membrane of the gland, or its pelvis and excretory tubes, are involved 
in the inflammatory process. However this may be, suppuration leads to ulcera- 
tion, to the formation of renal fistula?, to the establishment of a purulent dis- 
charge, and hectic fever ; and finally, in most cases, to a fatal event; whether the 
inflammation was at first idiopathic, or dependent on a calculus. 

I may illustrate these remarks, by stating the heads of a ease which has oc- 
curred to me since this course of lectures began. I admitted Caroline Barnard, 
a married woman, forty years old, into the hospital, on the 18th of October. 
Among other things she complained of pain in the situation of the right kidney. 
She had been ill six weeks, and at the commencement of her illness her urine 
had been very turbid, as indeed it still was : and she had experienced much pain 
and difficulty in passing it, and after it had passed. From that time she had fre- 
quent nausea and retching, and occasional numbness of the right thigh. She had 
been losing flesh fast; and her pulse was frequent. There was some tenderness 
discoverable in the right renal region ; and after a time a manifest fullness there, 
and hardness; and at length oedema of the integuments and extreme tenderness. 
She suffered also well-marked hectic fever, and had severe and repeated rigors. 
On the 4th of November, after a careful examination of the right loin, we satisfied 
ourselves of the presence of matter. I got Mr. Arnott,. therefore, to see her, and 
to put a lancet into the abscess ; and a large quantity of faint-smelling pus came 
out. She was greatly relieved by the operation ; and a purulent discharge, mixed 
with shreds of cellular membrane, came away in abundance for some days: but 
in time the discharge ceased, the swelling subsided, and the opening healed. We 
began to hope that it had been merely an abscess in the neighbourhood of the 
kidney, irritating it and affecting its functions. But in three weeks after the 
abscess was punctured, the swelling was found to have recurred ; and she again 
began to suffer much. The tumour was again opened, and pus of a more offen- 
sive character than before evacuated. In the early part of December she sank. 

We found the right kidney small, collapsed and hollow ; in some parts a mere 
flabby bag. On its posterior surface there was an opening, which formed a com- 
munication between the interior of the kidney, and the abscess in the areolar 



NEPHRITIS AND NEPHRALGIA. 



875 



tissue, which had pointed externally. The pelvis of the kidney was much 
dilated; and the substance of the gland destroyed to a considerable extent, by 
suppuration and ulceration. The ureter, where it left the pelvis of the kidney, 
was found to be impervious-. 

The other kidney was much enlarged, but of quite healthy and sound struc- 
ture. That kind of compensation had occurred which I formerly mentioned as 
not unusual when, of double organs, one has been rendered incapable of its natu- 
ral functions, and the other takes up its duty, and performs a twofold amount of 
work. The organ of which the function is thus increased, becomes hypertro- 
phied. This woman did not die because there was not urine enough secreted; 
but she sank under the wasting purulent drain, the irritation and pain she suf- 
fered, and the protracted hectic fever. In this instance the inflammation and sup- 
puration occurred independently of the formation of calculous matter. 

Sometimes the pus finds its way out of the body through the natural passages, 
and appears in the urine. This woman's urine was thought, by some of the 
pupils, to contain pus. It was quite thick, and of a yellowish colour. But heat 
rendered it transparent. You must not judge by a cursory look at the water. 
The effect of heat proved that the yellow material was not pus : the impervious 
condition of the ureter showed afterwards that it could not have been. 

When calculi exist in the kidney, they often betray their presence there, by 
causing bloody urine. But bloody urine may proceed from various causes ; and 
in conformity with my usual custom, I shall by and by offer you some general 
remarks on hematuria, as one of the hemorrhages. 

I showed you, at our last meeting, that gall-stones might inhabit the gall-bladder 
in considerable numbers, and be quite harmless, unless they attempted to escape 
from their prison, through the very narrow channel of egress from it ; and I inti- 
mated that the same observation was often applicable to urinary concretions. 
Renal calculi do, indeed, in many cases, produce abiding uneasiness, or fre- 
quently recurring pain, in the situation of the affected kidney, bloody urine, and 
gastric disturbance ; especially when the concretions are shaken or displaced by 
sudden jolts, or jarring movements of the body ; or when the system is deranged 
by intemperate habits. But in many other instances these calculi cause no pain 
or annoyance, so long as they remain in the kidney; although they inflict horri- 
ble suffering, in general, while, for the first time, they are forcing their way 
along the narrow ureter. A concretion cannot be formed in a moment; yet the 
attack of pain often comes on in a moment, without any previous warning. After 
a while it remits, perhaps, as suddenly ; the calculus having passed (it may be 
presumed) from the ureter into the bladder; and then indications, more or less 
palpable, usually begin to declare themselves of its presence in that reservoir. 
Moreover, it is not uncommon to find calculi in the kidney after death, of the 
existence of which there had been no symptom manifested during life. 

The treatment of nephritis — or of the nephralgia calculosa, when accompanied 
by fever, or occurring in young, strong, and plethoric persons — is just such as 
would be proper in cases of severe colic, or enteritis : and therefore it is that any 
mistake between these disorders at the outset is not of so much practical conse- 
quence. The objects of treatment are, to arrest the inflammatory process ; to 
quiet existing irritation; and to obviate any fresh causes of irritation. Venesec- 
tion, therefore, in proportion to the strength of the patient and the violence of the 
symptoms, will sometimes be proper: and it will always be advisable to take 
away blood freely from the neighbourhood of the suffering part by cupping. 
Warm fomentations ; the warm bath; the injection of warm water into the bowel ; 
these are all expedients of which practical men acknowledge the value. The 
warm enemata not only clear out from the large intestines any irritating matters 
they might contain, but, from the proximity of the colon to the kidney, they.per- 
haps have the effect of an internal fomentation. It is desirable also to get the 
bowels well acted upon by purgative medicines as soon as possible: the relief 
that follows free alvine discharges is often very marked. There is sometimes a 



876 



GRAVEL. 



difficulty, from the irritability of the stomach, in administering purgatives by the 
mouth. Calomel, however, will often be retained, when other substances are 
rejected. It is generally considered of importance to give those purgatives only 
which are not likely, after being absorbed into the blood, to irritate the urinary 
passages. On this account the saline purgatives are to be avoided. Nothing is 
so good as castor oil, if the stomach will bear it ; or infusion of senna, with manna, 
may be used ; or, if the stomach be very queasy, pills, composed of cathartic 
extract, and calomel. 

When there is no fever, i. e., when the case is one of nephralgia, and a calculus 
is passing, after the intestinal canal has been cleared by a purgative, it will be 
necessary to give opium in full doses to allay the pain : and it may either be 
administered in the form of pill through the stomach ; or introduced into the 
rectum. 

When a person suffers what is called a fit of the gravel, the pain, I say, is at 
length very suddenly relieved, in general, in consequence of the calculus having 
emerged from the ureter and entered the bladder. We judge that this has taken 
place, first, by the cessation of the pain ; and secondly, by the supervention, 
sooner or later, of symptoms indicative of stone in the bladder; viz., a more than 
usually frequent inclination to make water; pain, referred to the extremity of the 
urethra, especially just after passing urine: and stoppages and renewals of the 
stream of water while the patient is endeavouring to void it. 

The time which a calculus takes in traveling from the kidney to the bladder 
varies a good deal. The painful journey may be over in a few hours ; or it may 
last two or three days. More rarely the symptoms continue, with irregular 
intervals of comparative quiet, for weeks. And sometimes, notwithstanding the 
peculiar pain, which amounts to torment, all morbid symptoms cease, and yet no 
calculus has passed, apparently, into the bladder: none, i. e., of the symptoms of 
stone, ensue ; no calculus is voided by the urethra; and none found in the bladder 
when the patient at length dies. 

What is the explanation of these circumstances ? Why, as calculi have been 
discovered in such cases in the kidney, it has been supposed that a concretion 
may get into the very beginning of the ureter, where it is a little larger than else- 
where, and give rise to the peculiar symptoms, yet never pass fairly into that 
narrow tube ; but at length fall back again into the pelvis of the kidney : when the 
symptoms cease. 

But the same symptoms undoubtedly occur, occasionally, when there is no cal- 
culus at all. Sir B. Brodie has referred to this form of complaint. In people 
who live intemperate and luxurious lives, pain is apt to seize upon one renal 
region, and to extend round and downwards into the groin: and these symptoms 
will be followed by frequent, difficult, and painful micturition, the urine being 
unusually acid, high-coloured, and sometimes turbid. The* whole irritation ap- 
pears to be produced by this unhealthy urine : at least the complaint vanishes 
after cupping the loins, purging, the warm bath, and two or three full doses of 
colchicum given at short intervals. 

Sometimes the little stone becomes immovably wedged in the canal of the 
ureter. If it completely shuts the tube, the urine accumulates behind it, and that 
portion of the ureter dilates. The obstruction usually proves fatal, by its influ- 
ence upon the functions of the kidney, and thereby upon the whole economy. 
But if the urine finds a passage by the side of the impacted concretion, this dan- 
ger is averted, or postponed. 

When we have reason to believe, from the nature and course of the symptoms, 
that a calculus has come down from the kidney, and lodged in the bladder, then 
it becomes an object of deep interest to the practitioner, and of fearful importance 
to the patient, to try all means to bring about its expulsion before it grows too 
large to be voided. For grow it almost surely will, by the continual accretion of 
earthy matter upon its surface, if it remains long in the bladder. We know that 



GRAVEL 



877 



it may, at first, be voided, provided the urethra be in a healthy and natural state; 
that whatever has passed through the ureter, may pass through the urethra also. 

The objects to be kept in view are these : first, to procure a plentiful secretion 
of bland urine, wherewith the bladder may become filled; secondly, by lulling 
the sensibility of the parts concerned, to prevent or lessen that spasmodic effort of 
the sphincter of the bladder, which the presence of the calculus is apt to provoke; 
and, thirdly, to ascertain that the channel of the urethra is open and unimpeded. 

To effect the first of these purposes, the patient should be instructed to drink 
freely of diluent liquors ; such as barley-water, or linseed-tea, in which may be 
mixed a small quantity of the sweet spirits of nitre. To fulfil the second, he 
should take a full dose of opium at bed-time. By these means the pain and irri- 
tation which may have been produced by the calculus, will be soothed ; and the 
bladder will gradually fill. He should then make water, having first placed him- 
self in such a position that the outlet of the bladder shall be at the lowest part of 
that receptacle. He may stand up, and lean forwards ; or it may be well to make 
water while kneeling, in a warm bath. If these expedients are not presently 
successful, the urethra may be cautiously expanded, and habituated to the contact 
of a solid body, by the daily introduction of a full-sized bougie. Sometimes the 
calculus will follow the bougie, as it is withdrawn, through the urethra. In this 
way the patient will have a fair chance of getting rid of the stone. In this way a 
very near friend of my own, a physician now practising in this town, did expel a 
formidable, though not very large, piece of rough oxalate of lime several weeks 
after its entrance into the bladder. Out it came, at last, with a smart clink, which 
was music to his ear, against the chamber-pot. A gentleman was not long since 
sent up to me from Kent, by a former pupil of this College, with the following 
history. About a month before he had been suddenly attacked with acute pain 
in the loins, extending forwards into the left flank and pelvis, with nausea and 
vomiting. For nearly ten days these symptoms continued to occur at intervals; 
then they ceased : and then he began to be troubled by a frequent and very urgent 
inclination to make water, and by pain after voiding it, just above the arch of the 
pubes. I gave him directions, in accordance with the plan just now mentioned; 
and wished him to allow some surgeon to explore the contents of his bladder. 
To this he would not, as yet, he said, consent. I saw him on the 2d of August. 
He returned into Kent the next day. On the 5th, while taking a walk, he was 
seized with a most imperative desire to make water, but found that he could part 
with none. Concluding that a calculus had entered, and stopped up the urethra, 
he was proceeding homewards, but was soon constrained again to try to empty 
his bladder: and then he had the satisfaction of feeling, and seeing, a stone fly 
out with great force : but, as he had turned towards a hedge, he could not find it. 
From that moment he was quite easy. 

When a calculus of a certain size has once traversed the tubes that lead respect- 
ively to and from the bladder, others sometimes follow it with more ease. I show 
you here a large concretion which was passed, or pissed if you will, by a patient 
of mine without his knowing it. He is subject to epilepsy, which is probably 
eccentric, and excited by renal disease. He is closely and anxiously watched by 
his wife. One day last year she noticed that the urine he had just voided was 
slightly tinged with blood: and she then found this oblong stone, which is com- 
posed of lithic acid, in the vessel. 

If the renal calculus, after it has reached the bladder, cannot be got rid of by 
the expedients I have been recommending, the question arises, whether medicine 
can do any further good, or whether the patient is to be delivered over to the 
surgeon. 

Most of these small concretions admit of being mechanically crushed into 
smaller fragments, which are then readily washed out by the stream of urine. 
Larger stones are extracted entire, through incisions of the bladder. Yet there 
are many cases in which, for various reasons, surgery declines to attempt the 
removal of vesical calculi. Medicine still offers to these unfortunate patients the 



878 



LITHIC DIATHESIS. 



means of mitigating, at least, their sufferings. But it often can do more than this. 
It is very important for you to know that judicious medical treatment may retard 
or prevent, and that injudicious medical treatment may promote and hasten the 
enlargement of such calculi. Let us briefly consider the principles by which our 
judgment and our practice, in this serious matter, must be guided. 

I have described a fit of the gravel. We say that a patient has the gravel when 
he passes concrete matter with his urine, whether in the form of powder, of grit 
or sand, or of more massive calculi. We do not apply that term to the cases in 
which the urine is clear when recently voided, and warm; but throws down an 
earthy sediment as it cools: which sediment redissolves if the urine be again arti- 
ficially heated. Now besides the different forms which the gravel assumes, of 
powder, sand, and little stones, there are (as you may have guessed from certain 
terms that I have been obliged to employ) several kinds of gravel ; differing, I 
mean, in their chemical composition. The main signs — the pain, the sickness, 
the affection of the testicle, the subsequent bladder symptoms — are much the 
same, whatever be the nature of the solid matter that descends from the kidney, 
and lingers in the bladder. But other circumstances differ widely. The qualities 
of the water previously to the formation, and to the discharge, of the sabulous 
matter ; the state of the system at large. And it is quite impossible to treat cases 
of calculus in the kidney, or of stone in the bladder, with propriety, or safety, 
without constant reference to the condition of the urine. The morbid states of 
that secretion are of the greatest interest. I cannot undertake to enter upon the 
subject in much detail. Yet some outline of it I must attempt, especially where 
it touches upon points of practice. 

You know, probably, that the urine voided by a person in health always exhi- 
bits acid properties, always turns litmus paper red. Not that healthy urine con- 
tains a free acid; but only (according to Dr. Prout, who is the great authority in 
these things), that certain of the alkaline and earthy bases are not exactly neutral- 
ized, but exist in the state of supersalts. The pure lithic acid is nearly insoluble ; 
but the lithate of ammonia is very readily soluble: and it is this which reddens 
the vegetable blues. Now, whether out of the body, or within it, the lithate of 
ammonia will, of course, be decomposed, if any acid be present in the urine, for 
which ammonia has a stronger affinity than it has for the lithic acid : and the lat- 
ter will be thrown down, in the form of a red sand: little crystals, in point of fact, 
they are very much like, in shape, size, and colour, to the particles of Cayenne 
pepper. I show you some collected by one of my out-patients at the hospital. 
He must have passed a peck of it while under my observation: and I am sorry 
(having lately lost sight of him) that I did not procure a large quantity for the 
museum. 

Now this lithic acid, or red sand, or gravel, is liable to form in the kidney, if 
not in the bladder, and to concrete into calculi ; and the calculi once formed, or, 
indeed, any solid substance, will constitute a nucleus, upon and around which a 
further and repeated incrustation of a similar nature is almost sure to take place. 
You will at once perceive the importance of doing nothing to aggravate this dis- 
position to deposit lithic acid ; but of trying to prevent, or stop it. If there be 
symptoms of stone in the kidney, or in the bladder, and we have reason to believe 
that it consists of lithic acid, there are medicines which would tend to render mat- 
ters worse, and there are others of which the effect would be to correct the lithic 
acid diathesis as it is called. But how are we to know whether the presumed 
calculus be of that kind or not ? or, rather, how are we to know that the lithic 
diathesis exists ? Why, we learn that it exists by noticing the habitual qualities 
of the urine, and the habitual state of the patient's general health. 

In the urine of persons who have the lithic diathesis, you will find that there 
are frequent deposits, after it has become cool, of reddish sediments, looking like 
brickdust, and, therefore, called lateritious. These sediments consist chiefly of 
the lithate of ammonia, tinged with certain colouring matters in the urine. Some- 
times pure lithic acid appears, in the shape of fine sand, or in larger- crystals. 



LITHIG DIATHESIS, 879 

The urine itself is bright, of a dark coppery colour, like brown sherry. It is more 
acid than the urine of health, and gives to litmus paper a deeper shade of red. It 
is apt, too, to fall below the average quantity. 

The presence of this diathesis is likewise accompanied, and so far denoted, by 
a tendency to feverish and inflammatory complaints. The patients are troubled 
with acidity of stomach and heartburn ; many of them are subject to gout or rheu- 
matism. They are mostly also indolent and luxurious, or intemperate in their 
mode of life. Adults are peculiarly obnoxious to this condition of the system 
after the age of forty. But children, up to the period of puberty, are very liable 
to have lithic acid gravel. 

Whenever a paroxysm of nephritic pain befalls a person whose time of life, 
whose habits, the characters of whose health, and the habitual qualities of whose 
urine, are such as I have been describing, you may conclude that the concretion 
which has occasioned the symptoms is of the lithic acid kind : and you may expect 
that such attacks will recur; for it is observed of these lithic acid renal calculi, 
that they are generally numerous in the same individual. I speak of the habitual 
—or of the frequently recurring — qualities of the urine : for a deposit of lithic 
acid gravel, or of superabundant lithates, may occur to the healthiest individual, 
under accidental and transient disturbing causes. Many persons will tell you that 
their water becomes turbid with red sand whenever they have a cold. Febrile 
and inflammatory ailments will produce the sediment: even too full a meal: or 
exercise taken immediately after a full meal. In all such cases it seems probable 
that the customary evolution of lactic acid through the skin is somehow prevented: 
in consequence either of a check given to the perspiration, or of imperfect assimi- 
lation of the food. The lactic acid, thus diverted from its natural emunctory — or 
some other acid generated within the system — is determined to the urine, and pre- 
cipitates the lithic. 

Now the formation of lithic acid, and of the lithates, may be controlled by the 
exhibition of alkaline remedies. You will find that free livers use alkalies to 
neutralize the excess of acid which results from their intemperate habits; the 
carbonates of soda, or of potass. They do this, without any reference to the 
appearance of their urine, to prevent or appease the uneasy feelings produced by 
a debauch. But it is of importance to be aware that one of these alkalies is pre- 
ferable, for the purpose of obviating the lithic acid diathesis, to the other. Soda 
will sometimes combine with the lithic acid, and form an insoluble salt, as hard, 
and as pernicious, when deposited around a nucleus, as the lithic acid itself. 
With potass there is no such danger. If it should combine with the lithic acid, 
the resulting salt is perfectly soluble, and will pass away dissolved, in the urine. 
Magnesia is also a good medicine in such cases; but it has this disadvantage, as 
I showed you indeed before, that it is apt, when taken habitually, to cause intes- 
tinal concretions : and these may be as dangerous as the urinary ones. One of the 
best modes of giving the bicarbonate of potass is in the common saline draught. 
The stomach has the power apparently of destroying the vegetable acids ; and the 
remedial properties of the bicarbonate become thus equally certain with those of 
the pure alkali, while it is much less likely to derange or disagree with the 
stomach. Of course the mode of living ought to be changed when the lithic 
diathesis prevails; the patients should dine moderately and plainly, eating of one 
dish, and avoiding acids, and all articles of diet likely to generate acid in the 
stomach; saccharine substances, therefore, and fermented liquors.^ But, as I 
mentioned in a former lecture, they will not, if they can help it, give up their 
accustomed indulgences : and they attempt, and we attempt, but the attempt is 
often made in vain, to remedy disorders, which might with ease and certainty 
have been prevented. 

You must take care not to give these alkaline remedies too long ; nor in too 
great quantity. You must not push them to such an extent as entirely to de- 
stroy the acidity of the urine : for if you do, your patient is exposed to the same 
danger as before, but from an opposite cause. A white sand or gravel will be apt 



880 GRAVEL. 

to form in the alkaline or neutral urine: and this will collect itself, by the force 
of aggregation, around any existing calculus, or foreign substance. The white 
deposits consist mainly of the triple phosphate of ammonia and magnesia; and if 
you examine collections of urinary calculi, you will find that they are sometimes 
made up of concentric layers ; and one layer may be composed of lithic acid, and 
the next of the triple phosphates ; and so on, as the condition of the urine has 
alternated. You must test the urine, therefore, and see that it still reddens litmus, 
though perhaps faintly. Indeed it may do so, without containing any free acid : 
so that urine which only slightly reddens litmus paper may nevertheless be 
capable of depositing the triple phosphate. The saline draught has always a tend- 
ency to make the urine alkaline; and thus it is, probably, that it proves of use 
in febrile disorders: but it is an absolute poison to those whose urine is already 
alkaline. Colchicum has a similar tendency to diminish the acid reaction of the 
urine. So has mercury. And I may tell you — speaking generally of morbid 
states of the urine — that it is much more easy to correct too great acidity than 
to rectify the opposite condition. We can almost always make acid urine neutral 
or alkaline : but to render alkaline urine acid is often beyond our power. 

It is scarcely less important to attend to the functions of the skin, in persons 
having the lithic acid diathesis, than to the functions of the stomach. The warm 
bath is often an excellent adjuvant, in their treatment. In cold weather, warm 
clothing must be enjoined ; and the avoidance, in all weathers, of such exposure 
to cold as might suppress or materially lessen the amount of healthy perspiration. 

You will have gathered, from what I have already said, that there is a morbid 
condition of the system, the opposite of that in which the lithic diathesis pre- 
vails. The phosphatic diathesis, namely ; in which there is a readiness to de- 
posit white gravel ; composed of minute shining crystals of a triple salt, the 
phosphate of ammonia and magnesia. The way in which this is formed, accord- 
ing to Dr. Prout, is as follows. Healthy urine contains the phosphate of mag- 
nesia, which is very soluble ; and, therefore, is dissolved in that fluid. But, under 
certain circumstances, the urea of the urine becomes decomposed in the kidneys, 
and ammonia is extricated, which combines with the phosphate of magnesia, and 
forms an insoluble triple salt. Sometimes with the triple phosphate just men- 
tioned, there is also an admixture of phosphate of lime. 

It is a fact of great practical importance, that the tendency to the formation of 
the phosphates goes along with a debilitated condition of the system. Persons 
who have been rendered weak and feeble by overmuch toil, by mental anxiety, 
by insufficient nourishment, are very apt to pass water that is alkalescent or but 
faintly acid, and to exhibit the tokens, in their urine, of the phosphatic diathesis. 
They are, for the most part, cachectic, sallow, languid, spiritless, exhausted. 
The urine itself is pale, copious, slightly turbid or opaline, of a low specific 
gravity, and it does not smell like healthy urine : sometimes it has somewhat the 
faint odour of weak broth. It is occasionally alkalescent when voided ; never 
more than slightly acid. As the urine cools, the white sand is thrown down ; and 
in many cases a sort of film is formed upon the surface of the water, exhibiting, 
as you see it in different lights, all the colours of the rainbow: an iridescent 
pellicle. This has been found to consist of the triple phosphate. If you skim 
the pellicle off, by placing a bit of paper under it, and then suffer the paper to 
dry, you may distinctly see the little crystals. Urine of this kind speedily grows 
putrid and highly offensive. Sometimes it has a strong ammoniacal smell. You 
may estimate the intensity of the phosphatic disposition by the rapidity with 
which the urine becomes alkalescent. Occasionally the salt is so abundant that 
it is thrown down while the urine is still in the bladder ; and the last portions of 
the issuing stream look milky. 

Anything which tends further to depress the powers of the system will aggra- 
vate the phosphatic diathesis. When you find that your patient passes urine 
such as I have been last describing, which does not redden litmus paper, but on 
the contrary turns litmus paper that has been reddened by a weak acid, blue again, 



OXALIC DIATHESIS. 



881 



or even in some cases is alkaline enough to make turmeric paper brown — in such 
cases you must cautiously abstain from all remedies that are calculated to lower 
the vital powers ; from saline draughts, and alkalies of every kind; from mercury 
and colchicum; from bleeding; and even from active purgation: or you will add 
to the patient's dangerous weakness ; and promote the more abundant deposit of 
the alkaline phosphates. But you may do more than abstain from what is hurtful : 
you may counteract the phosphatic tendency by a generous diet and by the exhi- 
bition of tonic medicines ; bark, wine, and acids ; the muriatic acid, or the nitric, 
or both together, may be given in such cases with vast advantage sometimes. 
Opium is also a remedy to be employed in this form of disease. No single drug 
probably has so much power in rendering alkaline urine acid, as opium. And it 
is indicated for other reasons; it composes the nervous anxiety to which these 
patients are mostly a prey. Mental relaxation — freedom from care — the relin- 
quishment of all exhausting habits and pursuits — these, too, are points of vast 
importance, whenever they are attainable. 

I should state that the tendency to deposit the mixed phosphates, though some- 
times idiopathic, is much more often consequent upon local disease in some part 
of the urinary organs, especially in the bladder and prostate gland. It is also a 
frequent result of certain injuries of the back. 

There is yet another diathesis sufficiently common and important to claim your 
best attention. I mean the oxalic; in which there is a tendency to the formation, 
in the kidney, of the oxalate of lime, or mulberry calculus; an epithet derived 
from the occasional resemblance of the concretion to that fruit, in respect to colour 
and inequality of surface. This diathesis is not so obvious as the other two, but 
it is no less real. 

The urine differs much in its sensible qualities from that of both the preceding 
varieties. Unlike the urine of the phosphatic diathesis, it is bright and clear ; 
unlike that of lithic, it is remarkably free from sediment. The mulberry calculus 
is solitary also; or recurs at long intervals; and the diathesis prevails chiefly 
during the prime of life. In both these particulars the contrast with the lithic 
diathesis is striking. 

The persons who manifest this disposition are usually dyspeptic ; sometimes 
very much so ; sometimes very slightly. They are uneasy during the assimilation 
of their meals ; suffer flatulence when the stomach is empty ; prefer vegetable diet 
to animal ; are fond of sweets, especially of sugar. They are liable to boils and 
carbuncles, and to scaly cutaneous eruptions. According to their original tem- 
perament, they are nervous and irritable, or dejected and desponding in mind. A 
nephritic attack relieves them from all this discomfort for years perhaps. When 
the oxalic diathesis is strongly marked, the skin, Dr. Prout says, " is#apt to 
assume an unnatural appearance difficult to describe, but the colour of which may 
be said to vary from dull greenish yellow in the sanguine, to dark olive or livid in 
the melancholic temperament." 

The formation of the oxalate of lime within the body depends, according to 
Dr. Prout, either upon the non-assimilation of oxalic acid taken with the food, or 
upon the mal-assimilation of saccharine aliments. Hence, as a general rule, both 
curative and prophylactic, sugar and other saccharine substances should be rigidly 
excluded from the diet of these patients. They should avoid, also, all kinds of 
fermented liquor. The young stalks of the rhubarb-plant, which of late years 
have come into such general use in this country for tarts in the spring ; and sorrel, 
of which our neighbours, the French, consume a good deal in salads, and in other 
ways ; both contain oxalic acid ; and hard water contains lime. Dyspeptic per- 
sons who drink such water, and eat such articles of food, and are thus daily intro- 
ducing, without suspecting it, the constituent ingredients of the mulberry calculus, 
are very likely indeed to incur the pain and the exceeding peril of a renal con* 
cretion of that kind. You must see, therefore, the great importance of detecting 
the oxalic diathesis ; and of forbidding, to those who have it, all such viands as 
contain the oxalic acid, and of recommending them to use pure water, even dis- 
56 



882 



SUPPRESSION OF URINE, 



tilled water, for drinking. Aniraal food, and the stronger farinaceous matters, are 
best for them. 

Dr. Golding Bird refers the oxalate of lime to a different source : maintaining 
that it results from a re-arrangement of the elements of urea, whereby oxalate of 
ammonia is formed in the first instance; and afterwards oxalate of lime, by the 
decomposition of the calcareous salts natural to the urine. 

Agreeing with Dr. Prout that the mulberry calculus is not of very frequent 
occurrence — Dr. Bird nevertheless finds that small crystals of the oxalate of lime 
are extremely common: although from their transparency, and from their having 
nearly the same specific gravity with the urine in which they exist, they do not 
disclose themselves to the naked eye, nor sink down in manifest deposit. They 
are made plainly visible by the microscope. 

The same writer states that the persons whose urine is thus charged with 
crystals of oxalate of lime are, for the most part, highly sensitive and irritable, 
hypochondrically apprehensive of impending evil, full of gloomy fears concern- 
ing their bodily and mental powers, dyspeptic, weak, and usually emaciated. 

With respect to direct remedies for this diathesis, Dr. Prout tells us that he has 
seen more benefit derived from the mineral acids, alone or combined with tonics, 
than from any other. But the effects of these acids must be watched : and when 
they begin to produce a deposit of the lithate of ammonia, or of lithic acid, their 
use must be suspended. He recommends to patients who happen to be at a dis- 
tance, the muriatic, or nitro-muriatic acid, till the lithate of ammonia, or lithic 
acid, begins to appear in the urine ; or for a month. " By adopting," he says, 
" such a course of acids three or four times in the year, and by carefully regu- 
lated diet, I have seen the diathesis gradually subdued, and at length removed 
altogether." Dr. Bird also testifies to the efficacy of similar measures. 

These observations will serve, I hope, in some degree, as landmarks, to guide 
your treatment of patients labouring under renal or vesical calculi, or presenting 
symptoms such as warrant the apprehension that disorders so fearful may occur. 
It is impossible for me to do full justice to this interesting subject in these lec- 
tures ; and I must refer you, for more minute information respecting it, to Dr. 
Prout's invaluable volume; to Sir Benjamin Brodie's most instructive book on 
the Diseases of the Urinary Organs ; and to an excellent work recently pub- 
lished by Dr. Golding Bird, on Urinary Deposits. 



LECTURE LXXVII. 

Suppression of Urine. Diabetes: Qualities of the Urine; Symptoms; Ana- 
tomical Appearances; General Pathology of the Disease; Treatment, 
Diuresis. 

Systematic writers have adopted the term Ischuria to express that condition 
in which no urine is voided, it includes, therefore, those cases in which no urine 
is secreted ; and those in which, although secreted, it is not discharged from the 
body. Now these two conditions are exceedingly different from each other in 
most respects ; and I shall prefer making use of the two plain English names, 
suppression of urine, and retention of urine. Even these terms are sometimes 
confounded with each other. .In suppression, the secretion is suspended: in 
retention it may be as active as ever. Retention of urine is a surgical case; 
involving points of great practical interest. Suppression belongs to the physician: 
and the technical term for it is Ischuria renalis. It is sometimes spoken of as 
paralysis of the kidney ; a phrase to which I object, because I think palsy is a 
word which ought to be restricted to a loss of power over the muscular fibre. 

This affection usually occurs in persons who are advanced in life, and inclined 



SUPPRESSION OF URINE. 



883 



to corpulency. Why it should be so I cannot tell you, but such is the fact, as 
stated by most observers. Sir Henry Halford has related one of five instances of 
this disease that he had met with in the course of seven-and-tvventy years. He 
says it was an exact copy of all the others that had fallen under his notice : and 
as his account of the general course of the symptoms coincides with the statements 
of other writers, I may give you his narrative, in lieu of a formal description. 

" A very corpulent robust farmer, of about 55 years of age, was seized with a 
rigor, which induced him to send for his apothecary. He had not made water, 
it appeared, for 24 hours. But there was no pain, no sense of weight in the 
loins, no distension in any part of the abdomen : — and therefore no alarm was 
taken till the following morning, when it was thought proper to ascertain whether 
there was any water in the bladder, by the introduction of the catheter : and none 
was found. I was then called (says Sir Henry), and another inquiry was made, 
some few hours afterwards, by one of the most experienced surgeons in London, 
whether the bladder contained any urine or not : when it appeared clearly that 
there was none. The patient sat up in bed, and conversed as usual, complaining 
of some nausea ; but of nothing material in his own view : and I remember that 
his friends expressed their surprise that so much importance should be attached 
to so little apparent illness. The patient's pulse was somewhat slower than usual; 
and sometimes he was heavy and oppressed. 

" I ventured to state (continues the author) that if we should not succeed in 
making the kidneys act, the patient would soon become comatose, and would 
probably die the following night : for this was the course of the malady in every 
other instance that I had seen. It happened so ; he died in thirty hours after this, 
in a state of stupefaction." 

This is the curious and important point in the history of such cases. If no urine 
be separated from the blood, coma soon supervenes, and death. It is believed 
that these consequences result from the detention of urea in the system. Urea is 
a mere excrement, which, in health, is removed from the blood by the kidneys, 
as fast as it enters that fluid. When it is not so carried off, it accumulates in the 
blood, circulates with it to every part of the body, and acts as a poison, especially 
upon the brain. This is one of several cases, showing that the carrying fluid of 
the body may become the vehicle of disease and death, if it be not duly purged of 
deleterious matters which pertain to the unceasing processes of organic life. If 
carbonic acid be not extricated by the lungs, the animal functions are as certainly 
and almost as speedily extinguished by that gas, as the flame of a taper might be. 
And we have recently seen that when the outlet from the liver is shut up, when 
the blood is not purified from the excrementitious bile, the powers of animal life 
are weakened, and sometims utterly and rapidly destroyed. 

Suppression of urine, for a considerable time, is not, however, necessarily and 
universally fatal. Patients labouring under the epidemic cholera would secrete 
not a drop of water for some days; and yet recover. It was remarkable how 
entirely free such patients were from any approach towards coma. Was the urea 
here drained off from the blood in the enormous and unnatural flux from the 
stomach and bowels? I think it probably was: but I do not know that any 
chemical search was ever made for that substance in the fluids so effused. There 
are, however, some very singular instances on record of persons who have passed 
days and even weeks without secreting urine ; and without showing any other 
indication of impaired health. What degree of credit such narratives deserve I 
do not know; but assuming that there was neither fraud nor mistake, it may be 
suspected that either the natural secretion was compensated by some vicarious or 
supplemental discharge; or that a small quantity of urine was actually separated 
by the kidneys. " If any water, however small the quantity (remarks Sir Henry 
Halford), had been made in these cases, I should have thought it possible that 
the patient might have recovered : for it has often surprised me to observe how 
small has been the measure of that excrementitious fluid which the frame has 
sometimes thrown off, and yet preserved itself harmless. But the cessation of 



884 



DIABETES. 



the excretion altogether is universally a fatal symptom in ray experience, being 
followed by oppression on the brain." The same eminent physician states that 
in three of his five cases there was observed a remarkably strong urinous smell, 
in the perspiration, for twenty-four hours before death. This I believe is of 
common occurrence in such cases. Other patients have vomited, or passed by 
the bowels, watery matters possessing some of the sensible qualities of urine : 
and a urinous fluid is said to have been found in the ventricles of the brain in 
some of the fatal examples. 

I have spoken of suppression of urine as a malady, though it probably is never 
anything more than a symptom. Yet it is one of those symptoms which from 
our uncertainty respecting their origin and determining cause, we are obliged to 
treat, and to study, as if they were substantive diseases. In the only well-marked 
instance that I have seen of suppression of urine coming on in an apparently healthy 
person, some blood had appeared in the urine for a day or two before the secretion 
was totally suspended ; and the kidneys were found gorged with blood. Extreme 
congestion, or inflammation, of the substance of the gland, is probably at the 
bottom of many of these cases. The same train of symptoms supervene not 
unfrequently upon organic renal disease. They happen, too, when the ureters 
become impervious from disease, or from impacted gravel. In this condition 
urine continues to be secreted, for a time at least, and distends the ureter behind 
the seat of the obstruction. The apoplectic state which ensues may arise from a 
re-absorption of the secreted fluid ; or, in consequence of the obstacle, the secretion 
itself, after going on to a certain point, may stop, and then the case becomes a 
case of suppression. 

Respecting the treatment of this formidable condition I can say but little. Cup- 
ping upon the loins, venesection, if warranted by the state of the pulse, the hot 
bath, sudorific medicines, purgatives, and large warm enemata, seem to me the 
kind of remedies indicated. To endeavour to force the secretion of urine by strong 
stimulating diuretics, would strike one, a priori, as being hazardous. Yet this 
practice has its advocates; and should experience declare in its favour, theoretic 
objections ought to be disregarded. If benefit is so to be obtained, probably the 
best drug for our purpose would be cantharides. Dr. ElHotson refers to some 
examples of its success in the hands of Sir Astley Cooper; and afterwards of 
another practitioner who took the hint from Sir Astley. He suggests that as the 
tincture of cantharides is a very uncertain preparation, the remedy should be given 
in the solid form, a grain at a time, and that a large blister should be laid upon 
the loins. Beyond these hints I am unable to give you any assistance towards 
the management of this obscure but serious complaint. 

The opposite condition of the kidney, in respect to its peculiar function — that, 
I mean, in which its secretion is largely and morbidly augmented — is scarcely less 
fatal than the total suppression we have just been considering; but it is not so 
rapidly fatal. When the amount of urine secreted and passed is permanently too 
great, when it is constantly running off, as it were, from the system, the patient 
is commonly said to have diabetes : from S*aj3aifto, to pass through. 

But it is not every case of an excessive flow of urine that deserves to be called 
diabetes. Great quantities of aqueous urine are passed by hysterical and nervous 
patients. We all make more water in cold weather than in warm ; the functions 
of the skin and of the kidney compensating each the occasional defect of the other. 
Certain drugs and articles of diet are also well known to cause a temporary excess 
in the amount of urine secreted. 

In fact, although the quantity of urine voided is the most obvious and striking 
symptom of diabetes, its definite and characteristic symptom is a most remarkable 
change in the qualify of that liquid: in its becoming loaded with sugar. You 
will find, indeed, two species of diabetes mentioned by many authors — the diabetes 
insipidus, and the diabetes mellitus. The former term ought in my opinion to 
be abolished. If it refers merely to an unnatural abundance of urine, not other- 



DIABETES. 



885 



wise differing in its composition from healthy urine than in containing a large 
proportion of water — by calling such a state diabetes, we link together in the same 
genus two essentially different conditions. In true diabetes the urine is never 
without sugar. The quantity may indeed be small ; and it may not be sensible to 
that coarse test, the taste: but modern observers almost all agree in rejecting any 
species of diabetes, in which the urine is not at all saccharine. 

The sensible qualities of diabetic urine differ strikingly, in many particulars, 
from those of the urine of health. Its chemical quality differs strikingly too, as I 
have already told you ; but it is in one particular only. Fortunately, no extraor- 
dinary skill is required to recognize the morbid secretion. 

Diabetic urine is light-coloured, and transparent; of a pale straw, or greenish 
tint. Its odour is peculiar. According to Dr. Prout the scent somewhat resem- 
bles that of sweet hay, or that of milk; but to my nose it is more like the faint 
smell of certain apples, or rather of an apple chamber. Its taste is, more or less 
decidedly, sweet. Notwithstanding its limpid and aqueous appearance, diabetic 
urine is remarkably heavy. 

It was long believed that the quantity of urea in diabetic urine was reduced 
much below the natural standard ; and that the sugar was somehow formed at the 
expense of the urea. Dr. Prout, in his earlier researches, always detected a little, 
and but a little, of this peculiar principle. Later observations have shown, how- 
ever, that the urea is not so scanty ; nay, that it is generally as abundant as in the 
urine of health, and sometimes even more so. The presence of the sugar con- 
ceals the urea; inierferes with the action of the ordinary tests of that substance. 
By certain modes of procedure, which I need not stop to describe, the urea may 
readily be discovered : and it is often found, I say, to be rather excessive than 
deficient. The usual saline matters belonging to healthy urine are present also 
in that of diabetic persons; and in the same relative proportions; but, as might 
be expected, their absolute amount, in a given quantity of the liquid, is very much 
diminished. In short, the only essential deviation from the standard chemical 
constitution of the urine is, that it holds in solution a quantity of sugar. This 
explains its peculiar odour, its sweetness, and perhaps its excessive quantity. It 
accounts also for another very characteristic property of diabetic urine ; I mean its 
high specific gravity. In general, you know, the specific gravity of the urine is 
inversely proportional to the quantity secreted in a given time ; the more copious 
and dilute it is, the lighter it is. But in diabetes, so strong is the saccharine im- 
pregnation that the specific gravity more than keeps pace with the increased 
quantity of the liquid secreted. The specific gravity of diabetic urine is always 
much higher than that of healthy urine. 

The quantity of urine secreted and voided is sometimes enormous : far more 
than could be supplied by the quantity of fluid taken as drink, although that, as I 
shall presently explain, is excessive too. A healthy person passes from one to 
three or four pints of urine in the twenty-four hours. The quantity, as you well 
know, is liable to considerable variation : perhaps the average may safely be laid 
at about forty ounces. But patients in diabetes will void 40 pints in the same 
time. I have myself seen 26; 13 or 14 are not uncommon ; and cases are re- 
corded by writers of credit and veracity, in which 70 pints were passed daily. 
Nay, one Italian author declares that 200 pints have been discharged in that time. 

The saccharine matter thus held in solution may be obtained in its solid form 
by evaporating the urine. I have seen large flat cakes of beautifully crystallized 
diabetic sugar. It differs somewhat from common sugar, the produce of the sugar 
cane ; and approaches more nearly to the sugar of grapes. By rapid evaporation 
of the water a thick syrup is procured resembling treacle; but Dr. Maclntyre, 
who has presented to our hospital-museum some very perfect specimens of this 
sugar, prepared by Mr. Blandford, informs me that to get it well crystallized, the 
evaporation in a steam bath should be stopped while the urine is still of thin con- 
sistence. It may be quickly reduced to one-half, perhaps, of its original quantity* 



886 



DIABETES. 



Then it should be set aside, in shallow plates ; and in the course of ten days or a 
fortnight the sugar will be deposited in a regularly crystalline form. 

The sugar is sometimes so abundant, that it undergoes a rude crystallization as 
the urine dries, wherever it happens to fall. A girl who was in St. Bartholo- 
mew's Hospital, while I was a student there, observed that if her water was ac- 
cidentally sprinkled upon her black stuff shoes, every drop left a white powdery 
spot behind it. So also an aged patient under Dr. Maclntyre's care expressed to 
him her alarm at finding that her black worsted stockings were covered with a 
white dust, from the same cause. A -man recently under my charge in the Hos- 
pital, complained that two pair of his black cloth trowsers had been spoiled in a 
similar manner. I remember hearing from a diabetic patient in the Edinburgh 
Infirmary, that his attention was first drawn to his urine by the number of flies 
and wasps which its sweetness attracted to the chamber-pot. 

This daily produce of sugar from the laboratory of the human body, is surely 
a very singular and surprising phenomenon. Sugar is not a constituent of healthy 
urine. Dr. Prout (who is more consulted on this subject than any one else, and 
whose experience in respect to it is commensurably great), says that he has never 
known saccharine matter to occur in the urine of any other animal than man. I 
once had a coach-horse which I supposed might have diabetes. He was a greedy 
feeder, and drank eagerly, yet he grew thinner and thinner ; and wherever I had 
occasion to stop, there he invariably began to stale : so that I became thoroughly 
ashamed of his leaking. Dr. Prout was good enough to examine his urine for 
me. It contained no sugar, but its healthy properties were much changed : it had 
less than the natural quantity of hippuric acid, and more of earthy matters. The 
disease, he tells me, is known at the Veterinary College ; whence specimens of 
such urine have been sent to him for inspection : but it is not true diabetes. 

The unnaturally high specific gravity of diabetic urine is a constant quality ; 
and you must attend to this, for it is almost always a faithful index, not only of 
the presence, but of the severity of the disorder. Dr. Prout places the specific 
gravity of healthy urine between 1015 and 1025, that of distilled water being 
represented by 1000. Different authors vary somewhat in their estimate of the 
natural standard ; but we may be content to follow Dr. Prout. He says that the 
specific gravity of diabetic urine has been stated to vary from 1020 to 1050: that 
he has many times seen it higher than this, but very seldom so low. In fact it 
ranges generally between 1030 and 1060 ; and the average may be taken at 1040. 

So much with reference to the quantity and qualities of the urine discharged 
in this complaint. It is attended, however, as you may suppose, with other and 
important symptoms. 

As so much fluid is evacuated from the body through this channel, it might be 
expected that the other channels for the excretion of liquid matters would be com- 
paratively dry : and so they are. The skin is arid, harsh and unperspirable. 
The patients tell you that they never sweat : that they cannot get into a perspi- 
ration. This is a very general symptom ; yet in some few patients, especially 
as the fatal period of the complaint draws near, the surface readily becomes 
humid. Again, the bowels are mostly costive, and the feces remarkably solid 
and free from moisture. • The tongue is dry, parched and sticky ; sometimes 
unnaturally red and clean : and the waste of watery particles from the system 
seems to be felt and expressed by the inordinate thirst which the patients suffer. 
Their drought is often insatiable. I remember one girl telling me that when she 
was debarred from an excess of water to drink, she would get up if she heard it 
raining in the night, and catch some of the descending drops to satisfy the tor- 
menting sensation of thirst. And another patient, a very sensible fellow, informed 
me that, believing it could not be good for him to drink so much, and feeling no 
confidence in his own resolution to refrain, he was in the habit of betaking him- 
self in the summer time to the fields and dry pastures, where no water was at 
hand to quench his strong desire for it. The appetite for food is often, but not 
always, equally keen ; and the patients, especially those in the lower ranks of 



DIABETES. 



887 



society, are apt to think, while they wonder at their weakness, that there cannot 
be much the matter with them, since ihey continue to eat and drink so famously. 

Again, the enormous daily drain upon the system may be expected to cause 
various symptoms and sensations which may all be referred to debility and defect- 
ive nutrition. Dr. Henry published a table, showing the quantity of solid extract 
in every wine pint of urine of different specific gravities from 1020 to 1050. 
Taking 1040 as the average specific gravity, and ten pints as the average quantity 
of the urine discharged daily, the patient would in this manner lose, every twenty- 
four hours, 15 ounces 7 drachms — or more than a pound and a quarter — of solid 
materials. 

We need not be surprised, therefore, at the hunger, the wasting, the hectic 
fever, the feeling of emptiness and sinking at the stomach, the debility, the chilly 
state of the body, and especially of the extremities, the aching and sense of 
weariness in the loins and legs, the aversion to exercise, the loss of virility ; all 
of which symptoms are generally present. I may add, to complete the picture, 
some others, enumerated by Dr. Watt, and confirmed by Dr. Prout, and consist- 
ent with my own experience of the disease. They are, uneasiness in the sto- 
mach after meals, flatulence and acid eructations, dimness of vision, redness of 
the whole interior of the mouth, sponginess of the gums, looseness of the teeth, 
and some degree of irritation and inflammatory redness about the external orifice 
of the urethra: these last are symptoms noticed in persons dying of inanition. 
Again, listlessness and depression of spirits, weakness and peevishness of temper : 
" the once vigorous mind becomes feeble, oblivious, and vacillating — the once 
amiable temper, fretful, suspicious, and intolerant." With all this there is a 
peculiar faint and unpleasant odour of the breath and person ; an odour which 
Dr. Prout says is hay-like, which some call melleous, but which reminds me, as 
as I said before respecting the urine, of the smell of a room in which apples have 
been kept. I have recognized the complaint, upon first entering the sick chamber, 
by this peculiar scent. 

Diabetes is generally a chronic disorder, creeping on at first insidiously, and 
spreading itself, under judicious management, over many years. Yet it is some- 
times fairly entitled to be called an acute disease ; for it occasionally breaks out 
suddenly, is attended with much febrile disturbance, and runs a short course, 
uncontrolled by any treatment. One such instance I have seen. Much more 
frequently it proves fatal through the supervention of some organic mischief, such 
as debility is calculated to foster and develop. It often becomes associated in its 
progress with pulmonary disease, especially with tubercular phthisis. So com- 
mon is this, that some persons have thought it universal. But it is not so. I 
have myself witnessed more than one or two dissections of persons dead of 
diabetes, whose lungs did not contain a single tubercle. Sometimes the disease 
terminates in incurable dropsy : and sometimes the patient is cut off suddenly, 
either by apoplexy, or by some peculiar affection of the stomach. 

There is some kind of connection between diabetes and certain affections of the 
skin, and of the subjacent reticular membrane. Dr. Prout remarks that it usually 
follows cutaneous complaints, but accompanies or precedes those which involve 
the areolar tissue. Persons have been known to lose chronic eruptions upon the 
supervention of diabetes. On the other hand, carbuncles and malignant boils are 
frequently the companions of that disorder. The examination of the dead body 
throws little or no light upon the pathology of diabetes. We naturally look with 
interest to the kidneys. But we find nothing there to explain the symptoms 
noticed during life. What I have usually remarked has been a deep purplish red 
colour of the kidneys, which were veined and vascular, but not otherwise altered 
in texture. Andral and others tell us that the kidneys are found hypertrophied 
in diabetes. But hypertrophy, and unnatural vascularity, are circumstances 
which we are not surprised at when we reflect upon the vastly increased quantity 
of work which the glands have been performing. We must regard both these 
unnatural conditions rather as being the consequence, than as being the cause, of 



888 



DIABETES. 



the morbid flow of urine. In one instance, after sudden symptoms of gastritis, 
which followed the incautious potation of strong ale, I found the mucous mem- 
brane of the stomach distinctly inflamed, in its cardiac portion. I have found also 
the mesenteric glands diseased, converted almost entirely into bone. But neither 
of these changes is constant. They were purely accidental in those particular 
cases. 

What, then, is the origin and source of this strange complaint? whereabouts in 
the body is the sugar formed? is it made, by the kidneys, from the blood? or is 
it made, from the food, by the stomach ; and carried into the blood to be simply 
cast out through the urinary channels ? oris it elaborated in some intermediate 
stage of what Dr. Prout has called the secondary assimilation ; which includes 
the formative and the destructive processes that take place in the body subse- 
quently to the act of sanguification ? These questions, which are full of interest, 
have been much debated; and until very lately pathology was unequal to their 
solution. It was naturally thought that, if the sugar pre-existed in the blood, and 
was only withdrawn from it by the kidneys, it would be discoverable in the 
blood. Yet able chemists sought for it there in vain. Hence it was inferred, that 
by some new combination of its elements, saccharine matter was actually formed 
in the kidneys. The chemistry and the reasoning were both faulty. Sugar has, 
now, been detected in diabetic blood. It is detected with some difficulty, partly 
perhaps because its presence is masked by the albumen of the serum, but partly 
because its quantity is small ; and its quantity is small because it is continually 
decanted out of the blood, as fast as it enters, and with it a profusion of water also, 
through the kidneys. In this respect the sugar and the urea are alike. They 
are both excretions which the blood is in haste to cast forth. It would seem also 
as if the sugar necessarily carried with it a large quantity of aqueous fluid from 
the blood, and was simply diuretic. When the amount of sugar eliminated is 
diminished, as by certain remedies it may be, the quantity of urine diminishes too. 

Traces of sugar had, I believe, been found in the blood by some previous in- 
quirers : but it is to Mr. M'Gfegor, of Glasgow, that we are indebted for the full 
exposition of this interesting fact. His researches, published last year (1837) in 
the Medical Gazette, have thrown a new and strong light upon the pathology of 
diabetes. 

By a peculiar process, he did, I say, that which many preceding chemists had 
failed to accomplish ; he detected sugar in the serum of the blood of diabetic 
patients. The serum had a milky appearance he says; and I have seen that 
myself : its specific gravity was above the healthy standard. Having coagulated 
the serum by heat, he carefully dried it; then cut the dried mass into very small 
pieces, and boiled them in distilled water ; and lastly, he evaporated the decoction 
to a certain point. To the liquid thus concentrated he added a portion of yeast, 
and the presence of sugar was manifested by the fermentation which ensued, and 
which lasted for several hours. Yeast, I should tell you, is a most delicate test 
of sugar, and will readily detect half a grain in two ounces of liquid. 

Mr. M'Gregor went a step further back. He obtained, by means of an emetic, 
the digested food from the stomachs of two men who had dined two or three hours 
before. One man was in health ; the other had diabetes. In each case the food 
had been of the ordinary kind. Applying, after due preparation, the test of yeast, 
he found that the vomited matters fermented strongly; especially those from the 
diabetic patient. 

Then he varied the experiment. Thinking that the sugar, in these cases, might 
have been introduced in the vegetable portion of the food, he adopted precautions 
to exclude that possible source of fallacy. He administered to a healthy man, 
and to a diabetic man, a vomit and a purge, to clear out the alimentary canal. 
Next he fed them upon roast beef and water,'and nothing else for three days. Then, 
three or four hours after a meal, the contents of their stomachs were procured by 
the operation of the sulphate of zinc* as an emetic ; and treated as in the former 



DIABETES. 



889 



case. What the healthy man vomited did not ferment at all. What came from 
the diabetic patient fermented " pretty briskly." 

The fault, then, we may safely conclude, lies in the digestive organs. Instead 
of healthy and nutritive chyle, saccharine matter is prepared by the stomach, and 
enters the circulation. That which should be converted into muscle, and fat, and 
bone, and nerve, and membrane, is hurried out of the system, as sugar, with the 
urine. Thus far we see our way with tolerable clearness. But why the stomach 
should cease to perform its accustomed chemistry upon the food, and even upon 
sugar itself as an article of food, we have not yet learned. That single important 
step is still wanting to the complete solution of the pathological problem. 

I may mention that Mr. M'Gregor carried his inquiries further still, and met 
with some curious results. He examined the saliva ; the feces ; and the sweat. 
He found sugar in the saliva. He could find none in the sweat. The feces of 
one patient, allowed to dry spontaneously, became covered, after the lapse of some 
time, by distinct crystals of sugar. And yeast having been administered to two 
patients, in ounce doses, after each meal, had soon to be discontinued, because 
the patients, to use ther own expressions, felt as if they " were on the eve of 
being blown up." 

We know but little about the causes of diabetes. It is not a very common 
disorder; and in those who become afflicted with it, there probably has existed a 
predisposition to it. Dr. Prout remarks that the complaint runs sometimes in 
families, and is inherited. I had under my own observation, for some time, three 
children, two brothers and their sister, all affected with diabetes. The mother, 
a maternal uncle, and a sister of a friend of mine, all died of this malady. The 
same author mentions among the predisposing causes, long- continued intempe- 
rance, and especially the immoderate use of spirits, severe evacuations, excessive 
labour joined with a poor acescent diet. Distress and anxiety of mind are held 
also, and justly I think, to be among the predisposing causes. It occasionally 
seems to be produced, at once, by the operation of some exciting cause, such as 
exposure of the body to cold ; or the drinking of large draughts of cold fluid while 
the person was hot and perspiring. Dr. Bardsley states that, in twelve instances 
of the disease which had fallen under his own notice, the patients attributed their 
ailment to one or the other of these two causes. Now these are common causes 
of disease ; and that a predisposition does exist is probable from the fact, that 
where the exciting cause has acted on several individuals at the same time, one 
alone has become affected with diabetes. There is a narrative illustrating this, by 
Sir Henry Marsh, in the third volume of the Dublin Hospital Reports. A patient 
of his traced the apparent origin of his diabetes to exposure to wet, cold, and 
privation, at sea, while in imminent danger of shipwreck. Another of the crew 
fell ill of ague. Others escaped entirely, or had only common colds. 

If the account which I have been obliged to give you concerning the intimate 
nature, and the causes, of this curious malady, should appear unsatisfactory, so 
also, I fear, will what I have still to say respecting its cure. I dare not affirm that 
diabetes, although it seems a merely functional disorder, has ever been cured. Dr. 
Prout has known some few patients, two perhaps, or one, recover. Apparent 
recoveries — nay, apparent cures — are not very uncommon. And this it is of great 
importance to know. Remedies are not useless because they fall short of their 
full scope. It is better to keep a man on the edge of a precipice, if you cannot 
pluck him away from it, than to let him fall over. And many diabetic patients 
are kept in this predicament of dangerous safety. There are certain remedies 
that exercise a strong controlling influence over some of the most prominent and 
troublesome of the symptoms ; and that sometimes even restore the patient to a 
state which he mistakes for health; and which a medical man, unwarned of its 
fallacious character, might also mistake. The urine may recede within the natural 
limits. There may remain one morbid circumstance only, and that of a nature 
easily overlooked : indeed it is sure to escape observation if it be not especially 
searched after. 1 allude to the unnaturally high specific gravity of the urioe. 



890 



DIABETES. 



So long as the density of the urine continues permanently and decidedly above the 
healthy standard, there is no real security. The smallest disturbing cause — expo-' 
sure to cold, an intemperate, meal, unusual exertion and fatigue, sudden or strong 
mental emotion — may bring back all the symptoms in their former severity. If 
these and similar hurtful agencies can be averted, life may sometimes be prolonged, 
in much comfort, for many years. 

There are three objects to be kept in view, in the treatment of every case of 
diabetes. 

First, to restore the defective power of the digestive apparatus : 

Secondly, to cut off, or restrict as much as possible, the supply of saccharine 
matter from without: 

Thirdly, to mitigate or remove the most distressing symptoms. 

If we could achieve the first of these objects, the other two would fall out of 
sight ; for the disease, which is really a variety of dyspepsia, would be cured. 
But hitherto all the resources of our art have, in this respect, been baffled. Our 
main hope of ultimate success must lie in the regulation of the ingesta; whereby, 
also, the second indication is to be fulfilled. Some of the food is, in every case, 
carried to the proper amount, or the patient would speedily die. If we can sue 4 - 
ceed in directing a sufficient amount of healthy nutriment to the organic tissues of 
the body, the draining away of any superfluous sugar will be borne well enough. 

About the beginning of the present century, Dr. Rollo discovered and taught 
that a diet composed exclusively of animal matters had a signal effect in reducing 
the quantity and in diminishing the sweetness of diabetic urine. Mr. M'Gregor's 
experiments tell us why this is. Animal food furnishes but scantily the materials 
for the formation of sugar. " The saccharine alimentary principles are chiefly 
derived (says Dr. Prout) from the vegetable kingdom, and indeed constitute what 
may be called, by way of distinction, vegetable aliments.'''' If, then, we can ex- 
clude aliments of this kind, and confine the patient to animal food alone, we thus 
cut off the supply of the materies morbi; and without indeed curing the disorder, 
suspend its worst effects. But unluckily very few persons can long endure this 
mode of living. So far as they can endure it, they are comparatively safe. We 
are obliged to relax, in some degree, the rigour of our rule ; and it is curious to 
observe how suddenly and decidedly the saccharine properties and the quantity 
of the urine are augmented, when, by stealth, or by permission, the patient adds 
to his meal the smallest portion of vegetable food — even a biscuit or two. 

We must therefore contrive to vary the animal diet as well as we can ; encourag- 
ing the patient by a free license to choose among the different kinds of meat, 
game, poultry, and eggs, in their diversified modes of preparation, and admitting 
into his bill of fare as small an admixture as possible of vegetable substances. 
Green garden-stuff, the oleracea, spinach, cabbage, celery, and the like, may be 
taken with less risk of increasing the saccharine matters in the system, than 
potatoes, and those other articles of vegetable diet which contain a notable pro- 
portion of sugar, gum, or starch. All kinds of fruit must be forbidden. You will 
seldom be able to debar your patients entirely from bread : none should be allowed 
but such as is well fermented, and somewhat stale, or thoroughly toasted ; and 
even that as sparingly as may be. 

It is also of much importance to admonish the patient, whose appetite is gene- 
rally ravenous, against eating too large a quantity, even of animal food, at any one 
time. Not only is the digestion still further weakened and oppressed by an in- 
temperate meal, but the patient's life may be put in peril by every such act of 
unwise indulgence. Of this I have witnessed one example, and have heard of 
several more. 

The quantity of drink should likewise be limited. It may properly enough 
consist of animal broths: and these should be taken tepid, for they are then more 
likely to be taken in moderation. The patients must, however, and will, have 
something else, to slake their urgent thirst. I have found (acting upon a sug- 
gestion of the elder Dr. Latham) that distilled water, acidulated with phosphoric 



DIABETES. 



891 



acid, appeases, more than most things, that painful sensation. The water of the 
Bristol Hotwell, which contains carbonate of lime in solution, is praised by Dr. 
Prout for the same purpose. 

Dr. Christison gives an important caution in respect to drinks; viz., that, when 
the thirst has already been much indulged, the quantity of liquid taken must not 
be greatly reduced all at once. Sudden failure of the vital powers has not unfre- 
quently ensued upon abrupt changes of that kind. 

Very numerous are the remedies which have been tried, and which have been 
recommended, for this disorder. I shall notice those only of which I have had 
personal, and in some degree favourable experience. 

The first of these is blood-letting, which has been strongly advocated by Dr. 
Watt, of Glasgow, and by Dr. Satterley, formerly one of the physicians to the 
Middlesex Hospital. It is not a remedy which would naturally occur to one's 
mind as being likely to prove of service in such cases ; but both the authors I 
have mentioned speak of it in terms of high commendation. They affirm that, 
under small and frequent bleedings, the strength increases; the clamminess of the 
mouth, and dryness of the skin, diminish ; and the blood by degrees, assumes the 
bufFy coat. I have once seen the method of frequent blood-letting fairly put to the 
test. At first, the patient did seem to be benefited by it; but she ultimately died : 
and I am satisfied that her death was accelerated by one bleeding too many, or 
by too large an abstraction of blood at one time. 

This measure has the best chance of being useful, when the malady is recent, 
and attended with febrile disturbance. In chronic cases, in old persons, and when- 
ever the debility is already great, venesection can seldom be requisite or proper ; 
although even then, as Dr. Prout remarks, it may be borne better than one might 
expect. Local bleeding is, however, of much service in relieving local uneasi- 
ness. Leeches may be applied to the epigastrium, if the patient has tenderness 
there, or complains of a sense of fullness or of burning in the stomach. Cupping 
to the loins, if they greatly ache. 

Opium is a treasure to us in this disorder. It quiets the nervous irritability of 
the patient, allays many of his most distressing sensations, and restrains in a 
remarkable manner the morbid profluvium from the kidneys. But you must not 
suppose, from observing these favourable changes, that you are curing the disease 
by it. It appears to control the diuretic influence of the sugar in the blood ; but 
it does not banish the sugar itself. And, as far as my experience goes, Dr. Prout 
is in the right when he states that moderate doses of opium generally suffice to 
check the excessive discharge. Five grains of Dover's powder, for example, 
three times a day, will do as much good, and on the other hand be productive of 
far less inconvenience, than larger quantities of that narcotic substance. The 
sudorific properties of this compound are thought to render it eligible ; although 
it has seldom any apparent effect, in that way, in diabetes. If the ipecacuanha 
which it contains should disagree with the stomach, an equivalent quantity of any 
other preparation of opium may be substituted for it. 

There is another remedial measure which has also, in some cases at least, a 
most beneficial influence on the condition of the patient; I mean forced perspi- 
ration — perspiration induced by the hot-air bath. Of this I have seen some 
striking examples. A very well-marked case of diabetes came under my care in 
the Middlesex Hospital several years ago. A vapour, or hot-air bath, had just 
then been constructed in the hospital, and I thought it a good opportunity for 
trying whether the suspended functions of the skin might not be restored, and the 
extravagant action of the kidneys perhaps corrected, by that powerful mode of 
exciting perspiration. I should tell you that other plans of treatment had already 
been put in force, with but partial advantage. It would occupy more time than I 
can now spare to enter upon the details of this case ; but I will read to you the 
man's own statement, which he wrote down before he left the hospital, in evidence 
of the benefit he derived from the sudatorium, 

il The urine" (these are his words) «* is reduced more than one-ha.lf s and do©a 



892 



DIABETES. 



not contain much sweetness, but sometimes tastes salt, with a mixture of bitter. 
My stools, which were dry, and like balls packed together, are now quite natural. 
The pains in my limbs are entirely removed. My spirits, which were very much 
depressed, are now revived, and cheerful. The unpleasant aching of my kidneys, 
of which I spoke little lest I should be cupped in the loins, is now removed ; 
only I feel weak there. I am cured of the pain in my stomach, and the circuitous 
working of the wind in my bowels, which formed lumps in my belly as it passed, 
resembling those formed by the cramp. I have likewise got rid of the palpitation 
at my breast, which was accompanied with a sort of dread. My breathing is 
much improved; perspiration, in a great measure, restored ; and my skin, which 
was dry, is now become moist. J sleep well at night, whereas I could not sleep 
more than two or three hours out of the twenty-four. My thirst, which was 
excessive, has ceased to be troublesome." 

This man, who, in the statement I have just read, has so graphically described 
his own morbid sensations, and the relief from them which he had obtained, left 
the hospital thinking himself well : but, the specific gravity of his urine remained 
above 1030. 

In about half a year afterwards, he went one evening to Hyde Park to see some 
fire- works, got wet feet, and began to cough. The . diabetic symptoms returned 
more severely than ever ; and he soon died. I found his lungs stuffed with 
tubercles. 

In furtherance of the principle upon which the use of the hot bath is recom- 
mended, the other well-known methods of promoting the natural functions of the 
skin should be followed ; friction, and more especially warm clothing. 

Steel is sometimes singularly beneficial in repairing the strength, and enlivening 
the spirits ; as indeed it is well known to be in other forms of disease attended 
with a copious and permanent drain upon the system, and with a diminution of 
red blood. Of course it may be combined with opium, or with any other medi- 
cine which the circumstances of the patient may render needful. 

I scarcely need say that the bowels require attention. Not that active purga- 
tion is advisable, but simply their regulation. Castor oil, rhubarb, aloes, lenitive 
electuary, are more appropriate in these cases than the purgative salts, which are 
apt to be diuretic also. 

There is one other drug from which I think I have seen the happiest effects. 
I mean the creasote. I first became acquainted with its virtue, from prescribing 
it, almost accidentally, until a consultation could be arranged with Dr. Prout, for 
a child, eight years old, in whom the disease was well marked, and who had been 
brought to London from the country for advice. She had been rapidly wasting 
away for ten weeks, was extremely feeble, soon tired, very thirsty, especially at 
night, and had (what was also new to her) an enormous appetite. She was pass- 
ing from three pints , to two quarts daily of pale urine, having a specific gravity 
greater than 1040. I desired that her diet should be as exclusively animal as she 
could bear, and that she should take one minim of creasote, suspended by means 
of mucilage in an ounce and a half of water, three times a day. Curiously enough, 
the child liked the tarry flavour of the medicine. Upon this plan, with gentle 
aperients occasionally to regulate her bowels, she remained for upwards of a 
twelvemonth. Her urine soon fell in quantity within the limits of health, and in 
density to about 1030. She regained her lost flesh, strength, complexion, and 
spirits, and grew considerably. At length she suddenly sank under an obscure 
affection of the chest. A brother of this little girl has lately manifested unequi- 
vocal signs of the same complaint; and in him it appears to have been equally 
checked by the same method of treatment. I have detected sugar in the urine of 
another boy belonging to the same family. 

There were two points in this young lady's case which deserve a passing 
remark. As her urine diminished in quantity it began to deposit the lithates. 
This Dr. Prout considered a very promising earnest of a return to a better diathe- 
sis ; and I find that in bases which have crept on insidiously from the first, he is 



CHRONIC DIURESIS. 



893 



accustomed to date the malady from the time when lateritious sediments, pre- 
viously common, disappeared from the water. 

The other point was, that calomel always sickened this child, and aggravated 
all the diabetic symptoms. This is consistent with Dr. Prout's experience, who 
tells us that he has never seen mercury do good in diabetic disease ; but on the 
contrary almost invariably do mischief. I would advise you to read his judicious 
observations upon the too common abuse of that mineral. 

I am quite aware of a possible fallacy in the case I have been mentioning, with 
respect to the efficacy of the creasote. With the use of that drug was associated 
a stricter adherence to a purely animal diet ; and it is impossible to estimate with 
precision the separate effects of these two remedial measures. I am, however, 
disposed to believe that the creasote, by its well-known preservative property, 
cheeks the conversion of the food into sugar. And I think it is a mistake to go 
on increasing the dose. To most stomachs it proves irritating and hurtful when 
pushed beyond a certain small amount. Dr. Maclntyre tells me that he has 
found the creasote very useful in diabetes. I must, however, acknowledge that, in 
common with others, I have sometimes been totally disappointed by it. 

For many years of my professional life I had not met with an instance of what 
has been called diabetes insipidus: from which I infer the rarity of that disorder. 
I shall use the term chronic diuresis to express this affection. , 

Very recently a marked instance of such chronic diuresis has presented itself 
in the hospital. A boy, eleven years old, not unhealthy looking, but lean, was 
admitted there under my care. He was much troubled by thirst ; and by frequent 
micturition, which, even in the night, disturbed him many times. His bowels 
were costive, he had a capricious appetite, and his skin was dry. He voided 
during the twenty-four hours several pints, seldom less than nine or ten, of simply 
dilute urine, of a faintly yellowish hue, and having the specific gravity of 1002. 
Sometimes* indeed, it was found to be scarcely heavier than distilled water. In 
other respects he appeared tolerably well. It was supposed that he had been 
affected in this way for about twelve months ; his desire for drink having been 
the first symptom noticed. 

During his residence, of many weeks, in the hospital, under my observation, 
I made trial of every plan and drug that I could think of, for repressing the un- 
natural flux of urine. Nothing did him any good : some things, I fear, by dis- 
turbing his stomach and bowels, did him some temporary harm. He went out 
much as he came in. 

Although I can tell you neither upon what this disorder depends, nor how it 
may be remedied, I mention the case because it afforded me a proof that liquid 
may be absorbed into the body from the atmosphere ; either by the external skin, 
or by the pulmonary mucous membrane, or by both these surfaces. Dr. Prout, 
to whom I showed both the urine and the patient, advised that, for a time, his 
supply of drink should be limited. Accordingly, very much to the poor boy's 
sorrow, he was put upon a daily allowance of a pint and a half. I have no doubt 
that my injunctions were strictly observed, both by himself and by the nurses. 
Nevertheless, without losing flesh or weight, he passed, during the corresponding 
twenty-four hours, ten pints and a half of urine. 

I got evidence of the same fact in another way also ; namely, by weighing the 
boy at short intervals : although the experiment was not repeated so often as I 
wished it had been. I give you the results of one of these trials. 

Immediately after he had emptied his bladder he was found to weigh 3st. 81b. 
0 oz. 3 dr. Three hours subsequently, having taken nothing in the interim, he 
weighed 3 st. 9 lb. 0 oz. 2 dr. Then he voided 16 oz. of urine : after which his 
weight was again 3 st. 8 lb. 0 oz. 3 dr. So that he must have imbibed about a 
pound of liquid in that brief space of time.* 

* This boy lived more than two years afterwards, and continued to void an excessive 
quantity of pale, neutral urine, scarcely heavier than distilled water. After death, scrofu- 



894 



ALBUMINOUS URINE. 



In this instance there was merely an excess in the aqueous ingredient of the 
urine ; the solid matters were apparently there, in their due proportion to each 
other, but in a very small ratio to the water. 

But the aqueous ingredient may be in excess, while the absolute quantity of 
urea is deficient. On the other hand, with an excess of the watery material, there 
may be an excess also in the quantity of urea it contains. 

Dr. Willis has distinguished these three varieties of chronic diuresis by the 
terms hydruria, anazoturia, and azoturia, respectively. Although I am no friend 
to the multiplication of technical names, I must tell you that the distinctions 
expressed by these terms are real, and of some importance. Anazoturia we shall 
find to be often symptomatic of a peculiar organic disease of the kidney, which 
I hope to describe in the next lecture. 

Azoturia, which is accompanied by an unnaturally high specific gravity of the 
urine, is apt, on that account chiefly, to be mistaken for diabetes. As recoveries 
from it are not uncommon, it may be suspected that some of the boasted cures of 
diabetes were cures of this less serious disorder. In the one case, the yeast test 
detects the presence of sugar in the superabundant urine ; in the other case it finds 
none. 



LECTURE L XXVIII. 

Albuminous Urine. Means of detecting the Albumen. What it imports. 
Anatomical characters of Brig/it's Kidney. Symptoms to which this renal 
disease gives rise. Nature of the affection. 

Another morbid condition of the urine, imperatively demanding your attention, 
is that in which it is habitually impregnated with albumen. This albuminous 
condition is much more common, and in general not less serious, than the saccha- 
rine condition which I described yesterday. 

There is no albumen in healthy urine. Neither can we recognize its presence, 
in any urine, by mere inspection. We detect it by certain tests : and I will tell 
you, in the first place, what these are; and how to use them. 

Albumen — of which we have so familiar an example in the " white" of eggs 
— begins to pass from the fluid to the solid state at the temperature of 160° Fah- 
renheit. When diluted it may require for its complete coagulation the heat of 212°. 
Hence one simple and easy test of its presence. We discover that albumen is 
contained in the urine, by heating that fluid to the boiling point. This is most 
conveniently done in a small glass tube, by the flame of a spirit lamp. It is 
seldom that any preparation of the suspected urine is requisite. It may, perhaps, 
be hazy in consequence of its containing mucus ; and if its transparency be much 
troubled, it will be well to filter the fluid before testing it. When, as sometimes 
happens, albuminous urine is already turbid from the presence of the lithates, 
these dissolve as the heat is applied, and the urine first becomes clear ; and then, 
as the temperature rises, the albuminous opacity begins to be visible. 

The phenomena observable in the heated urine vary in different cases, chiefly 
by reason of the variable amount of albumen. The whole is sometimes converted 
into one gelatinous mass: but this is uncommon. Usually the albumen first 
appears in the form of a whitish cloud, of which the constituent particles multiply, 
and collect, in proportion as the quantity is considerable, into small curdy fragments 
or flakes. These soon subside to the lower part of the tube, leaving the super- 
natant liquid clear. The amount of albumen is of course to be estimated by the 
portion of the tube that it occupies. 

lous tubercles were found in his brain, and in his lung??. His kidneys were gorged with 
venous blood, but of healthy structure. There was nothing wrong, apparently, in his or- 
gans of digestion. 



BRIGHT'S KIDNEY. 895 

Now this test, by heat, is not conclusive, nor sufficient. There are circum- 
stances that may impede or prevent its effect in coagulating albumen, which, 
nevertheless, is present. On the other hand it may, under other circumstances, 
produce a fallacious appearance of albumen where none exists. 

Albuminous urine has often a less acid reaction with litmus paper than healthy 
urine. The reason of this I will explain presently. When recently discharged 
from the bladder the urine may be neutral or even alkaline; or it may become 
neutral or alkaline, by spontaneous decomposition after it has left the bladder. 
In any case, the urine, thus alkaline or neutral, will not coagulate when heated, 
even though it may be full of albumen. Again, although there may be no albu- 
men, heat may cause a flaky precipitate, consisting of the earthy phosphates. 

We avoid, or remedy, these sources of fallacy, by testing the suspected urine 
with nitric acid also, which has the property of precipitating the albumen in a 
flaky or pulpy form. It will thus detect albumen when the tested urine is alka- 
line ; and by restoring its acidity, it would make the albumen discoverable by the 
test of heat. It has likewise the effect of redissolving the spurious precipitates 
which may be thrown down by the application of heat, and consequently of show- 
ing that they are spurious. 

Nitric acid alone, however, is not, any more than heat alone, an unequivocal 
touchstone of the presence or absence of albumen ; for it may occasion a flaky 
precipitate of lithic acid, when there is no albumen. But this defect is compen- 
sated by the complementary criterion of heat; the precipitate being redissolved 
by raising the temperature of the urine, while any coagulated albumen remains 
insoluble. 

Dr. Christison states that, in his experience, "sometimes nitric acid added in 
excess did not separate albumen which had been present in large quantity" — a 
fact which he thinks " is probably to be ascribed to the albumen itself having un- 
dergone more or less decay, along with the other principles of the urine." Hence 
the urine should, if possible, be examined before it has become decomposed by 
lapse of time. If, however, you employ both these tests with different portions 
of the same urine at the same time, and with the same portion in succession, you 
will avoid all risk of mistake. 

Other tests there are, frequently spoken of, and sometimes recommended: par- 
ticularly the ferrocyanate of potass, corrosive sublimate, creasote, and oxalic acid. 
They are unnecessary, in addition to heat and nitric acid ; and they are liable to 
fallacies from which these last, when combined, are free. Unless you are expert 
chemists, you had better avoid them. 

Now it is quite certain that the presence of albumen in the urine does often 
accompany and bespeak a very serious organic disease of the kidney. For this 
disease we have no appropriate name. I wish we had. Some call it granular 
degeneration of the kidney, but the epithet granular is not always applicable. It 
is most familiarly known, both here and abroad, as Brighfs kidney or Briglifs 
disease; after the eminent physician who, in 1837, first described it, and showed 
its great pathological importance. These are odd-sounding and awkward terms; 
but in the lack of better I must employ them. 

It is very difficult to describe, in words, the anatomical characters proper to 
this renal disease ; for they are neither very definite nor very constant. The 
description that I am about to attempt will be made more intelligible by Dr. 
Bright's plates, and those of M. Rayer, which are both before you. 

The morbid appearances presented by the substance of the kidney are such as 
denote some change in its intimate structure. Its cortical (or secreting) portion 
is the primary and chief seat oj" this degeneration ; yet what is called its medul- 
lary (i.e., its excreting) part, is also sometimes implicated, but in a less degree. 

These morbid appearances relate to the size, figure, and consistence of the 
kidney; to the colour and condition of its surface, and of its interior. With 
respect to some of these points there is much variety in different cases ; and 
studying this variety under the light which is thrown upon it by the clinical his- 



896 



BRIGHT'S KIDNEY. 



lory of the disease, we have reason to believe tKat it is connected with different 
stages of the disorganizing process. Thus if we look to the size of the diseased 
organs, they are sometimes much larger than natural, sometimes of the ordinary 
magnitude, sometimes considerably smaller. The average weight of the adult 
human kidney is four ounces. M. Rayer has met with some, in this disease, 
weighing twelve ounces. Both the increment and the decrement of the natural 
bulk belong principally, if not altogether, to the outer secreting portion of the 
gland. If a longitudinal section of the exaggerated kidney be made, its cortical 
part is seen to be unduly broad ; and the same part is disproportionally narrow 
when the whole organ is smaller than common. For this reason, in the latter 
case, the radiating medullary portions approach nearer to the surface than they 
are observed to do in a healthy kidney. And it furthermore appears that the en- 
largement is most commonly coincident with the earlier, and the contraction or 
shrinking with the later, stages of the renal disease. 

The consistence of the diseased gland is variable also. Sometimes, and for the 
most part in the earlier periods, it is soft and flabby : sometimes, and especially 
in the later periods, it is remarkably compact and hard. The size and the con- 
sistence of the kidney are, in most cases, inversely proportional to each other. 

Again, the form of the kidney, in the disease in question, often undergoes some 
modification. As the special change proceeds, the exterior of the gland shows a 
tendency to become indentedjby linear depressions, and to present a lobular shape. 
This, however, is by no means a constant phenomenon, even in the most ad- 
vanced stage of the malady. 

When its proper investing tunic is stripped off — and less distinctly through the 
same tunic, before its separation — the surface of the kidney appears mottled, 
marbled, or stained ; of a yellowish-gray colour in one place, and of a dark or 
purple tint in another. Occasionally it is pale throughout its whole extent; more 
commonly of divers hues, and variegated with little streaks, which are portions 
of vessels containing red blood. Sometimes the surface is curiously speckled ; 
often uneven as if strewed with prominent grains ; in some instances quite rough 
and scabrous. These several unnatural appearances are usually the more con- 
spicuous, in proportion as the complaint is the more advanced. 

The most uniform, however, and the most characteristic of the morbid appear- 
ances, are those presented by the cut surface of the kidney, when it has been 
divided into two symmetrical portions by a longitudinal incision. We then per- 
ceive that the cortical substance is the main seat of the morbid alteration. It has 
lost, in a greater or less degree, its proper red colour and uniform aspect. Some- 
times it puts on a speckled or granular appearance ; but this, in my experience, 
is less common than a pale, nearly homogeneous surface, somewhat like the sec- 
tion of a parsnip. Its natural striae are confused or obliterated. The incised 
surface gives one the notion of some deposit, whereby the original texture of the 
part is obscured. The blood-vessels seem, many or most of them, to have been 
emptied by compression, or to be blocked up by yellowish solid matters ; while 
the healthier pyramidal masses belonging to the medullary portion of the kidney 
are displaced, and pushed aside, or encroached upon by the same yellowish mat- 
ter, which sometimes interposes itself between, and opens out, their radiating 
tubuli. Together with these changes of appearance and structure, I have several 
times found the veins that emerge from the kidney firmly plugged up by coagula 
of blood. 

In some rare cases the kidney is studded, both on its surface and throughout its 
interior, with numerous small cysts or cells, containing a thin transparent liquid. 
These cysts have been inaccurately termed hydatids. It is not at all uncommon 
to meet with one or two such cysts in this diseased state of the organ. 

It has been made a question whether the various appearances which I have 
been attempting to describe, and which sensibly differ in degree and combination 
in different cases, are characteristic of different morbid conditions, or merely of 
different stages and varieties of the same essential change. Our knowledge of the 



SYMPTOMS. 



897 



subject is scarcely sufficient to supply a positive solution of this question. Ex- 
cepting perhaps the cysts, ray own opinion is, that they are all accidental forms 
and effects of one and the same morbid process. At the same time I ought to tell 
you, that both Dr. Bright and Dr. Christison appear to incline to the opposite 
conclusion. 

There is still another state of the kidney, very different to the eye from any 
that I have yet mentioned, but which has been thought, and which 1 think, to be, 
in some cases at least, the first stage of all in the disorganizing process. This 
state, which I referred to when speaking of suppression of urine, may be briefly 
described in two words — sanguine congestion. The whole organ is gorged with 
blood, which sometimes drips freely from it when it is cut open. The kidney is 
in general large, somewhat flabby, of a deep dark red, even of a chocolate or 
purplish colour nearly uniformly diffused, except that the cut surface is usually 
diversified by still darker tuft-like spots, which have been ascertained to be the 
Malpighian bodies filled with blood. This change from the natural appearance 
of the kidney is evidently of a recent kind ; and the symptoms that have been 
observed to belong to it are these:— Fever preceded often by rigors ; uneasiness 
or dull pain in the loins ; nausea and vomiting; a very scanty secretion of urine, 
which is sometimes tinged with blood, and always albuminous ; occasionally 
complete suppression of urine. To these symptoms there is presently added, in 
most cases, sudden and general anasarca — what is commonly called inflammatory, 
active, or febrile dropsy. If the secretion of urine be entirely suspended, death 
soon ensues by coma, as I explained to you yesterday ; but if not, the disorder is 
frequently fatal by the supervention of some acute internal inflammation ; pleurisy, 
or pericarditis, or pneumonia, or peritonitis. Many persons recover completely 
from the condition expressed by this combination of phenomena. Many seem to 
recover, but bear about with them the germs or beginnings of those more chronic 
and latent changes which constitute " Bright's kidney." 

And what are the signs which indicate, to an instructed eye, the presence of 
those changes? Some of them are precisely the same, in kind, as those which 
denote the acuter disorder; only mitigated in degree, and of slower march and 
succession. The patients are subject to obscure lumbar pains.: to sickness from 
time to time, and retching; and their urine is apt to be red, brown, or dingy, as 
well as albuminous, from the intermixture of some of the colouring matter of the 
blood. They are obnoxious to inflammations of the serous membranes also ; and 
more particularly to head affections, of which they often die ; drowsiness, con- 
vulsions, apoplexy. And, to finish the resemblance, many of them, ay, most of 
them, become at length anasarcous. Besides these symptoms there are others 
which are not seen in the acute malady ; because it is acute. Gradually increasing 
pallor is almost constant ; disease of the heart is common ; and the skin, in general, 
even in the absence of fever, is remarkably dry and unperspiring. The patients 
are troubled by a frequent want to make water ; by flatulence of the stomach and 
intestines ; and by caprice of the bowels, which are sometimes obstinately cos- 
tive, sometimes prone to diarrhcea. 

Now it is worth your while to remark, with respect to this category of symp- 
toms, that (the state of the urine excepted) they have no special prima fade refer- 
ence to renal disease. They are all common enough in various other complaints. 
In truth they are mere secondary consequences of Bright's disease ; and in so far 
as they are symptoms of it, they are indirect symptoms. Before Dr. Bright no 
one perceived, in such symptoms, any indication of disease of the kidney. The 
primary and fundamental organic malady reveals itself by no direct symptoms^ 
excepting those which are furnished by the urine. 

Seeing, then, that this peculiar disease of the kidney is coupled with effects so 
grave and perilous, and seeing that one of its most positive and distinctive marks 
is an albuminous state of the urine, two questions of great interest at once present 
themselves. 

1. Does albuminous urine always imply the presence of Bright's disease ? 



898 



BRIGHT'S KIDNEY. 



2. Is Bright's disease, when present, always accompanied by albuminous urine ? 
To both these questions the answer is — no. 

It is certain that some articles of food have the effect, in some persons, of ren- 
dering the urine for a time albuminous: perhaps it would be more correct to say- 
that certain forms of indigestion cause this change. Albumen has also been de- 
tected in the urine under that general state of irritation produced occasionally by 
mercury, or by a blister to the skin. In the crisis of some febrile disorders, and 
in some cases of pregnancy, the same phenomenon has been observed. When- 
ever blood, proceeding from any part of the long tract of mucous membrane 
which lines the urinary organs, mingles with the urine, that fluid of necessity 
contains albumen, and eoagulates if tested by heat or by nitric acid. 

On the other hand, when the kidney is really affected in the way already de- 
scribed, the admixture of albumen with the urine is apt to disappear, for a while, 
even suddenly. I have known it vanish for several hours, immediately after the 
effectual application of a hot-air bath ; and after profuse purging by a full dose of 
elaterium. Sometimes it is absent for a longer period. 

Another important question, therefore, now arises. Finding albumen in the 
urine, how are we to know whether it does, or does not, indicate the presence of 
Bright's kidney ? 

We may judge, in part, by frequently testing the urine, and noticing whether 
the albuminous impregnation be transitory or persistent. In part also we judge 
by the absolute amount of the albumen in a given measure of urine. If the water 
be deeply charged with that unnatural ingredient, the presumption is strong that 
the kidney disease is in progress; and when that disease is confirmed, another 
remarkable change is found to have taken place in the urine. Its specific gravity 
is very low ; and strikingly in contrast with that of diabetic urine. This is there- 
fore a very strong additional diagnostic circumstance. 

On Dr. Prout's authority we have assumed the specific gravity of healthy urine 
to range between 1015 and 1025. Other writers make it higher. But the urine 
voided in Bright's disease is sometimes as low as 1004; and its mean specific 
gravity does not exceed 1013. 

I need scarcely again remind you, that the question of specific gravity must 
always be viewed in relation to the absolute quantity of urine seereted. The 
specific gravity depends, of course, upon the proportion of the solid constituents 
of the urine contained in a given quantity. If the aqueous portion be augmented, 
the effect upon the absolute density will be the same as if the solid contents were 
proportionally diminished. But when, as frequently ha-ppens in certain stages 
of this renal disease, the specific gravity decreases while the quantity of the urine 
decreases also, that conjunction of phenomena becomes especially significant. 

The density of the urine being thus unnaturally low, notwithstanding the addi- 
tion of the new substance albumen, it follows, as a matter of inference, that the 
solid constituents proper to healthy urine must be sensibly diminished: and they 
are found, in fact, to be so. These solid ingredients consist mainly of urea, and 
of certain salts. The aggregate solid contents amount, in health, to sixty-seven 
or sixty-eight parts in every 1000. In Bright's disease the amount has been 
ascertained to be diminished to twelve or fourteen parts, and even, in an extreme 
case, to less than this — to about six parts. 

The urine contains, then, albumen : and it is deficient in urea. These two 
facts suggested, naturally enough, to M. Solon, and to others, the notion that the 
albumen might be formed, by a sort of conversion, at the expense of the urea; 
since these substances, by a slight alteration in the ratio of their elements, pass 
respectively each into the other. But it is not so. Dr. Christison had observed 
many years ago, that when the urine was deprived of the greater part of its urea, 
the quantity of albumen contained in it was small ; and, on the other hand, in 
cases where the urea was considerable in quantity, the albumen was plentiful also. 
In a recent work on this subject, the same physician states that the whole of his 
subsequent experience has been in conformity with this observation. 



STAGES OF THE DISEASE. 



899 



It being certain, therefore, that the albumen is not vicarious of the urea, what 
(you may ask) becomes of the urea? It is detained in the blood ; and may readily 
be recognized there in considerable quantity : and herein lies, as I conceive, the 
secret of the secondary affections which belong to this disorder, and of its great 
fatality. The body is poisoned in detail by the retention of its own excrements. 
The blood not being duly purified through that great emunctory, the kidneys, is 
spoiled for its purpose of nutrition. Besides containing urea, it undergoes other 
and more manifest changes. Its proportion of fibrin varies ; and it gradually 
becomes poor in colouring matter; the serum is less albuminous also, and of a 
lower specific gravity, than in health. The quantity of albumen in healthy blood 
averages from sixty-five to sixty-nine parts in 1000. In this malady Dr. Babing- 
ton has found it reduced to sixteen parts. The average specific gravity of healthy 
serum is 1030; but in Bright's disease it descends to 1024, 1020, and even to 
1013. Now Dr. Christison has made out the very interesting fact, that there is 
a definite inverse ratio between the coagulability of the urine, and the density of 
the serum. The more albumen there is in the former of these fluids, the less is 
there in the latter, and the lower is its specific gravity. So that the deficiencies 
of the one fluid balance the superfluities of the other. All this is very different 
from what takes place in diabetes, in which sugar is excreted with urine that is 
otherwise healthy: whereas, in Bright's disease, urea, which ought to be dis- 
charged, remains in the blood; and albumen, which ought not to be separated, is 
taken from the blood and carried out with the urine. 

I have now described the changes presented by the kidneys in this disorder, 
the symptoms which attend it, and the morbid conditions both of the urine and of 
the blood. But these all vary and fluctuate at different periods of the complaint. 
I must next, therefore, endeavour to state what has been ascertained of its course 
and progress. 

When the chronic disorder is not a legacy left by the more severe and acute form 
of disease which I have termed febrile dropsy, it is apt to creep on very i si- 
diously, and to escape our notice: and its history is not yet fully known. It vviil 
be enough if I distinguish two stages of the malady— the early, and the advanced. 

In the early stage the urine is generally scanty. Instead of about 40 ounces 
in the twenty-four hours, the patient voids 16, 12, 8, or even so little as 2 or 3 
ounces. Sometimes the secretion is nearly or quite suppressed: and then the 
head seldom fails to become affected in the way already described. The urine 
has also an unnatural appearance. It is red, or dark, obscurely turbid, like muddy 
beer. It froths more than usual : and if you blow into it through a tube, you raise 
bubbles similar to those which may be formed in soapy water. Its specific 
gravity is somewhat, yet not greatly, reduced; about 1021, perhaps; it is seldom 
at this period so low as 1016. It contains an abundance of albumen. 

At the same early period, blood drawn from the arm exhibits the buffy coat. 
The serum is much diminished in density, and contains a considerable quantity 
of urea. There is no decrease in the fibrin ; perhaps it is a little augmented : and 
there is no great change in the amount of colouring matter. 

In the more advanced stages of the disease, the quantity of urine is frequently 
not below the standard of health; and it sometimes considerably exceeds that 
standard, so as to constitute one variety of chronic diuresis (anazoturia), which 
some call diabetes insipidus. It is usually pale, slightly opaque, and of a very 
low specific gravity; 1014, 1010, 1007. Once, when the quantity of the urine 
was not in excess, Dr. Christison found the specific gravity to be no more than 
1004. There is a corresponding reduction in the natural solid ingredients of the 
urine. Albumen, too, is present, but more uncertainly than in the earlier periods: 
fluctuations in this respect are more common than before. It is a mistake to 
suppose that the amount of albumen increases as the disorder advances. The 
contrary rule would be more near the truth. In general the albumen is plentiful 
and almost constant in the outset of the malady ; less surely present as it proceeds ; 
and sometimes entirely absent in its latter periods; and it is of importance to 



900 



BRIGHT'S KIDNEY. 



remark that the alteration in the specific gravity follows the opposite law. The 
declension of density, so far from being corrected, augments with the progress of 
the disorder. Hence the one of these morbid phenomena is a valuable check 
upon the other, considered as an index of what is going on in the kidney. 

And another fact, which it is essential for you to know and to remember, is, 
that, in any stage of the disease, the supervention of febrile disturbance, from local 
inflammation or whatever other cause, tends to renew, for the time, those qualities 
of the urine which belong to the early period. 

Meanwhile, the disease advancing, the serum of the blood recovers more or less 
its lost specific gravity, in proportion to the decrease of albumen in the urine. 
The quantity of fibrin seems, in some cases, to diminish. But the striking and 
most characteristic change is the rapid disappearance of the colouring matter, the 
hematosin, as it is called. This may at length be so much reduced, as to form 
less than a third of the healthy average. If venesection be occasionally employed, 
this process of depravation is accelerated ; but it takes place whether blood be 
artificially withdrawn from the system or not. "I am acquainted," says Dr. 
Christison, " with no natural disease, at least of a chronic nature, which so closely 
approaches hemorrhage in its power of impoverishing the red particles of the 
blood." Hence the peculiar pallid or dingy hue of the patient's skin; the leuco- 
phlegmatic and even waxy aspect which invariably stamps the victims of this 
complaint. 

These characters, then, of the urine and of the blood, when rightly compared 
and interpreted, reveal not only the existence of the renal disease, but also, with 
much probability, the stage or degree that it has reached. 

Let us next review, a little more in detail, those secondary affections which I 
have already pointed out as being incidental to the subjects of this renal malady. 
They are of much consequence: for in the course of the disease, more or fewer 
of them are almost sure to occur; most of them are productive of very serious 
distress ; and some of them place the patient's life in immediate jeopardy, and 
often bring it to a premature end. Moreover, it is by these secondary affections 
that our suspicion of the primary disease upon which they depend is, in general,, 
first awakened : and it is to the prevention or the removal of these same secondary 
affections that our curative endeavours must chiefly be directed. 

The most common, and practically the most important, of them all, is anasarca; 
but of this, although I mention it first, I shall postpone, for a while, the further 
consideration. 

Another very common, and very important secondary complication, is the oc- 
currence of what we compendiously call head- symptoms : various manifestations 
of derangement in the cerebral functions; headache, drowsiness, delirium, epi- 
leptic seizures, apoplexy. So frequently indeed is the death of the patient pre- 
ceded by coma, with or without convulsions, that Dr. Christison considers this 
to be the " natural termination" of the disease, or " the mode in which it proves 
fatal when life is not cut short by some other incidental or secondary affection." 
Of seventy fatal cases observed by Dr. Bright, death was ushered in by well- 
marked cerebral symptoms in thirty. 

I have already told you the circumstances under which these affections of the 
brain usually arise. They almost always follow any great diminution, or the en- 
tire suspension, of the secretion of urine. But this rule is not so strict as to 
admit of no exception. Occasionally, but I believe very seldom, the urine, in 
this disorer, is reduced to a very small amount, while the head remains undis- 
turbed. Of this Dr. Christison has recorded a remarkable instance.- One of his 
patients voided no more than two ounces of light urine daily, for nine days before 
iris death ; yet he continued sensible to the very last minute of his existence, and 
died simply of inanition. Sometimes apopletic symptoms occur, and carry the 
patient off, although there has been no extreme or material reduction in the quan- 
tity of urine. 

Now when death has thus taken place in the way of coma, and the case had 



SECONDARY AFFECTIONS. 



901 



been complicated with anasarca, and serous liquid is found accumulated in unna- 
tural measure in the cerebral ventricles, and in the tissue of the pia mater, it seems 
reasonable to ascribe the coma to the presence and the pressure of that liquid. 
The dropsy has extended to the brain. And this view of the matter is strength- 
ened by the connection which may sometimes be noticed between the accession 
of coma and the visible increase of the dropsy in other parts of the body. My 
own experience accords entirely with that of Dr. Christison as expressed in the 
following statement. "If the dropsical fluid be allowed greatly to accumulate, 
drowsiness, the first symptom of the affection of the head, very soon makes its 
appearance in the generality of cases, and it will speedily pass to fatal coma if not 
controlled, but the removal of the dropsy will usually remove the drowsiness." 

To many cases, however, this explanation will not apply, there being no mor- 
bid collection of water within the skull, nor any other appreciable change there; 
nor, perhaps, any dropsy elsewhere. In such cases we refer the ultimate symp- 
toms, the stupor and the death, to the poisonous influence of the urea in the 
unpurified blood upon the organs of animal life. Yet this explanation also has its 
difficulties. Urea must often circulate with the blood without affecting the brain. 
Dr. Christison states that he has repeatedly known the daily discharge of the 
solids of the urine to be reduced, for weeks together, to one-fourth of the natural 
amount, while, moreover, analysis of the blood showed that it was loaded with 
urea, without the appearance of any head-symptom. Dr. Bright also relates a 
case to the same purpose. A person labouring under this disease of the kidney 
lived for four or five years under his occasional observation. The blood was 
analyzed in the earlier stage, and found to contain a large quantity of urea; as 
much as the urine itself contained. Yet this patient had no fits till towards the 
close of his life. 

I have sometimes fancied that the pale and watery condition to which the blood 
is at last reduced, may have something to do with the stupor and coma. I showed 
you, some time ago, when speaking of spurious hydrocephalus, that similar symp- 
toms are apt to ensue, in conjunction with a similar defect of hematosin. It would 
seem that, under such circumstances, the functions of the brain are exercised 
irregularly, languidly, and at length, not at all, in consequence of the failing' sup- 
ply of its appropriate stimulus through the arteries. 

Another striking circumstance observable in this disease, is a readiness of vari- 
ous organs of the body to inflame, and particularly of the serous membranes. 
According to M. Solon, who has lately- published a thick volume on Albuminuric 
this disposition has not been so manifest in France; but of its frequent appear- 
ance in this country I can add my own testimony to that of Dr. Bright, of Dr. 
Christison, and of Dr. Gregory. Such intercurrent acute inflammation is not an 
uncommon cause of the patient's death. The pleura appears to be much more 
often affected in this manner than either the peritoneum or the pericardium. 

It follows from this tendency that when we come to inspect the dead body, we 
seldom find the kidney to be the only part in which structural changes are plainly 
visible. Most commonly evident traces of disease are met with in various organs. 

Disorder of the stomach and bowels is, certainly, a frequent companion of the 
renal malady: nausea, vomiting, flatulent distension, diarrhoea. 

It would appear, however, that these incidental and secondary complications 
prevail with irregular frequency in different places. They are probably deter- 
mined, in some measure, by local and peculiar agencies. Thus vomiting and 
diarrhoea have been more familiar to the Edinburgh observers than in London to 
Dr. Bright, or in Paris to M. Solon : while the headaches and coma, so often 
witnessed by the British physicians, have been comparatively uncommon in 
France. 

Disease of the heart, if not a secondary consequence, is a very frequent ac- 
companiment of Bright's kidney. It is probable that the cardiac disease, and the 
renal disease, have sometimes no connection in respect to cause and effect, but 
are both results of some common cause; of habitual intemperance, for example 



902 



BRIGHT'S KIDNEY. 



I am, however, of opinion that the renal malady has a direct tendency, by its 
effect upon the blood, to generate disease of the heart. It induces anaemia ; and 
anaemia, as I showed you on a former occasion, implies debility of the muscular 
texture of the heart, and leads to dilatation of its cavities; and the weak muscle, 
becoming irritable also, grows thicker as it labours more. In fact, this is the 
kind of cardiac disease which, more than any other, has been found coincident 
with the peculiar change in the kidney. Among 100 cases, recorded in a tabular 
form by Dr. Bright, there are 27 in which no affection of the heart could be de- 
tected. In 52 instances the heart presented the characters of hypertrophy, and 
of these no fewer than 34 were free from any trace of valvular disease. Among 
the 34 there were 11 cases of disease affecting the aorta: in the remaining 23 
no cause for the existing hypertrophy and dilatation could be found in the heart 
itself, or in the great blood-vessels. The true cause may therefore be reasonably 
supposed to have been the renal disease, operating upon the involuntary muscle 
through the quality of the blood. 

Whether the renal disease be ever produced by the cardiac, is more question- 
able. In the acute renal affection, when it proves early fatal, the kidney is always 
found to be gorged with blood. And the customary intermixture of blood with 
the urine warrants the belief that the same condition was present in the patients 
who have recovered. From this state of engorgement springs, apparently, the 
subsequent series of changes. It is therefore a plausible conjecture that whatever 
tends to produce congestion of the kidney, tends also to aggravate, and may even 
cause, the peculiar changes in question. I need not now tell you that disease of 
the heart does frequently occasion congestion of the venous system, and gorge 
the viscera with blood. Under this influence the liver often enlarges. On the 
other hand, disease of the heart, even such as gives rise to venous congestion 
and to dropsy, often lasts long, and proves ultimately fatal, without the occur- 
rence of albuminous urine, and without any appreciable change of structure in 
the kidney. 

Pain or tenderness of the loins, is sometimes, and sometimes only, an accom- 
paniment of the renal disease. This symptom is more often present in the early 
than in the later stages of the malady. It occurred in one-third of twenty-eight 
cases narrated by M. Solon. Dr. Gregory noticed it in the half of his patients. 

The causes of the disease of which 1 have been endeavouring to sketch the 
outline, are often obscure. Its more obvious symptoms, in the chronic form of 
the malady, have been observed, in very many instances, to begin soon after the 
exposure of the body to wet and cold under unfavourable circumstances. But it 
is by no means certain — indeed the probabilities preponderate on the other side — 
that, in these instances, the renal disorder had not previously existed in a latent 
state. 

It is certain, however, that the acute kidney affection, which may be considered 
identical with febrile dropsy, does often arise under similar circumstances of ex- 
posure, and is attended with a marked disturbance of the functions of the kidneys. 
And Bright's disease, in its chronic form, has been noticed as occurring in persons 
who had previously suffered, and had apparently recovered from, an attack of 
febrile dropsy. Are we not warranted in believing that the recovery was imper- 
fect in such cases? that the kidney had sustained irretrievable injury? and that 
the disease, although from the treatment employed, or by lapse of time, it had 
become tranquil or latent, was ready again to give indications of its existence upon 
any repetition of its exciting cause? 

Again, it is matter of common observation that intemperate habits have often 
preceded the development of this disease. Yet we may conclude that intempe- 
rance in drinking is rather a predisposing than an essential cause, from the fact 
that the malady is not unknown among children, and other persons whose man- 
ner of life has been strictly sober. I hid lately an example of this in 3 young 
girl, fifteen years old, who had never mr-nstruated. And this leads me to remark 
that the renal disorder has been known, in many instances, to follow a sudden 



1 



NATURE OF THE DISEASE. 903 

check or suppression of the catamenia. It has sometimes seemed to owe its origin 
to blows received upon the loins. 

. The complaint happens at all ages : less often, however, in extreme youth than 
afterwards. Sabbatier records that he saw, while in the service of M. Baude- 
locque, a young infant affected with anasarca and albuminous urine. The first 
case described by M. Solon is that of an infant, seventeen months old, in whom 
similar symptoms appeared shortly after exposure to cold and wet. In 1838 a 
boy between five and six years old, anasarcous and- passing bloody and albuminous 
urine, was in the Middlesex Hospital, under the charge of my colleague Dr. 
Wilson. M. Constant, in the Gazette Medicate for 1835, cites the case of a 
child of five years of age ; and M. Rayer gives two plates, representing the kid- 
neys of two children, the one five and the other six years old, who both died of 
dropsy with albuminous urine, the sequel of scarlet fever. In each of these the 
changes described by Dr. Bright were well marked, and the bulk of the kidney 
was considerably increased. 

The malady is, however, much more common in adults: not, in all probability, 
because the kidney is more readily susceptible of it at one period of life than 
another, but because, as life advances, the circumstances which tend to produce 
or to foster it become of more frequent operation ; intemperance, exposure to great 
vicissitudes of temperature, and (perhaps) disease of the heart. 

It occurs, I presume for the same reasons, oftener in men than in women. 

Dr. Christison suspects that Bright's kidney happens chiefly in persons of 
scrofulous habit; and he found it, in several instances, coincident with phthisis 
pulmonalis. My own experience would not have led me to that opinion. I par- 
take in M. Solon's doubts, whether the co-existence of pulmonary consumption 
and of this renal malady is more than casual. Dr. Bright tells us that " the in- 
stances in which phthisis, or any form of scrofulous or tubercular disease, has 
been connected with the renal affection, have been decidedly rare." 

What, after all, is the true character and essence of the organic metamorphosis 
which constitutes this formidable disorder, Bright's kidney ? All that has been 
ascertained of its early stages, of its course, and of its causes, furnishes to my 
mind a strong presumption that the structural change, in all its varieties of aspect, 
may be ultimately traceable to an undue accumulation and stagnation of blood in 
the blood-vessels of the kidney. Those curious arterial bunches, the Malpighian 
bodies, appear especially to be over-filled and obstructed. Rayer calls the com- 
plaint albuminous nephritis; and perhaps the congestion (which unquestionably 
is present in what I consider the acute form of the malady) may sometimes pass 
into chronic inflammation. We do not, however, find that it ever terminates in 
suppuration: yet suppuration is no uncommon event of true inflammation of that 
part, excited by violent injuries, or by the lodgment of calculi within it. It seems 
to me more probable that the mischief done to the kidney is owing to extreme 
congestion, and its usual consequences — the oozing forth of the blood in substance, 
or of some of its constituents, into the interstitial textures, as well as into the ex- 
.cretory tubes of the kidney. The appearance of these ingredients of the blood, 
and even sometimes of blood itself, in the urine; the increased size of the gland 
in the earlier stages; the various shades of colour which its surface and parts of 
its interior present, as the colouring matters of the effused fluids are more or less 
absorbed; the impermeability of those altered parts by artificial injections; the 
ultimate shrinking and hardness of the organ as the disorder becomes chronic, 
and absorption proceeds ; these are all consistent with this theory. It is plain 
that the morbid conditions of the urine depend, in part at least, upon the mechani- 
cal transudation of certain portions of the blood, which pass through the kidney 
unchanged, as through an inert filter. Mixed with the urine we find serum, with 
its albumen, and its salts, which diminish the acidity of the mixture, or even ren- 
der it neutral; and in many cases we find more or less of the colouring matter 
also of the blood. Those portions of the extravasated fluid which have no outlet 
of escape, solidify, and thus obliterate the natural texture of the part they have 



ANASARCA. 



invaded. The obstruction of the emergent veins of the kidney by firm clots of 
blood is in harmony with the same supposition. 

When the kidney is thus spoiled, is natural function is imperfectly or but par- 
tially performed. The change which it should effect upon the blood, by purifying 
it from urea, fails to be accomplished. The albuminous impregnation, and the 
other altered qualities of the urine when voided, may be explained either by sup- 
posing that the secreting power of the whole gland is interfered with, but not 
absolutely suspended; so that the urine is incompletely elaborated: or, by sup- 
posing that portions of the gland are spoiled, and portions remain sound and 
effective ; that true urine is formed by the healthier portions, and mixes with the 
constituents of the blood which pass, as such, through the diseased portions. The 
latter of these hypotheses is most in accordance with the fact that, in the advanced 
stage of the disorder (when we may conceive the spoiled parts to have become 
mere solid unchanging masses) the albumen is apt to disappear from the urine: 
and also with the fact, that complete recovery does, sometimes, appear to take 
place ; in which cases we may imagine that, although a small portion of the sub- 
stance of the gland has undergone irremediable change, enough of it remains healthy 
to serve the wants and purposes of the economy. 

I have yet something to say respecting the dropsy, which is so common an 
accompaniment of these renal changes ; but I must defer it till to-morrow. 



LECTURE LXXIX. 

Anasarca ; its consideration resumed. Distinction of chronic General Dropsy 
into cardiac and renal. Characters and signs of each of these varieties. 
Treatment. 

We were yesterday occupied with the circumstances of that remarkable disease, 
which has never received a good, distinctive name, but which is sometimes called 
Bright 9 s disease, after the distinguished living physician who first recognized and 
described it, sometimes yellow degeneration of the kidney, sometimes granular 
degeneration. I endeavoured to represent to you, by words and by drawings, the 
morbid appearances that are most commonly noticed in the several stages of the 
complaint: which morbid appearances may, one and all of them, be traced, (as I 
think,) to congestion of the kidney; to the detention of blood in that organ, and 
to the physical consequences of such detention. I spoke of the symptoms which 
appear essential to the malady, and which consist in certain striking changes in 
the urine and in the blood of the patient. I mentioned also the symptoms which 
are incidental to the renal disease. But of one of those incidental symptoms, or 
secondary consequences, I postponed the full consideration till to-day ; I mean the 
anasarca, with which most commonly, yet by no means always or necessarily, it 
is complicated. 

This is, for several reasons, a very important symptom. It is usually the first 
thing that prompts us to suspect, and to inquire after, the renal malady. It was 
through his researches into the relation subsisting between chronic dropsy and the 
conditions of the urine, that Dr. Bright was led to the discovery of the associated 
affection of the kidney. The dropsical accumulation adds greatly to the patient's 
distress, and sometimes constitutes nearly the whole of it. It adds proportionally 
to his danger.- Moreover, it is that consequence of the renal disorder over which 
our curative measures have the most control. Indeed, under this complication we 
have, practically, to consider the remedies of the dropsy, distinct from the remedies 
of the renal change. 

In most cases, at the outset at least of the dropsy, the skin is dry, and the urine 
is scanty: and the anasarca is observed to increase, or to decrease, as the quantity 



CARDIAC DROPSY. 



905 



of urine diminishes or augments. The aqueous fluid, which should escape from 
the surface and through the kidneys, collects in the subcutaneous areolar tissue. 
As the disorder advances, the tendency to effusion of serum through the sides of 
the blood-vessels is probably increased, not only by the sluggish movement of the 
blood in the veins, from progressive debility of the heart, but also by the cause 
of that debility, the thin and watery condition of the blood itself ; a condition 
which I yesterday pointed out to you as one of the most uniform and striking 
effects of the primary disease. 

And here I again take up the subject of anasarca and general dropsy. You 
will remember that, in the earlier part of the course, I entered somewhat fully into 
the general pathology of dropsies. At the same time I promised you that I would 
afterwards, and when you were better prepared to understand them, endeavour more 
fully to explain some grand distinctions which have been found to exist between 
different forms of general dropsy. Having now, at last, brought before you all the 
organic changes which are apt to give rise to anasarca, I am in a condition to redeem 
that promise. In doing so I shallprobably have to remind you of some things 
which you have already heard from me. 

Anasarca, you will please to recollect, signifies the filling up of a considerable 
part, or of the whole, of the subcutaneous areolar tissue, with serous or watery 
fluid : and when to this is added a collection of liquid in the large serous cavities 
also, we call the complaint general dropsy. 

It is obvious that this condition may exist, and in nature it does exist, in various 
degrees: from slight infiltration of the areolar tissue, scarcely noticeable until, 
after some hours passed in the upright posture, it accumulates in visible oedema 
about the ankles — to the other extreme, in which the integuments are everywhere 
stretched to the utmost, even to bursting; the insteps bulging upwards ; the legs 
and thighs enormously enlarged, cylindrical, unshapely, and exhibiting partial 
vesications ; the surface of the trunk of the body capable of being kneaded and 
moulded like dough; the skin of the penis distended, and in consequence of its 
confinement by the fraenum, twisted and circumvolved so as materially to impede 
the outward passage of the urine ; the scrotum, as big as a child's head, preventing 
the miserable patient from approximating his thighs, and from lying upon either 
side ; the hands swollen ; the face and neck bloated. With all this, the peritoneum 
is generally full of liquid, and at length the pleurae; and as the scene is about to 
close, there is water in the ventricles of the brain, and an anasarcous pia mater. 

Now from whatever cause this watery condition of the whole body may arise, 
the effects resulting/rom the presence of the water are the same. And of what 
do patients in this state usually complain? Why of shortness of breath, and 
palpitation of the heart; of a sense of impending suffocation if they intend to lie 
down, or actively to bestir themselves ; of tightness and distress across the epigas- 
trium, relieved somewhat by eructation, augmented by food and drink; of weight 
and stiffness of their limbs ; and, sometimes, of drowsiness. 

The explanation of all this is easy and obvious. The shortness of breath may- 
be accounted for on various grounds : by oedema of the lungs themselves, a state 
that is revealed to us through auscultation; by water in the pleura ; by the pressure 
upwards of the diaphragm which embarrasses still more the labouring heart and 
lungs ; and this upward pressure is increased by any kind of distension or repletion 
of the stomach, diminished when the stomach is collapsed and the upright position 
is maintained. The heaviness and want of pliability of the unwieldy limbs are, 
like the rest of these phenomena, purely mechanical. All parts are oppressed by 
the unnatural load of water. 

But we must look beyond the dropsy: and inquire whether the complaint has 
set in suddenly, and simultaneously with febrile disturbance, invading all the dis- 
tricts of the body at once, and quickly reaching its present degree ; o» whether it 
has crept upon the patient slowly and by stealthy steps: whether it has had any 
obvious or probable exciting cause ; or whether it has approached insidiously we 



906 



ANASARCA. 



know not whence or why: whether (in a word) the case be one of active and febrile 
dropsy, or of chronic and passive. 

Now setting aside, for the present, any more particular consideration of the 
acute or febrile form of general dropsy, and contemplating those forms only which 
are chronic, we find that all, or nearly all of them, may be arranged in two great 
classes ; those which depend upon disease or debility of the heart forming one 
class, those which depend upon disease of the kidney constituting the other. To 
these classes we accordingly apply the terms cardiac dropsy, and renal dropsy. 
They are often combined in the same individual; but taking the pure cases of 
each form, we may proceed to inquire into their peculiar features, how they may 
be distinguished, and what differences of treatment they may require. 

And first of cardiac dropsy. 

The mode in which disease of the heart may occasion general dropsy has been 
sufficiently explained already. We infer that the dropsy, in a given case, has this 
origin, if we find that thoracic symptoms, such as cough and dyspnoea, preceded 
the dropsy : or if we perceive direct signs of cardiac disease, such as distended 
jugular veins, irregular movements of the heart, unnatural impulse, altered sounds: 
or, if we trace the history of some previous acute disease affecting especially the 
left side of the thorax : or if we learn that the patient has formerly suffered acute 
rheumatism : or if the patient's age is so much advanced as to make it probable that 
some of those organic changes in the heart and large blood-vessels are in progress, 
which are almost natural in the decline of life. And our inference is confirmed if 
there be no discoverable indication of renal disease. 

But we see many persons who labour unequivocally under organic disease of 
the heart, yet who survive, even for many years, without becoming dropsical. 
The interesting question therefore arises, of what kind of heart-disease is dropsy 
a consequence and symptom ? You already know the answer. It is such disease 
as offers a certain amount of permanent obstruction to the passage of the venous 
blood. Hence dropsy is especially associated with dilatation of the right chambers 
of the heart. It would not be correct to say that the anasarca is dependent on such 
dilatation, for the dilatation itself is at once an effect and a sign of impeded trans- 
mission of blood from the right side of the organ. Nor is such dilatation a neces- 
sary attendant on the general accumulation of water. The impediment may be 
sufficient to gorge the right cavities, while it is yet too slight in amount, or too 
recent in duration, to have dilated them. 

What, then, are the physical conditions which oppose to the blood in the veins 
such an impediment as we are now considering? The two great vital organs 
contained within the thorax, the heart, namely, and the lungs, form different parts 
of one common mechanism, the object of which is to supply every tissue of the 
body with blood that has recently been purified by exposure to the air: and these 
organs, thus closely related in their functions, are moreover so reciprocally depend- 
ent, that structural disease occurring in the one, tends to produce disease, sooner 
or later, in the other also. 

And I wish you again to observe the order and direction in which disease is, 
almost always, propagated from one part of this apparatus to another. It is a 
backward direction — opposite, I mean, to the course of the blood. There are, 
strictly speaking, two hearts, which lie side by side, in respect to their anatomical 
position, but which, reference being made to their vascular inter-communication, 
are really separated from each other by the lungs. The great veins precede, and 
the great arteries follow, this chain of connected organs. Disease occurring in any 
one part of the chain becomes a cause of consecutive disease in the part immedi- 
ately behind it. And this law obtains, as I have shown you before, in regard to 
the several chambers of the heart, considered as a single organ. 

Thus, stcuctural disease situated at the aortic outlet of the heart, and of such 
a kind as to hinder the exit of the blood from the left ventricle, gives rise to per- 
manent changes in that ventricle ; to hypertrophy with, or less commonly without, 
dilatation. The hypertrophy is strictly a compensating and conservative change; 



CARDIAC DROPSY. 



907 



and when it is exactly proportioned to, and keeps pace with, the impediment 
which has given it birth, so as precisely to balance and countervail it, no delay 
takes place in the stream of arterial blood, and the injury is, as yet, confined to 
the left ventricle. That chamber is remodeled, and adapted to its purpose by the 
vis medicatrix naturae; and no other evil manifests itself than, perhaps, some 
slight encroachment and pressure upon the neighbouring parts, in consequence of 
the augmented volume of the heart. 

So long as the mitral valve remains Healthy and effective, it offers a barrier of 
protection against the extension of the disease in the direction which is retrograde 
to the course of the blood. But at length, in most instances, the stress becomes 
sensible further back. The left auricle and the pulmonary veins become choked 
and distended ; the blood is detained in the lungs. Then commences dyspnoea; 
at first occasional only, whenever the heart is tasked with the conveyance of a 
greater quantity of blood in a given time than usual, as in brisk movements of the 
body, or sudden emotions of the mind ; or when it is oppressed by circumstances 
that diminish the capacity of the chest; by a full meal, therefore, by flatulent 
distension of the stomach and intestines, by the recumbent posture. Afterwards 
the shortness of breath becomes more or less constant and distressing. 

Now this loaded and embarrassed state of the lungs, even when it is perma- 
nent and has reached a considerable degree, may exist without materially inter- 
fering with the functions of the right or venous heart: for the pulmonary plethora 
may be relieved by increased secretion from the bronchial mucous membrane. 
Dyspnoea, even when it has become habitual, may precede for some time any 
appearance of dropsy. 

At last, however, the effects of the original evil augmenting and extending, the 
right ventricle also becomes unable duly to propel its contents into the pulmonary 
vessels ; it continues morbidly full, is first distended occasionally, then perma- 
nently, and at length really dilated ; and with that dilatation we have a turgid 
venous system, of which we see a part in the prominent veins of the neck. 

In this way then may be explained a series of symptoms which you will often 
witness, and be consulted about, in persons who are growing old. You will find 
irregularity of the pulse; preternatural impulse perhaps of the heart; occasional 
shortness of breath ; large crepitation, habitually audible in the lower portions of 
the lungs ; more or less expectoration, sometimes tinged, sometimes even loaded, 
with blood. Eventually the ankles begin to swell; and the patient (if his life is 
not cut short earlier in some other way) becomes by degrees decidedly and uni- 
versally dropsical. 

Many of the direct signs of diseased heart may exist, therefore, while there is 
no anasarca: intermissions and irregularity in its movements, palpitation, the 
impulse proper to hypertrophy. But when dropsy has supervened, we may 
expect also the signs which denote dilatation of the right chambers. The heart 
is heard and felt to beat beyond the precordial limits ; the pulsations become 
feeble and unequal, if they were not so before; the patient is liable to fluttering 
palpitations, to extreme and panting dyspnoea on the slightest exertion, even on 
taking food into the stomach, or adopting the recumbent posture ; his skin assumes 
a dusky hue, and his lips and extremities are apt to be livid. 

In these cases the anasarca first becomes manifest about the ankles. During 
the earlier stages the oedema disappears in the night, and returns towards the 
next evening. It is sometimes confined, for a long while, to the legs ; but ulti- 
mately it creeps up towards the trunk of the body ; the loins and flanks become 
doughy, the scrotum fills, and water collects in the serous bags of the abdomen 
and thorax. In extreme cases the dropsy is universal, pervading the areolar tissue 
of the head and face and upper limbs. 

As the accumulation of serous liquid is commonly gradual, the reticular tissue, 
partly perhaps through maceration, but chiefly from continued pressure and 
stretching, loses its elasticity ; and the oedema is soft, and pits readily. 

Sometimes, the fluid continuing to increase, the cuticle is raised by it, and large 



908 



ANASARCA. 



vesications take place on the limbs ; or some part of the areolar tissue sloughs, 
and a breach of surface is made, and the fluid drains off by this vent in great 
abundance, to the signal relief of the patient. This beneficial accident furnishes 
us with a valuable practical hint. 

Such, then, is the consummation of disease commencing in the left heart, and 
working its gradual way, through the lungs to the right heart. But the obstacle 
may originate at a less distant link in the chain. The circulation may be checked, 
first of all, in the intermediate lungs : and ft may be worth our while to consider, 
for a moment, the relations which subsist between general dropsy and certain 
pulmonary diseases. 

Whenever, in pneumonia, a large portion of one or of both lungs becomes im- 
pervious to air and to blood — or when pleurisy fills one side of the thorax with 
liquid, which, by its pressure, shuts out both air and blood at once from one-half 
of the respiratory apparatus — the egress of the blood from the righ t heart, and, there- 
fore, from the venous system, must be checked. We might expect that dropsical 
effusion would be the result of these changes ; and in truth it does sometimes 
occur. That it does not happen more frequently is to be attributed, I believe, to 
the free evacuations, and the strict abstinence, which are early put in force in those 
complaints, and which relieve the venous plethora before it produces effusion. 

So, again, lungs that are hollowed out into large cavities, or rendered solid 
over a wide space by numerous tubercles, are manifestly incapable of admitting 
into their vessels from the right ventricle the ordinary quantity of venous blood. 
In these cases, however, the whole mass of blood is diminished, and kept within 
the limit which does not imply distension of the veins, by the constant agency of 
various causes; by the imperfect nutrition consequent upon abdominal disease ; by 
the sometimes copious expectoration ; by the wasting diarrhoea ; by the profuse 
nocturnal sweats. Accordingly anasarca is an unusual symptom in pulmonary 
phthisis, or shows itself in the latter periods only of the disease, in the form of 
oedema of the legs : and its occurrence then is mainly owing to the debility which 
affects, in common with the other muscular parts of the body, the moving organ 
of the blood. 

The pulmonary disease which more commonly and certainly than any other, 
though often very slowly, leads to dropsy, is emphysema of the lungs. I showed 
you, some time ago, that in this morbid condition many of the smaller blood- 
vessels of the lung become gradually obliterated; and when the disease is exten- 
sive and advanced, large portions of the organ are visibly white and bloodless. 
Meanwhile, the nutrition of the body is not impaired; the same quantity of blood 
continues to be returned towards the heart, but it finds not a ready entrance into 
the pulmonary blood-vessels, when delivered from the right ventricle. A certain 
amount of accumulation becomes habitual in that chamber, and in the great veins ; 
and at length the capillary vessels feel the mechanical congestion, and more or 
less anasarca ensues. 

So much for dropsy that is purely cardiac. Let us next consider the circum- 
stances from which, during the lifetime of the patient, we draw the conclusion 
that the dropsy he exhibits is of renal origin. 

There is nothing, that I know of, very peculiar or distinctive in the characters 
of the anasarca itself. When the renal complaint sets in suddenly, and with 
acute symptoms, dropsy usually supervenes soon. So, also, during its more 
chronic progress, anasarca is apt to show itself, or to increase, whenever local 
inflammation, or febrile disturbance, happens to arise. The more rapid and 
copious the effusion, the less do the dropsical parts pit upon being pressed. It 
may be said also of this renal form of dropsy, that accumulation in the larger 
serous cavities is not, in general, a prominent feature. 

If we find, upon due scrutiny, no material or adequate embarrassment of the 
respiratory functions, no deviation from the natural sounds of the heart, no de- 
rangement of its regular movements, no alteration in the force of its pulsations, or 
in the space over which they can be felt and heard, no distension of the large 



RENAL DROPSY. 



909 



veins of the neck — then we have strong reason for suspecting that the anasarca is 
connected with some vice of the kidney. 

But we cannot infer from the presence of heart-symptoms, that the kidney is 
free from disease. 

Our judgment is guided, or assisted, in some degree, by the complexion of the 
patient. When general dropsy depends upon disease of the heart, the cheeks and 
lips are occasionally florid, often purplish or livid, frequently dusky and loaded. 
Sometimes (as in chlorotic women, where the heart may be temporarily distended 
without any positive organic disease, and the blood is thin and poor) the face and 
mucous membranes are pale : but in the renal variety of dropsy there is a very 
characteristic hue ; an evident lack of red blood, indeed, in the capillaries, but 
withal an unhealthy dingy sallowness, significant, to a practised eye, of some 
deep-seated alteration of structure. 

Our suspicion that the kidney is the organ primarily in fault is strengthened, if 
we trace certain accidents in the history of our patient. An attack, for example, 
of illness, attended perhaps, with temporary swelling of the body and disturbance 
of the urinary functions (acute dropsy, in short), soon after some exposure, under 
unfavourable circumstances, to the influence of cold ; either applied to the external 
surface, or to the stomach by a draught of cold drink. For, as I told you yes- 
terday, there is reason to believe that in acute dropsy is often laid the foundation 
of those peculiar changes in the kidney which, since they were first pointed out 
by Dr. Bright, have been chiefly studied in their connection with chronic dropsy. 
That as rheumatic carditis may occur, and become latent as to its effects for some 
time, and yet implant the germs of future cardiac dropsy, so the stress or strain 
which befalls the kidney in cases of febrile anasarca, may set on foot a morbid 
process that long works silently and unobserved, but at last declares its operation 
by symptoms ; the reproduction of the dropsy in a more chronic form being the 
most significant symptom of all. The acute attack may have been forgotten; 
there may have been no obvious (though there may have been ill-understood) 
indications of the renal affection ; and its existence has been, therefore, unsuspected. 

The discovery of intemperate habits would also be of importance in aid of our 
diagnosis, if these same habits had not a like influence in causing disease of other 
organs as well as of the kidney, and especially of the heart. There may, how- 
ever, be no such episodes as these in the patient's history. The dropsy may 
have come on immediately after some exposure, or obviously injurious influence, 
yet not with acute symptoms, and in a temperate subject: in which case it is pro- 
bable that the renal disease had pre-existed in a latent state. Or the anasarca may 
have stolen on by degrees, without any apparent cause. 

But the most conclusive evidence of the renal disease is to be found in the 
conditions of the urine: which were fully explained to you in yesterday's lecture. 
I shall therefore only add four rules upon the subject, which have been laid down 
by Dr. Christison, and generally acquiesced in by Dr. Prout. These rules assert 
that organic disease, or granular degeneration, or granular disorganization of the 
kidney — all which phrases we may condense into the compendious expression 
" Bright' s kidney"— -is present: 

1. In most cases of febrile dropsy, including those which are consequent upon 
scarlet fever. To this proposition I have already given my full assent. 

2. In all cases of anasarca, wherein the cedematous parts are elastic, and do not 
pit upon pressure. I am not so sure of this rule. I believe that the firmness of 
the cedematous parts has relation rather to the rapidity with which the effusion 
has taken place, than to the local origin of the dropsy. In proportion as the 
accumulation in the areolar tissue has been chronic and gradual, does the swelling 
receive and retain indentation from external pressure. 

3. In most, or all cases of dropsy attended with diuresis, provided the urine be 
not saccharine. Such cases, Dr. Christison truly remarks, are far from being 
uncommon. Of course the diuresis here spoken of is such as occurs independ- 
ently of diuretic remedies. 



910 



ANASARCA. 



4. In all dropsies associated with urine of a very low specific gravity (say below 
1010), and not exceeding the natural standard of quantity, whether it be albumi- 
nous or not. To the last two rules there are probably very few exceptions. 

The dropsy which is dependent upon " Bright's disease" yields, not unfre- 
quently, to treatment ; but it is prone to recur. Of the renal disease itself the 
prognosis is, no doubt, very unpromising. Yet I do not think so despairingly of 
these cases as I once thought ; and as many think. I have known a few instances 
of what seemed complete recovery after well-marked symptoms of the disorder. 
Certainly success enough has followed careful treatment to encourage us to use all 
diligence in prosecuting such remedial measures as are already known, and in 
devising new ones. 

I have been speaking of dropsies that are purely cardiac, and of dropsies that 
are purely renal. But I have already told you that disease of the heart and dis- 
ease of the kidney, frequently go together ; and I have endeavoured to estimate 
their relation, in such cases, to each other. When both organs are structurally 
affected, the disposition to dropsical accumulation must evidently be augmented. 
What share they have, respectively, in producing the dropsy, it would be very 
difficult, and practically it is not very important, to determine. 

In chronic general dropsy of a purely cardiac origin, the kidneys, being sound, 
offer the most convenient and eligible channel for carrying off the superfluous 
water. Diuretic medicines, therefore, rank among the most important of our 
curative expedients. When they fail to act, or prove insufficient for the purpose 
sought, we next have recourse, the state of the bowels permitting, to drastic or 
hydragogue purgatives. 

Diuretics are notoriously of most uncertain operation; sometimes completely 
answering our wishes, oftener perhaps disappointing them altogether. When the 
urine is strongly acid, and deposits, on cooling, a sediment like brick-dust, it may 
be well to try, at first, the alkaline diuretics, and particularly the salts of potass. 
Nitre added to the common saline draught; or a combination of the acetate and 
bicarbonate of potass ; or the bitartrate in small doses ; or the iodide of potassium : 
or the liquor potassae. In my own experience the tincture of squills also has 
seemed to correct this superacid and turbid condition of the urine, while it increased 
its quantity. 

The benzoate of ammonia is anoiher salt which I have found to operate very 
powerfully, in several instances, as a diuretic. 

Digitalis sometimes promotes, in a remarkable degree, the flow of urine; and 
this, in my judgment, is its most useful and manageable property. Small quantities 
of the tincture, or of the infusion, may be added to other formulae. Or the pow- 
dered leaves may be combined in pills. But one of the best modes of exhibiting 
digitalis for this purpose is to give larger doses of the infusion, half an ounce, for 
example, in some cordial water, at intervals of four or six hours, till three doses 
have been taken in succession ; and then to pause and note its effects ; and to 
repeat the three doses, or not, accordingly. 

The spirit of nitrous aether, and the compound spirit of juniper, have both of 
them well-marked diuretic properties, and may, with propriety, be added to most 
of the liquid formulae for augmenting the discharge of urine. And, as vehicles for 
more active, or more concentrated ingredients, those vegetable infusions or decoc- 
tions should be chosen which are reputed to possess similar virtues; such as the 
decoction of broom-tops, or of juniper-berries, or of winter green, or the infusion 
of buchu. 

Squills, turpentine, ( the tincture of cantharides, are drugs of a more stimulant 
nature, more peculiarly adapted to cases in which there is no febrile disturbance, 
and the kidneys are obstinately inactive. 

Sometimes a combination or farrago of diuretic substances proves more effica- 
cious than larger doses of any of the ingredients administered singly: and the 
operation of some of these combinations is undoubtedly quickened and exalted, 
in many instances, by the addition of mercury. A fluid drachm of the officinal 



TREATMENT. 



911 



solution of the bichloride in each dose of a mixture ; or small quantities of calomel 
or of blue pill when the medicines are given in a solid form. A very useful pill 
of this kind, much recommended by the late Dr. Baillie, consists of three or four 
grains of the pilula hydrargyri, mixed up with one grain of the dried powder of 
squills, and half a grain of the dried leaves of digitalis ; to be given twice or thrice 
a day. Dr. Baillie states that squills and digitalis are much less effectual by them- 
selves, than when combined with mercury. 

In choosing purgative drugs to aid the effect of diuretics in carrying off the 
dropsical fluid, or to take their place when these fail to act, we select those which 
produce copious and watery discharges from the bowels. A combination of jalap 
and cream of tartar has been long and deservedly esteemed for its excellent opera- 
tion in this way. Gamboge is also a good cathartic. It may be given two or 
three times daily, in grain or two-grain doses, with a drachm of cream of tartar, 
suspended in two ounces of peppermint water. Or half an ounce of cream of 
tartar, mixed in six ounces of peppermint water, may be administered in one dose 
every morning. Croton oil, and elaterium, are still more powerful evacuants of 
serous liquid from the intestines. One or two drops of the former, or from a 
quarter of a grain to a grain of the latter, will be about a proper dose. It is asto- 
nishing how much relief to the feelings of the patient, and how great a diminution 
of the dropsical symptoms, are sometimes obtained by these active cathartics. 
Patients will earnestly beg for a repetition of them, even when their operation 
is attended, for the time, with considerable pain or sickness, and much general 
distress. 

In addition to these measures for the removal of the collected water, attention 
must be paid to the actual condition of the heart. If the dropsy has been the 
result of anaamia, or of cachexy of the system, you must endeavour to strengthen 
your patient, and to repair his impoverished blood, by nutritious food and tonic 
medicine, and especially by the administration of steel. I told you formerly that 
preparations of iron have an exceedingly good effect, oftentimes, even in cases of 
organic disease of the heart, consisting in dilatation and tenuity, and consequently 
weakness of its muscular parietes. 

On the other hand, if there be violent palpitations of the heart, with a strong 
heaving impulse, you may appease the excessive action, and afford sensible com- 
fort to the patient, by applying leeches, from time to time, to the prcecordia. 

Of the renal variety of chronic general dropsy, whether pure or mixed, the 
treatment is less accurately ascertained. The uncertainty which has perplexed 
men's minds respecting the nature of the renal disorder, has extended, in some 
measure, to their choice of remedies for it. 

Whenever (in renal dropsy) acute symptoms and febrile disturbance occur, much 
relief may be expected from the abstraction of blood. When drawn from a vein, 
it usually shows the buffy coat. The existence at the same time of pain in the 
loins, would indicate the propriety of applying cupping glasses to that part. 
Nevertheless, the impoverishing effect of the disease itself upon the blood, and 
the probable dependence of some of the more distressful and alarming symptoms 
upon the thin serous condition of the circulating fluid, as well as the increased 
facility with which the dilute blood may transude outwards — these are circum- 
stances which should induce every cautious practitioner to have recourse to this 
heroic remedy only when it is clearly demanded. 

One definite object, in the renal as well as in the cardiac variety, is to remove 
the dropsical fluid, from which the danger and the suffering often chiefly proceed. 
But it is a more nice question, when the kidney is involved in the disease, how this 
is to be accomplished. Can we, with the same safety as in cardiac cases, employ 
diuretics ? It has been thought that we cannot. As the primary morbid state of the 
kidney is certainly often, and probably always, a state of congestion, it has been 
feared that direct diuretics, such as are calculated to cause, keep up, or augment 



912 



ANASARCA. 



congestion of the kidney, or to stimulate and irritate that organ, would be likely 
to accelerate the disorganizing process of which it is already the seat. 

Now, although these views are theoretical, and their justness has not yet been 
established by positive proof, you had better, when you can, observe the caution 
which they suggest. You had better endeavour to empty the distended cavities, 
and to relieve the loaded areolar tissue, through the bowels, or through the skin. 
Sometimes, however, — more often indeed than in cardiac dropsy — we have the 
untoward complication of irritable bowels, or habitual diarrhoea; and then drastic 
cathartics are inadmissible. But when this complication is not present, they are 
eminently useful. 

Much benefit is sometimes derived from measures that act powerfully or steadily 
upon the cutaneous transpiration; and especially from warm, or hot-air, baths. 
The hot-air bath is, in many respects, preferable to the common warm-water bath, 
and even to the vapour bath. Upon the principle of heterogeneous attraction, the 
escape of the liquid from the surface of the body is more promoted by a dry heat 
than by water artificially raised to a high temperature, and even than by an atmo- 
sphere made moist, as well as hot, by vapour. The risk, moreover, of exposure 
to cold, and the inconvenience and hazard of fatigues, are much less : for the hot 
air can be brought, with but little trouble or expense, to the patient as he lies in 
bed. I have often applied the sudatorium to patients labouring under renal dropsy, 
and they have obtained much relief from it : but the relief is seldom of itself 
sufficient, or of more than temporary duration. Still it is an expedient that should 
never be neglected ; and in pursuance of the same indication, diaphoretic medicines 
should at the same time be diligently exhibited. Dr. Osborne states that when 
the renal disease has been uncomplicated with other organic mischief, he has always 
found the dropsy to disappear upon the re-establishment of the functions of the 
skin. 

These measures failing — as fail they often will; and diarrhoea forbidding the use 
of drastic purgatives ; or drastic purgatives and diaphoretics together proving 
insufficient ; we must, even in renal dropsy, choose the least of two evils; or rather 
we must incur the risk of one possible and contingent evil, for the chance of 
obtaining what, if obtained, is a certain and positive benefit; we must endeavour 
to remove the dropsical accumulation by means of diuretics, whether these accele- 
rate the progress of the disease in the kidney or not. 

Such diuretics, therefore, are, in the first instance, to be selected, as seem the 
least likely to stimulate the kidneys injuriously; The bitartrate of potass has 
been found one of the most certain and useful. Digitalis also is esteemed safer, 
and therefore more proper for this purpose, than many others: and the simulta- 
neous exhibition of these two has, perhaps, the surest effect of all. 

When diuretic medicines act as we intend them to do, and increase the quantity 
of urine, they are commonly of great service by reducing the dropsical swelling. 
But they are apt to be very capricious and disappointing. In some unhappy cases 
of renal dropsy I have tried every known form and combination of diuretics with- 
out augmenting the secretion from the kidneys. And sometimes, although a 
plentiful discharge of urine takes place, no impression is made upon the anasarca. 

It is yet an unsettled question whether mercury be advisable, or even admissible, 
in these cases. The current of medical opinion sets against it ; perhaps too 
strongly. It has been observed that salivation is apt to be produced by a small 
quantity of this drug ; and to be unusually troublesome and severe, without bringing 
any commensurate advantage. I mentioned to you formerly Dr. Farre's opinion, 
that mercury has the property of rapidly destroying red blood: if so, it must be 
regarded rather as an ally, than as an antagonist, of this malady. On the other 
hand, some patients have appeared to recover altogether, after passing through a 
furious salivation. One of the reputed virtues of the mineral is that it promotes 
interstitial absorption — a property which the changes apparent in the kidney in 
renal dropsy would seem to render valuable. 

When internal remedies prove ineffectual, and outward applications to procure 



TREATMENT. 



913 



sweating miss their ajm, we turn to those mechanical expedients which (in either 
variety of general dropsy) often afford ease, and prolong life, and may even some- 
times, perhaps, achieve a cure. 

I have told you that the tense and stretched integuments occasionally give way ; 
the areolar tissue sloughs, and from the breach thus made water wells copiously 
forth, and great relief ensues. Sometimes, though very rarely, the whole of the 
accumulated liquid has so escaped, and the dropsy has not reappeared. The sore 
has healed, and the natural cure has been complete. 

This spontaneous mode of draining away the liquid has been imitated by art. 
For the unwieldy legs become painful as well as cumbrous ; the integuments 
threaten to inflame, or to mortify ; and if we can diminish the tension by removing 
a portion of the included fluid, we avert or lessen this danger. The penis and 
scrotum also in the male, and the labia pudendi in the female, become, in many 
cases, enormously swollen, and hinder the exit of the urine, which is therefore 
spilled upon the tumid parts, rendering them erythematous and raw, to the 
grievous aggravation of the patient's sufferings. 

Now seeing that vesications sometimes form upon the dropsical limbs, and give 
vent, in some degree, to the fluid, practitioners have been induced to follow that 
indication by exciting artificial blisters. But they are highly dangerous; leading 
often to gangrene of the surface thus inflamed. Within my recollection it was 
the custom to make incisions, with a lancet, in the cedematous legs. These 
gashes seldom healed again; but degenerated into sloughing sores; and not 
unfrequently they hastened the dissolution of the patient. 

A vast improvement upon these expedients is the modern practice of acupunc- 
ture, which consists in perforating the integuments here and there with a fine 
needle. 

It is surprising how much fluid may be let out in this way; and how much 
relief may be bestowed by this trifling operation. The liquid trickles rapidly 
forth ; and I have known it soak through the patient's bed, and form a pool on 
the floor of the room. In one instance, a physician being the patient, the limpid 
fluid which thus oozed from a puncture in the thigh was caught, and collected in 
a glass, by means of a little gutter of oiled silk. It was found that ninety minims, 
or a fluid drachm and a half, escaped in a minute; which is at the rate of eleven 
ounces and a quarter in an hour : and this drain went on for upwards of four 
hours. 

The surface on which punctures of this kind have been made sometimes be- 
comes red; erysipelas supervenes, which it is difficult to arrest, and the patient 
sinks. In some of these cases the same event would probably have occurred, 
even although no punctures had been made, from mere tension of the integuments, 
and the progress of the disease. When such appearances present themselves, 
the affected limb should be kept in the horizontal position; and strips of linen, 
wetted with a solution of goulard, should be applied to the inflamed surface. 

Under the old system of incisions it was found (and reason would teach us to 
expect this) that there was more hazard of sloughing when they were made on 
the legs, than on the thighs. The risk is much less whea needles are used. But 
even these punctures are not to be made without attending to certain precautions. 
They should not be too near each other: an inch and a half, at least, should 
intervene between them. Neither should they be too numerous, nor too deep. 
The depth must depend upon the circumstances of the case; and especially upon 
the place where the puncture is to be made. The needle must not be pushed so 
deep as to penetrate or wound any fascia; for the danger of subsequent inflamma- 
tion would thereby be increased. 

The peritoneum may, at the same time, require to be emptied in the same 
mechanical way, by help of a trocar. I am always loth to recommend tapping, 
until the symptoms actually call for it, and until all other means of dispersing the 
water have been tried in vain. But the circumstances that warrant or demand 
the performance of the operation, the dangers that attend it, and the means of 
58 



914 



CHYLOUS URINE. 



obviating these dangers, were fully pointed out when we were on the subject of 
ascites. 

By whatever means we may succeed in getting rid of the dropsy, there will 
still remain (except in the comparatively few cases that are unconnected with 
organic disease, and depend simply upon debility and anaemia), the necessity for 
guarding against the re-accumulation of the water, by remedial measures addressed 
to the faulty organs. You may sometimes keep the disease of these organs in 
check, even when you cannot cure it. 

In cardiac dropsies, besides the medicines already specified, undeviating tem- 
perance and regularity of life must be enjoined ; and the patient should carefully, 
and always, avoid all active motion or exertion of the body, and all strong emotion 
of the mind; whatever, in short, might tend to hurry the circulation. You will 
scarcely be able to enforce this prudence, without plainly showing the patient the 
risk he will incur by its neglect. 

In the renal variety of the disorder, in addition to the appropriate remedies 
already enumerated, particular attention must be paid to the avoidance of all ex- 
posure to cold and vicissitudes of the weather, and to keeping the surface of the 
body warm. Such patients should be constantly clothed in flannel from head to 
foot. To those who are able to choose their piace of abode, I should strongly 
recommend resort to a warm climate. Some benefit may also be hoped for from 
counter-irritation — blisters or issues to the loins. 

The diet in the chronic forms of the disease should be nutritive but unstimu- 
lating. M. Solon suggests that if, in the renal cases, urea be detected in the 
blood, the patient should be restrained from too annualized a diet. Dr. Budd has 
had the same thought, and has put to the test, I believe in the Hospital-ship 
Dreadnought, the utility of withholding all articles of food that contain azote. I 
have found this restriction entirely useless in one painful case, in which it was 
fairly enforced. In fact, the principle of such restriction appears to be wrong : 
the urea is furnished to the blood, not in the primary assimilative process, but in 
that which is secondary and destructive. 

One more point, and I have done. Much unnecessary penance used to be 
imposed upon dropsical persons, by stinting their allowance of drink. It was 
natural to suppose that the accumulation would increase in proportion to the quan- 
tity of liquid swallowed. But experience has shown this opinion to be erroneous, 
and 

" Crescit indulgens sibi dims hydrops" 
has ceased to be more than a poetical doctrine. The patient may safely be al- 
lowed to exercise his own discretion in this respect. When the peritoneum is 
full, distress is apt to ensue upon the distension of the stomach by drinks; but 
this source of suffering is soon discovered and avoided. The sick man is better 
able than his physician to judge which evil is the greatest; the torment of un- 
slaked thirst, or the discomfort that may be produced by its immoderate indulgence. 



LECTURE LXXX. 

Chylous Urine. Hematuria ; its diagnosis, general and particular : Local dis- 
orders of the Urinary Organs on which it depends; Treatment. Abdominal 
Tumours. 

I hope I have convinced you that the morbid conditions of the urine are worth 
studying. You have heard, probably, of the quacks who call themselves " water- 
doctors," and who pretend that, by mere inspection of the urine of a patient living 
at a distance, they can tell what is the matter with him, and how he may be 
cured. This skill, which looks like conjuration, the scientific physician of the 



CHYLOUS URINE. 



915 



present day does really possess. Of some very important forms of constitutional 
disorder, and of some specific local maladies, he reads the sure evidence in the 
sensible and chemical qualities of the secretion from the kidneys. And I do not 
hesitate to say, that a rightly instructed person might form a more accurate opin- 
ion respecting a sick man fifty miles off, and prescribe for him more judiciously, 
upon being furnished with a vial of his urine, than some practitioners whom I 
have known could do, if they had the patient bodily before them. You may 
learn much, (and so, no doubt, you ought) by prying into the arcana of the night- 
chair : but you may learn more, I am persuaded, by the habitual perusal of the 
chamber-pot. 

I have not yet quite done with the subject. 

Sometimes urine is voided which appears to contain chyle. It looks white and 
milky, and stiffens as it cools into a tremulous jelly, like blanc mange, and takes 
the shape of the vessel into which it was passed. The coagulum gradually sepa- 
rates again into two portions : one of which is liquid and whitish, and when left at 
rest for a few hours, throws up to the surface a sort of creamy matter, containing (as 
cream does) a butyraceous or oily principle : the other is a delicate fibrinous mass, 
of flesh-like appearance, having a red tinge from the presence of some of the 
colouring matter of the blood. This is the character of the urine passed a few 
hours after a full meal. When the patient has long been fasting, the urine is 
simply opalescent, and the coagulum small and partial. 

Dr. Prout attributes this curious deviation from the natural qualities of the 
urine to a double fault; first, in the organs of assimilation; secondly, in the func- 
tions of the kidney. The chyle, from some derangement of the assimilative 
process, is not raised to the blood standard; and being unfit for its purpose, is 
ejected through the kidneys ; and these organs, instead of converting it, as usual, 
into the lithate of ammonia, suffer it to pass through them unchanged. 

Of this rare disorder I have not met with an instance. Dr. Prout has seen 
more or less of thirteen cases. Five of the patients were males, eight females. 
Two of the males, and one of the females, were below the age of puberty. Se- 
ven of the cases occurred in natives of the East or West Indies, or in persons 
who had lived for many years in hot climates. Mr. Thomas informs me, that 
during a residence of ten years in Barbadoes, he saw at least a dozen well-marked 
examples of chylous urine in negroes. It would seem, therefore, that a tropical 
climate predisposes certain individuals to this affection. In one case, drinking 
cold water while the body was warm seemed to have been the exciting cause; 
and exposure to cold was thought to have had something to do with the attacks in 
other cases. 

The general health suffers less than you might suppose. Two of the females, 
while labouring under the complaint, became pregnant, and brought forth healthy 
children; and one of the two lived nearly twenty years, with the disorder upon 
her all the time. 

In the slighter cases there is usually some degree of feverishness, some uneasi- 
ness in the back and loins, some thirst, a dry skin, and torpid bowels. When 
the malady is more severe, the symptoms approach to those of diabetes ; the thirst 
is more urgent, the appetite unnaturally craving; and there is some degree of 
emaciation and debility. In this severer variety the urine is apt to coagulate 
before it leaves the bladder; and the patient experiences difficulty in passing it, 
the urethra being blocked up by the clots. Dr. Prout states that he has known 
this to constitute the most troublesome symptom of the disease. In one of the 
fatal cases the body was examined, and the kidneys found perfectly healthy. 
Occasionally the complaint ceases of its own accord, even for years, and then 
recurs, without any apparent cause. We may conclude from these circumstances 
that it is a purely functional disorder. 

With respect to treatment, little can be said. Dr. Prout has found several 
things of temporary service, in the chronic state of the affection. The mineral 



916 



HEMATURIA. 



acids ; astringents, such as alum, and the acetate of lead ; opium ; counter-irritation. 
But the suspended symptoms have always soon returned. 

Lastly, the urine may contain blood: and I proceed to consider some of the 
phenomena that occur in connection with hematuria; under which term I would 
comprehend every kind of bleeding from the urinary organs. 

Blood alters, of course, the colour of the urine with which it is mixed ; giving 
it, in some instances, a bright red tinge, and causing it, in others, to assume a 
dark hue ; to become brown, like coffee, or even to approach to blackness. Hence 
we are sometimes too ready to conclude that urine of a distinctly red colour, or so 
very dark as to appear almost black, derives its peculiar tint from blood that has 
somehow mingled with it. 

But, in truth, urine may be perfectly red, or nearly black, and yet be quite free 
from blood. There are certain substances which, when taken as food, invariably 
impart a red colour to the urine. One of these is the prickly pear, or Indian fig 
as it is sometimes called, the cactus opuntia of botanists. When the Spaniards 
first took possession of America, many of them were alarmed by observing that 
they passed what they supposed to he bloody urine : but it was soon discovered 
that the red colour of the secretion was owing to the liberal use they made of that 
fruit. Dr. Hennen, in his book on Military Surgery, quotes a precisely similar 
example from Elliot's Journal of his Travels for determining the boundary of the 
United States. He says that "his people ate very plentifully of this substance at 
an island of the Mississippi (Kayo-ani), and were not a little surprised the next 
morning at finding their urine appear as if it had been highly tinged with cochineal. 
No inconvenience resulted from it. It would seem (he continues) that the juice 
of this plant may be analyzed into a crimson dye by other processes besides that 
of the cochineal insect." 

Another vegetable substance with which, in this country, we are more familiar, 
and which will produce the same effect, is beet-root. Desault relates the case of 
a person who noticed that he every morning voided urine of a deep red colour; 
exactly such as would result from adding fresh blood to that. liquid, except that 
no deposit took place. The man became frightened at this, and consulted M. 
Koux, who, after some examination, began to suspect that ihe water owed its red 
appearance to some other cause than an admixture of blood. It turned out that 
his patient was in the habit of supping every night upon the red beet-root; and as 
soon as, by M. Roux's advice, he relinquished this article of diet, he was freed 
at once from his supposed bloody urine, and from his fears. 

A similar tinge is said to be given to the urine by the use of madder as food, 
by some species of strawberries, and by drinks made of sorrel. Logwood, which 
we sometimes use in medicine, has the same effect. 

It is right that you should know these facts : for by swallowing large quantities 
of such substances, and by complaining of sensations which they do not really 
feel, impostors may endeavour, without any difficulty, or pain, or danger to them- 
selves, to deceive others into a belief that they are suffering under some serious 
and disqualifying disease, and are proper objects of charity. Moreover, a know- 
ledge of the effects of these vegetable matters may sometimes enable you, as in 
the case mentioned by Desault, to remove unfounded anxiety and alarm from the 
minds of persons who are innocently and unconsciously giving themselves red 
urine. 

The natural tint of the urine inclines towards redness, independently of any 
admixture of blood, in many instances of fever, and of acute inflammation. 
Occasionally urine of a pink colour is passed by persons who are subject to obsti- 
nate dyspepsia connected with organic disease. This pink tint is most apparent 
when the water is contained iti an opaque, shallow, white vessel. 

Again, urine of so deep a colour as to be called, in common parlance, black, 
may or may not owe that hue to the presence of blood. When blood is the cause 
of the' unnatural colour, the blackness must be ascribed to the chemical action of 



HEMATURIA. 



917 



some free acid upon the blood : as I showed you formerly to be the case with 
blood that is vomited in haematemesis. 

I also pointed out to you some little while since, that the urine, in jaundice, 
sometimes, seems to be black, when it is collected in large quantity, and in a deep 
vessel. This colour is merely a concentration of yellowness, as appears at once 
by diluting the urine with water. It then assumes a bright yellow colour. The 
aspect of the skin in icterus will always secure you against mistaking or overlook- 
ing this cause of black urine. 

There has been observed, also, though very rarely, a form of black urine, 
depending upon the presence in that secretion of a peculiar principle to which 
Dr. Marcet gave the name of melanic acid. The only specimen of really black 
urine that I ever saw, was shown to me by Dr. Prout; who knew nothing, how- 
ever, of the circumstances under which it was voided. It appeared to me to be 
full of coal-dust. 

With these two exceptions, almost all urine that is of a very dark or blackish 
colour owes that quality to the circumstance of its containing blood, which has been 
more or less altered, by various causes, from its original appearance. 

When blood is present in any considerable quantity, a portion of it subsides to 
the bottom of the vessel, and may be recognized without any difficulty. And 
even when there is not enough blood to give a marked and characteristic deposit, 
a very small admixture of it will be found to disturb the natural transparency of 
the urine, rendering it of a smoke-brown, or dull cherry colour; whereas the 
reddish or pink urine which contains no blood is clear and untroubled; and if, on 
cooling, it throws down a sediment, that sediment may be redissolved by heating 
the urine— a result which does not take place when a portion of blood has been 
deposited. Another rough test is, that a mixture of urine and blood tinges a piece 
of white linen dipped into it, of a red colour. A better criterion is afforded by 
gradually raising the suspected urine to the boiling temperature. If it contains 
blood, a grayish-brown flocculent precipitate, consisting of coagulated albumen 
tinged with the colouring matter of the blood, will form, and gradually subside, 
and leave the supernatant liquid clear, and with its natural tint. But if you use the 
microscope, that will furnish you with the best evidence upon this point. If there 
be blood in the urine, there' will be blood-corpuscles, turgid or collapsed, diffused 
through the urine, or collected at the bottom of the vessel: and whatever modifi- 
cations they may present, they may always, Dr. Bird says, be identified by " their 
non-granular surface, uniform size, and yellow colour under the microscope." 

We have by no means accomplished the diagnosis when we have merely ascer- 
tained that there is blood in the urine ; and that the case is a case of haematuria. 
The question remains, of what is such haematuria a sign. The blood emerges 
from the urethra, but it may have been poured out at any point of a long and 
somewhat complex tract of mucous membrane. It may have proceeded from one 
or both of the kidneys ; from each or either ureter; from the bladder; from the 
prostate gland or from the urethra. 

Haematuria strictly idiopathic must be very rare. Cullen remarks that neither 
he nor any of his friends had ever met with an instance of it. I shall mention 
presently the only example of hemorrhage from the urinary organs, apparently 
idiopathic, that has fallen under my own notice. 

Blood is excreted with the urine in that acute affection of the kidney which I 
have already spoken of as lying at the root of most, if not all cases of febrile 
dropsy. The albuminous urine proper to the chronic form of Bright's disease 
sometimes contains the colouring matter as well as the serum of the blood. 
Haematuria is occasionally, I believe, vicarious of some other hemorrhage, and 
especially of bleeding from the hemorrhoidal vessels: so that it is always right, 
in obscure cases, to inquire whether the patient has been habitually subject to 
hemorrhage from the rectum; and if so, whether that hemorrhage is suspended. 
These cases have even been called hsemorrhoides vesicae. 

Haematuria occurs also, independently of any strictly local complaint, in the 



918 



HEMATURIA. 



course of certain disorders which affect the system at large ; especially in scurvy 
* and purpura hemorrhagica. Bloody urine is sometimes a symptom, and one of 
the most fatal augury, in typhus fever, small-pox, measles, and the plague. 

But setting aside these more general forms of haematuria, let us inquire what 
local affections of the urinary organs themselves may give rise to hemorrhage ; 
and how, under different circumstances, we are to interpret this symptom. 

One very common source of hemorrhage from the urinary passages, is the 
presence within them of calculous matter. The pressure occasioned by the aggre- 
gation of the earthy mass, when it is formed in the kidney, or by its accidental 
change of position, lacerates, or lays open by ulceration, some of the smaller 
vessels with which it is in contact. And in those cases in which a calculus 
descends into the bladder, and is ultimately voided, it may, in succession, give 
rise to hemorrhage, first from the kidney from which it is separated; secondly, 
from the narrow tube of the ureter through which it is forced ; thirdly, from the 
bladder which it enters, and wounds, or irritates ; and fourthly, from the urethra 
in the last stage of its progress out of the body. 

There will be the same liability to haematuria, if the concretion, instead of 
coming down from the kidney, is formed originally in the bladder. The appear- 
ance of blood in the urine suggests, therefore, in many cases, the fearful suspicion, 
that there is, or is likely to be, a stone in the bladder. Dr. Heberden, in his 
Commentaries, says, "urine made of a deep coffee colour, or manifestly mixed 
with a large quantity of blood, has within my experience been very rarely the 
effect of anything but a stone in the urinary passages. I therefore suppose a 
strong probability of this cause, whenever I see this appearance." 

Again, blood may proceed from the kidney, or from the bladder, in consequence 
of malignant fungous growths, to which those parts are liable : a disease which, 
though more surely fatal than the stone, is scarcely, to the unhappy subject of it, 
so appalling. 

Hemorrhage may take place from the surface of the bladder from chronic disease, 
not cancerous, of that membrane. Mr. Howship has recorded an instance of this 
kind which occurred in Mr. Heaviside's practice. An old East Indian, who had 
long been subject to nephritic complaints, was suddenly seized with what was 
thought to be retention of urine. A catheter was passed, but as no water flowed 
it was supposed that it had not entered the bladder, in the situation of which 
there was a manifest tumour. The patient died the next day; and the bladder 
was found distended by a very large coagulum of blood which had come from the 
diseased mucous membrane. There was no trace of hemorrhage in the kidneys, 
nor in the ureters. 

I hold in my hand a preparation showing disease of the prostate gland, which 
had been accompanied by haematuria. 

Now we judge of the exact seat of the hemorrhage, and of its cause, partly by 
the nature and appearance of the effused blood, and partly by the symptoms that 
precede or accompany the bleeding. 

Dr. 'Prout states that " when blood is derived from the kidney, it is in general 
equally diffused throughout the whole urine: on the contrary, when derived from 
the bladder, the blood for the most part comes away in greater or less quantity at 
the termination of the discharge, the urine having previously flowed off nearly 
pure." 

There are also certain modifications of the sensible qualities of the excreted 
blood, by means of which the same distinguished physician thinks he can pro- 
nounce, with considerable confidence, that the hemorrhage is owing to malignant 
disease. " The red particles of the blood (he says) discharged in the earlier stages 
of fungoid disease, have often a remarkable appearance, and appear to the eye 
larger than natural ; so that after they have subsided to the bottom of the urine, 
they at first sight somewhat resemble grains of lithic acid gravel, and, like that 
substance, when the vessel is inclined, may be distinctly seen to roll along the 
bottom. From this peculiar appearance of the red particles of the blood, the 



HEMATURIA. 



919 



presence of malignant disease may be often suspected before the symptoms assume 
a decided character." In a more advanced stage of the disease, there is often a 
dark-coloured offensive bloody sanies in the urine, and more or less of mechanical 
impediment in passing it. I should conceive that the microscope might aid the 
diagnosis of such cases. 

There is one phenomenon which, whenever it occurs, is very characteristic of 
hemorrhage from the kidney, or the commencement of the ureter. I mean the 
expulsion, with the urine, of slender cylindrical pieces of fibrin, which have evi- 
dently been moulded in the ureter, and subsequently washed down into the bladder 
by the descending urine. These little coagula are commonly of a whitish colour, 
the red particles of the blood having been removed; and they look like slim mag- 
gots, or small worms. They denote, with much certainty, that the hemorrhage 
which they accompany is renal. 

Such, then, are some of the points of diagnosis furnished by the qualities of 
the excreted fluid itself. 

The bleeding may be presumed to come from the kidney, or from the upper 
part of the ureter, when it is accompanied or preceded by a sensation of heat, or 
of weight, or by some degree of pain, in the situation of the kidney ; especially 
if these uneasy feelings are confined to one side of the body. This presumption 
will of course be strengthened if calculi have been known to descend from the 
kidney ; and converted into certainty if the patient suffers, together with the hema- 
turia, a fit of the gravel ; and if there be no symptom of stone, or of disease, in 
the bladder. 

On the other hand, when no symptoms referable to the kidney or the ureter 
are present, while there are signs of stone, or of disease of the bladder, or of a 
diseased prostate — a mixture of mucus with the blood ; occasional retention, or a 
sudden stop in the stream of urine; pain referred to the glans penis immediately 
after the bladder is emptied — then we conclude that the blood proceeds originally 
from that receptacle. 

When pure blood comes away, either gultatim, or in a stream, unmixed with 
urine, and neither preceded nor accompanied by any desire to make water, it is 
probable that the urethra is the locus of the hemorrhage. 

Bleeding from the surface of the urethra doubtless may, and commonly does, 
proceed from some mechanical injury done to that channel : as in the passage 
outwards of a fragment of stone, or inwards of a surgical instrument. But it is 
probable that blood is sometimes exhaled from the same membrane in consider- 
able quantity, under circumstances which favour or produce a strong determination 
of blood to the genital organs. A young man came to the Middlesex Hospital 
with hemorrhage from the urethra, and said that he had lost a considerable quan- 
tity of blood in this way, within a few hours. The hemorrhage appeared to have 
been the consequence of excessive indulgence in sexual intercourse. His own 
account of the matter was that he had passed the night with a female, in whom 
the monthly period had just returned ; and he ignorantly fancied that the hemor- 
rhage from his own person was the result of a sort of contagion. However, the 
bleeding was permanently arrested by the introduction of a bougie, which was 
allowed to remain for a short time in the urethra. This was the solitary instance 
to which I alluded just now, of (perhaps) idiopathic hemorrhage, occurring within 
my own knowledge. When the hemorrhage comes originally from the urethra, 
the blood may regurgitate into the bladder, and coagulate there; and mislead an 
observer into the belief that the hemorrhage was vesical. 

It appears, then, that, in many instances, certain local symptoms are associated 
with haematnria, and point distinctly to the part of the urinary apparatus whence 
the blood proceeds. 

But many cases are very obscure. Blood sometimes appears, mixed in greater 
or less quantity with the urine, when there is no pain, nor any other sign which 
would lead us to fix upon one part rather than another as the source of the hemor- 
rhage. Now I believe that hematuria, bearing this indeterminate character, will 



920 



HEMATURIA. 



generally turn out to be renal, and to depend upon earthy concretions in the kid- 
ney. It is true that the hemorrhage which results from cancerous disorganization, 
whether of the kidneys or of the bladder, may also be painless. But cancerous 
disease of these organs (unless it extends from parts in the neighbourhood, as 
from the rectum, or from the uterus, to the bladder) is very rare; and when it 
does occur, the nature of the case may usually be ascertained from those peculiar 
qualities of the effused blood which I have mentioned as being characteristic of 
malignant growths. 

A calculus can seldom remain long in the bladder, at any rate will seldom cause 
bloody urine, without giving some other notice of its presence there : but concre- 
tions form in the kidney, sometimes in great numbers, and reach a considerable 
size, and remain there long, without furnishing any signal from which we might 
suspect their existence ; except (perhaps) the occurrence of haematuria. We 
know this, because calculi are frequently met with in the kidneys of persons who 
had never suffered any pain or obvious derangement of the urinary organs during 
life; and because, in other persons, in whom such calculi pass down from the 
kidney towards the bladder, the first notice of their existence is often given by 
the acute suffering they inflict during their transit through the narrow ureter. 

Yet though calculi may lodge in the infundibula, or in the pelvis of the kidney, 
without manifesting their presence by exciting pain, it is very conceivable that, 
by progressive enlargement they may lay open, or, by accidental change of posi- 
tion they may wound, some of the smaller blood-vessels of the part, and so give 
rise to painless haematuria. It will strengthen the presumption that such is the 
source of the bleeding, if it has succeeded (as hemorrhage from the urinary pas- 
sages often does succeed) to a fall; a shock, or jar of the body; or jolting on 
horseback or in a carriage. Similar movements may occasion bloody urine when 
there is stone in the bladder; but then the irritation will be felt in that sensible 
part; the haematuria will not be painless; the bleeding will not be the only 
symptom. 

It is, then, I say, my belief that very many of the obscure cases of haematuria 
may be referred to renal calculi: and if this view of the subject be correct, it will 
render it probable that the alleged instances of idiopathic hemorrhage from the 
kidneys ought thereby to be reduced in number. 

The expulsion of the blood in haematuria, whether it be painful or not, is some- 
times attended with severe rigors. I mentioned before, that, in some persons, 
almost any irritation of the urethra, the passing a bougie, for example, will bring 
on a shivering fit. I had some time ago a patient under my care in the hospital, 
who had haematuria of an obscure kind, and the discharge of blood was always 
marked by a smart rigor. Dr. Prout speaks of an instance of obstinate haema- 
turia in which a shaking fit constantly preceded hemorrhage. Dr. Elliotson, too, 
in one of his lectures, gives an account of a case of intermittent haematuria. The 
patient was under his care in St. Thomas's Hospital, and had formerly had the 
Walcheren fever. He was admitted for ague, and every time that the cold stage 
of his attack came on, he voided a quantity of pure blood from the urethra. He 
was cured, by quina, both of his ague and of his hemorrhage. 

If we may trust to the records of physic, instances of periodic haematuria are 
not uncommon. 

One circumstance yet remains, worth noticing, in respect to haematuria; and it 
depends upon the hemorrhage itself rather than upon the disease of which the 
bleeding is a sign. I allude to the coagulation of the effused blood in the blad- 
der, however it may have got there. This circumstance is sometimes the source 
of much inconvenience, and suffering, and even of danger, to the patient. It may 
cause retention of the urine and all its evil consequences; and a still worse event 
is, that the coagulum sometimes supplies a'nucleus, around which calculous matter 
is deposited, and thus lays the foundation of that horrible malady, "the stone." 

You will perceive, from what I have said, that the treatment of hematuria re- 



HEMATURIA. 



921 



solves itself, in most cases, into the treatment of the disorder, or bodily condition, 
with which the hemorrhage is associated, and of which it is merely a symptom. 
. Sometimes, however, the bleeding itself is so profuse, or so long-continued, as 
to require direct efforts on our part towards its restraint. 

" When (says Dr. Prout) the bladder becomes distended with blood, and com- 
plete retention of urine in consequence takes place, recourse must be had to a 
large-eyed catheter, and an exhausting syringe, by the aid of which, and the oc- 
casional injection of cold water, the coagula may be broken down and removed. 
If the hemorrhage be so profuse that the bladder becomes again distended with 
blood in a very short time, the injection of cold water into the rectum or bladder 
is sometimes of. great use; and should these means fail, from twenty to forty 
grains of alum may be dissolved in each pint of water injected into the bladder; a 
remedy that seldom fails to check the bleeding, even when the cause is malignant 
disease. I have never known any unpleasant consequences follow the use of this 
expedient, and have seen it immediately arrest the most formidable hemorrhage, 
when all other means had failed; and when the bladder had repeatedly become 
distended with blood, almost immediately after its removal." 

Among remedies given by the mouth, the same physician thinks highly of the 
acetate of lead. I have mentioned before, in these lectures, a nostrum called, 
after the name of its inventor, RuspinVs styptic. This has often been known to 
put a stop to hemorrhage which had resisted other remedies. I will read you 
one example of this from Sir Benjamin Brodie's published lectures. Speaking of 
hematuria, dependent upon disease of the prostate gland, he says: "Those 
medicines which operate as styptics when taken internally, and which are useful 
in cases of hemorrhage from the lungs, are also useful in hemorrhage from the 
prostate. I had a patient with very diseased prostate. A frightful hemorrhage 
took place. The usual methods of treatment were adopted, but were of no avail. 
The skin became pale, the pulse became weak, and the patient was exhausted ; 
yet the bleeding continued. Large quantities of blood were drawn off with the 
catheter: nevertheless the bladder continued to become more and more distended 
with blood, and was felt prominent in the belly as high as the navel. All other 
remedies having failed, I gave the patient a dose of the nostrum known by the 
name of Ruspini's styptic, and repeated the dose two or three times in the course 
of the next twelve hours. In about half-an-hour after the first dose was taken the 
hemorrhage ceased ; and it never returned. The patient lived a year and a half 
afterwards, and there was no reason to believe that any ultimate harm arose from 
the bleeding." 

For a long while this nostrum seems to have baffled analysis. The late Dr. 
Maton told me that Dr. Wollaston had examined it, and had arrived at the negative 
conclusion, that it contained no metallic substance. Dr. A. T. Thomson has since 
announced that it mainly consists of a solution of gallic acid in alcohol diluted 
with rose-water. 

There is no substance more highly spoken of as a remedy for internal hemor- 
rhages by foreigners, and especially by the French, than the extract of Rhaiany 
root, the Krameria of our Pharmacopoeia. A female was sent to me by my col- 
league, Mr. Arnott, complaining that for some weeks she had been passing bloody 
urine. She had gone through the ordinary routine of treatment without benefit. 
There were no symptoms present which threw any light on the precise source or 
cause of the hemorrhage. I recommended a trial of the rhatany, and she began 
to take a scruple of the extract, mixed with water, three limes a day. As in Sir 
Benjamin Brodie's case, the haematuria ceased after the first dose, and it did not 
return for many months. I mention this instance the rather, because the gallic 
acid enters into the composition of this vegetable extract also. 

Now the gallic acid is one of those substances which, when introduced from 
the digestive organs into the blood, passes through the round of the circulation 
unchanged, and reappears in the urine. We may conceive, therefore, that it stays 
internal hemorrhage by exciting its astringent property upon the ultimate capillary 



922 



ABDOMINAL TUMOURS. 



blood-vessels in its passage through them. It certainly is applied, in solution, 
after its elimination from the blood, to the urinary passages : and thus, in hema- 
turia, it may be presumed to produce its styptic effect upon the bleeding surface. 

To the same principle are owing, I believe, the astringent and styptic virtues of 
the uva ursi, bistort, tormentil, the pomegranate, kino, catechu, and the several 
preparations of gall nuts. I am sorry that I have not had much opportunity of 
trying the gallic acid itself, in its separate state; for I have heard of several 
instances of its successful employment in cases of internal hemorrhage. If, as I 
believe, it really has this power, it is very desirable that it should be prescribed 
in a more definite and precise manner than is afforded by its natural combinations 
with so many different vegetable matters. 

I am unwilling to take leave of the cavity of the abdomen, without saying a 
few words (very few they must be) respecting the various kinds of tumour to 
which it is obnoxious. It may seem strange that the diagnosis of abdominal 
tumours, which manifest themselves to the touch, and to the sight, should be so 
difficult and puzzling as it often is. I mentioned some reasons for this before : 
the loose and shifting manner in which some of the viscera of the belly are 
packed and fastened ; their liability to enlarge beyond their natural limits ; their 
accidental dislocations under disease. It would be vain to attempt even a sketch 
of the infinite variety of these deviations from the healthy state. Every case of 
abdominal tumour forms a separate object of study, and must be judged of by its 
proper circumstances. All that I can profess to do, is to offer you some rough 
hints on this interesting subject.- 

Some kinds of tumour result from morbid growths; such are all the varieties 
of cancer: some from the presence and multiplication of parasites; of which we 
have examples in collections of hydatids : some are produced by the distension 
of hollow organs ; as when concretions, or fecal matters, or gases, lodge in the 
intestines ; or when urine accumulates and is pent up in the bladder : some consist 
in the mere enlargement of parts. 

Let us enumerate the principal of these; that you may know what chiefly to 
expect. 

1. There are, I say, tumours from lodgments in the bowels; and these are 
more hopeful than most kinds of abdominal tumours. Sometimes the stomach, 
or some part of the intestinal canal, is distended in consequence of a mechanical 
impediment to the course of its contents : and this impediment may be invincible. 

2. Ovarian tumours are very common. Of these I spoke at some length in a 
former lecture. 

3. The liver is very liable to enlargement: either from simple congestion of 
blood ; or from the interstitial deposit of adipose matter; or from the intrusion of 
malignant growths ; or from colonies of hydatids. 

4. So also the spleen swells, from fullness of blood, or from specific deposits in 
its substance. 

5. The kidneys sometimes attain a vast size ; being occupied by malignant 
disease, or swollen by pus that finds no vent. 

6. Enlargements of the mesenteric glands ; cancerous degeneration of the peri- 
toneum, especially where it forms the omentum; tumours connected with the 
uterus; aneurisms of the aorta; vast distension of the gall-bladder; constitute 
other species of abdominal swelling, which I simply mention without further 
comment. 

Now our judgment of the character of a given tumour is naturally influenced 
by its place. In the right hypochondrium, we suspect the liver; in the left, the 
spleen ; in the epigastric region, the stomach ; in the hypogastric, the womb, or 
the bladder ; in either flank, an ovary, or perhaps a kidney ; in the track of the 
colon, we guess at fecal collections. 

But sometimes the situation of the tumour fits more than one, or than two, 
suppositions. Between the ribs and the ilium on the right side we may have an 



ABDOMINAL TUMOURS. 



923 



enlarged ovary, a tumid kidney, a distended caecum. A prominence in the epigas- 
trium may be due to cancer of the stomach, to an infarcted transverse colon, to a 
ventral aneurism. Above the pubes, the distended bladder, or the enlarged uterus, 
may equally project. The sigmoid flexure of the colon loaded with feces, the 
left kidney exaggerated by disease, a bulky ovary, may either of them occupy 
the same sinistral space. > 

Moreover, the colon deviates strangely, and not seldom, from its natural course 
and position : and the magnified viscera may invade, by their displacement, or by 
their irregular expansion, the regions that are proper to other organs. 

Our conjectures are assisted by the associated symptoms, and by observa- 
tion of the regular performance, or of the disturbance, of particular functions. 
Yet here, also, we meet with continual sources of fallacy. Pressure from a 
tumour without may, as well as infarction within, impede the passage of aliment- 
ary matters through the bowels, of urine through the ureters; and cause, in the 
one case, flatulence and tormina, in the other, retention or suppression of urine. 
Growths foreign to the liver may, nevertheless, press upon it's excretory ducts, 
and occasion jaundice. And so of other parts and functions. I mean, that the 
functions prominently deranged are not always the functions of the part occupied 
by the tumour, but of organs which are secondarily and accidentally subjected to 
its disturbing influence. Your sagacity will be abundantly tried *n balancing the 
evidence of different symptoms in these obscure, yet palpable, forms of disease : 
and after all you will often doubt; and often, when you do not doubt, you will 
mistake. 

Enlargement of the liver may usually be distinguished from other tumours of the 
right hypochondrium, by percussion. Try from the clavicle downwards. At 
first, you get a hollow sound. Then a little below the nipple perhaps, (for the 
spot varies much in different subjects,) the sound begins to grow dull. If this 
dullness be traceable, without change or interruption, to the tumour, the inference 
is strong that the tumour is hepatic. Any other tumour there situate leaves, most 
commonly, when the patient is recumbent, a palpable sulcus above it: or a space 
in which the sound, upon percussion, is different from that which is yielded by 
the liver. 

Percussion helps us to discriminate an ovarian from a renal tumour. When 
the swelling is large, the intestines lie behind the one, in front of the other : and 
the sound is affected accordingly. 

Tumours that are readily movable, are generally intestinal, omental, or ova- 
rian. 

A pulsating tumour is not necessarily an aneurism. The healthy artery will 
lift almost any sort of hard swelling that happens to lie directly over it. 

The occurrence of haematemesis or melaena would corroborate your belief that 
a tumour in the right hypochondrium was hepatic — in the left, was splenic. 

Even when you are satisfied as to the organ affected, there comes another ques- 
tion, scarcely, in some cases, less difficult than the first — What is the nature of 
the tumour ? 

Suppose, for the sake of illustration, that your inquiry relates to the liver. If 
the tumour be large, smooth, roundish, of slow growth, and the general health be 
not materially deranged, it is most likely, an hydatid tumour. If along the edge 
and upon the surface of the augmented liver, you can feel large inequalities and 
projections, and if the complexion and general state of the patient are expressive 
of failing health, the enlargement is, in all probability, cancerous: and if there be 
other traces of carcinoma in the system, this conclusion becomes almost certain. 
Small hard irregularities betoken the hobnail liv er ; which is, sooner or later, 
accompanied by ascites. When, without pain or jaundice, the liver of a phthisical 
patient transgresses its natural boundaries, it is, presumably, a fatty liver. 

By applying a similar method of investigation to other ventral enlargements, 
you may frequently hit the right scent, and trace the mischief to its true source. 
To treat the subject in detail would require a volume. I may refer you to a series 



924 



ACUTE RHEUMATISM. 



of papers by Dr. Bright, in the Guy's Hospital Reports-; where you will find a 
host of examples, and much valuable information, concerning the most common 
and the most important kind of " abdominal tumours and intumescence." 



LECTURE LXXXI. 

Jicute Rheumatism; Symptoms; Varieties; Treatment. Chronic Rheumatism; 

Phenomena : Plan of Cure. 
Gout: Description of a Paroxysm; Progress of the Disease: general state of 

the Health in Gouty Persons ; Causes of the Disease; Diagnosis between 

Gout and Rheumatism. 

I proceed, this afternoon, to the consideration of that very common, very pain- 
ful, and sometimes very perilous disease, rheumatism. There are two species of 
it, the acute and the chronic. They graduate, however, insensibly into each other; 
and the chronic js often a sequel of the acute form. Yet this is not necessarily 
so. Chronic rheumatism occurs in persons who have had no preceding attack of 
the disorder in its acute stage or degree. 

Rheumatism implies inflammation : but as I mentioned in an early part of the 
i course, it is inflammation of a peculiar or specific kind. In the first place, it is 
inflammation of a particular tissue — the fibrous tissue: and it may, therefore, 
manifest itself wherever that tissue is employed in the fabric of the body. No 
doubt the inflammation does involve other tissues also : but it is always, probably, 
by extending to them through what has been called cojitiguous sympathy. Thus 
we have the synovial membrane of a joint inflamed in many cases, the inflamma- 
tory action having spread from the fibrous textures around the joint : or, as I 
formerly pointed out to you more in detail, the serous surface of the pericardium, 
and the serous surface (or what is analogous to a serous surface) of the inside of 
the heart, and especially that part of it which is carried over the valves — each and 
all of these serous membranes are extremely liable to be affected with inflamma- 
tion in the acute form of rheumatism : but in all of them it is probable that the 
fibrous tissue was the first to suffer. The pericardium is, as you know, a fibro- 
serous membrane; and fibrous tissue is interposed between the folds of the serous 
membrane, in the cardiac valves. 

Rheumatism, therefore, is essentially inflammation of the fibrous tissue : and it 
most commonly seizes upon the fibrous parts that lie round the larger joints : the 
ligaments and the tendons : and in this respect you may almost consider the per- 
petually moving heart as one of the large joints. Yet this inflammation when 
confined to the fibrous tissues, is not common inflammation. At any rate, it does 
not reckon among its events (as common inflammation does) either suppuration or 
gangrene. If suppuration sometimes occurs (and it certainly occurs very rarely) 
it is because the rheumatismal inflammation has extended to contiguous textures, 
and then has run the ordinary course of inflammation. Inflammation of the 
areolar tissues around a joint may thus inflame and suppurate. The inflammation 
of the synovial membrane may be of sufficient intensity to give rise to the forma- 
tion of pus. When, however, the inflammation extends to the serous tissues 
within and around the heart, the products of the inflammation are just the same as 
when inflammation of the same texture, of the common kind, is any how produced. 

Acute rheumatism, then, consists in redness, heat, pain, and swelling (that is 
to say, in inflammation) of the parts lying around, or entering into the composition 
of, one or more of the larger joints of the body; generally of several at the same 
time, or in succession ; with a disposition to shift from one joint to another, or to 
certain- internal organs, and especially to the membranes of the heart ; and with 
fever. 



ACUTE RHEUMATISM. 



925 



This tendency to shift its place — to what is usually called metastasis — is a very 
remarkable feature of the disease. The inflammation will appear, in one joint, 
suddenly, and as suddenly subside in another which it previously occupied : and 
then, perhaps, it will jump back again to its old quarters. In many instances, 
however, it invades fresh joints without wholly ceasing, and sometimes even with- 
out diminishing at all, in those formerly affected. It may visit in this way every 
large joint in the body, and even seize upon some of the smaller ones ; or it may 
possess nearly all of them at once. It is most commonly seen to affect the ankles 
and knees, the knuckles, wrists, and elbows. It is often seated in the shoulders 
also; and in the hips. 7'he joints of the fingers frequently suffer; and I have 
seen one instance in which the joints of the jaws were manifestly implicated in the 
rheumatic inflammation. But by far the most serious and dangerous leap which 
the diseased action is apt to take, is to the membranes of the heart. 

But I pointed out to you, in a former lecture, the symptoms of rheumatic car- 
ditis, its consequences, the various ways in which it connects itself with the joint 
affection, and the treatment by which we are to attempt to moderate it. I dismiss, 
therefore, this, the most momentous complication of acute rheumatism, from the 
present discussion ; and shall confine myself solely to the disease as it manifests 
itself externally. 

The shifting and migratory inflammation of the textures lying round or com- 
posing the larger joints, is attended with high inflammatory fever; with a remark- 
ably full, bounding pulse; with flushed cheeks; headache; profuse, drenching, 
sour-smelling perspirations, which distress and weaken the patient, but bring no 
relief to his pain ; with a white-coloured, dirtyish, thick fur on the tongue, which 
is -red, however, at its tip and edges ; with turbid and acid urine. But this severe 
and inflammatory fever (synocha Cullen calls it) has no tendency to degenerate 
into a typhoid form : and that is a striking feature in the complaint. Neither is 
the intellect affected, except when carditis takes place : and then, as I stated for- 
merly, violent delirium is apt to ensue, misleading the practitioner, drawing his 
attention away from the chest, where fatal changes are in progress, and fixing it 
upon the head, where no inflammation at all exists, but which is disturbed through 
sympathy with the cardiac disorder. With this exception, we do not find patients 
in acute "rheumatism delirious. Throughout all this febrile disturbance, there is 
no coma, no marked trouble of the stomach or of the bowels, no vomiting, no 
diarrhoea, no petechias, no aphthae, no sordes about the mouth, all which are of 
ordinary occurrence in the course of common continued fevers. 

The joints are exquisitely tender, as well as painful. The fibrous tissues, 
which are endowed with but little sensibility in their sound and healthy state, 
become acutely painful when occupied by inflammation. The pain is increased 
by pressure; and therefore by whatever implies pressure; by movements of the 
joints consequently. The patients are reduced to perfect helplessness by the 
pain. Their common phrase is, that they have entirely lost the use of their 
limbs : and this is true enough in fact, but not true in the medical sense of those 
words. They have not lost the power of moving them ; there is no palsy ; but 
they dare not move them, because the effort gives them so much torment. 

Pain in the affected joints is more constant than swelling; and swelling more 
constant than redness. The swelling differs also in different cases in rather a 
remarkable manner. In fact, two varieties have been made of acute rheumatism. 
The distinction was first drawn by Dr. Chambers, at St. George's Hospital : and 
afterwards made public by Dr. Francis Hawkins in his Gulstonian lectures. The 
varieties are spoken of under the names of fibrous or diffused rheumatism ; and 
synovial rheumatism. I will briefly state their distinctive characters. 
* In the one, then, the inflammation commences in the immediate neighbourhood 
of one of the larger joints : not in the joint, but near it. It attacks the tendons, 
fasciae, ligaments, and possibly also the muscles. There is not at first much red- 
ness, or swelling; but after the pain has been of some duration, there is a puffi- 
ness around the parts affected, caused apparently by turgescence of the blood- 



926 



ACUTE RHEUMATISM. 



vessels, and at length slight pitting, or oedema, may supervene, from effusion into 
the surrounding areolar tissue : and what redness is present is disposed in streaks, 
following the course of the tendons. 

On the other hand, in the synovial variety, which shows itself more frequently 
and more plainly in the knee than anywhere else, the pain which marks the onset 
of the complaint does not last long before some degree of swelling is perceptible, 
together, in most instances, with slight redness of the skin: and this swelling is 
not due so much to turgescence of the blood-vessels, or to oedema of the areolar 
tissue, as to fluid poured into the cavity of the joint. And the form and character 
of the swelling indicate that it is the result of the fullness and distension of the 
synovial membrane. It is tight and elastic, and protrudes, as it were, through 
the spaces that intervene between the tendons and ligaments by which it is in other 
parts bound down and restrained: and fluctuation is often distinctly perceptible 
in the superficial joints, when both hands are applied to them. 

These are the local differences between the two forms of the disease, And 
there are differences equally well marked between the constitutional symptoms 
that attend them. 

It is in that form which xai \%oxv\v is called fibrous rheumatism, that the in- 
flammatory fever runs so high; that the tongue is so thickly furred ; that the 
round, full, bounding pulse occurs ; that the profuse, spontaneous, acid perspira- 
tions break out, which exhaust the patient's strength without alleviating his suf- 
ferings ; that the urine is high-coloured, and deposits a copious sediment like 
brick-dust. 

In the synovial form, the fever is either less intense from the beginning, or 
soon moderates after the joints begin to swell; the tongue is less foul ; the patient 
sweats much less. It is to this form that the term rheumatic gout is often applied. 
And growing experience has led me to believe, that in this popular appellation the 
real nature of the complaint is most truly expressed. Gout and rheumatism are 
very similar in kind : and what has been called synovial rheumatism, while it 
forms a connecting link between the two, and partakes of the characters of both, 
is more nearly allied to gout than it is to rheumatism. 

Conformably with this belief, it has been noticed that the tendency of the in- 
flammation to settle upon the cardiac membranes is much greater in the fibrous 
than in the synovial disease. This is a most important difference. 

I know of no other exciting cause of acute rheumatism than exposure to cold, 
and especially cold combined with moisture. And this is the reason why the 
disease is very common among the poorer classes of society, who are more in the 
way of that cause, and cannot guard against it so effectually as their wealthier 
brethren; among whom it is comparatively rare. 

Acute rheumatism is principally a disease of youth; prevailing most, I believe, 
from the age of puberty to that of thirty-five or forty. I have repeatedly, how- 
ever, seen it in children; sometimes as early as the third or fourth year: and I 
stated to you some time ago, that the chance of the joint affection being compli- 
cated with rheumatic carditis is the greater in proportion as the patient is the 
younger. With, perhaps, one exception, I never knew the disease occur in an 
unequivocal form before puberty, without its being attended with inflammation of 
the lining or investing membranes of the heart. 

I have already told you what I believe to be the proper plan of treatment to 
pursue when rheumatic carditis is present: in that case the affection of the limbs 
is of secondary consequence. But what are we to do when there is no complica- 
tion of the joint disease; no invasion of any of the viscera? 

Why, if you seek for instruction upon this matter in books, or even among 
practical men, you will meet with a very perplexing diversity of opinion. Apart 
from the cardiac affection, acute rheumatism has no danger about it; and the arti- 
cular inflammation usually terminates, sooner or later, in recovery whether the 
heart be implicated or not. And most persons who have been for any considera- 
ble time in practice have their own favourite method of conducting the disorder 



ACUTE RHEUMATISM. 



927 



to its termination. While many employ free blood-letting, and other active anti- 
phlogistic remedies, some, on the contrary, even in the present day, put their 
trust in bark. Some give large doses of calomel in the outset of the disease, such 
as half a scruple or a scruple, with or without a grain or two of opium ; and they 
repeat the dose daily, or oftener, till the urgent symptoms give way ; and in this 
manner I have seen the disease apparently cut short. But I have also known 
many instances in which the disease was painful, and protracted, and obstinate, 
although this practice was adopted early, and fairly prosecuted. Some physi- 
cians, again, give smaller and more frequent doses of calomel and opium: and 
some think opium alone to be as useful as this combination. Others depend 
mainly upon colchicum: others, upon large and repeated doses of conium : and 
some attempt the cure of acute rheumatism by sweating the patient by means of 
guaiacum and similar stimulant medicines, and a profusion of bed-clothes. 

Now you may be sure — when men's opinions concerning the treatment of a 
disease which is of common occurrence and easy recognition, are thus unsettled 
and diverse — you may be sure, first, that no specific for that disease has yet been 
discovered ; and secondly, that the disease is not very obedient, or not steadily 
obedient, to any remedial plan. When I first began to practice, I pleased myself, 
now and then, with the belief that I had ascertained the best cure for acute rheu- 
matism : so rapidly and decidedly did the disorder recede and cease upon the ad- 
ministration of such or such a remedy. But, on the next trial of it perhaps, my 
expectations have been miserably disappointed. This marked improvement has 
happened under the use of colchicum, of conium, of calomel with opium, of alka- 
lies. I did not, in the prosperous cases, mistake spontaneous recovery for cure. 
The change was too great and immediate, and the instances of success were too 
numerous, to admit of that explanation. Whether it be (as I suspect) that slighter 
diagnostic marks have been overlooked, and that sometimes goat has in reality 
been cured under the semblance of rheumatism — whether bodily idiosyncrasies 
have withstood the influence of remedies — or whether atmospheric agencies have 
kept up the disorder in spite of proper treatment — I cannot tell : certain it is that 
we are occasionally baffled, and the patient continues to suffer, notwithstanding 
the diligent enforcement of all the approved remedies and plans of treatment, one 
after the other. I am far, however, from thinking that remedies are useless: and 
I do by no means assent to the dictum of the first Dr. Warren, who, when asked 
what was good for acute rheumatism, answered "six weeks." 

In the fibrous or genuine form, with the bounding pulse, the flushed face, the 
high inflammatory fever, you may bleed your patients from the arm ; especially 
if they are young and robust. They will bear to lose a large quantity of blood 
without fainting ; and you will always find the blood drawn to be remarkably 
buffed and cupped. The pain and inflammation are local ; but the case is not 
adapted to local remedies. We may, by leeches, or cupping, or cold applications, 
be able perhaps to subdue the inflammation in a knee or an elbow: but from the 
migratory character of the disorder, we incur the risk, by such topical measures, 
of giving the inflammation a new and a more serious location. 

Venesection will, almost always, afford a marked degree of relief to the suf- 
ferings of the patient : but the relief will seldom be complete or permanent : and 
we may sometimes with propriety repeat the bleeding. In very few instances, 
however, can we hope to extinguish the disease by blood-letting. And this is 
one of the cases in which you must not take the state of the blood already drawn 
as a criterion of the propriety of abstracting more. The blood will remain ready 
to show the buffy coat long after the use of the lancet has ceased to be available 
or safe. 

The advantages of blood-letting in this complaint are, first, the partial relief 
which it bestows. It is seldom that the pain is not sensibly mitigated, and the 
fever calmed, provided the bleeding has been carried to a proper extent, suffi- 
ciently soon. Secondly, free and early venesection may sometimes perchance 
(but not often) cut short the attack. This, however, is a favourable effect which 



928 



ACUTE RHEUMATISM. 



you must not reckon upon, and which I would not advise you to aim at. But, in 
the third place, blood-letting may be serviceable, by preparing the body for other 
remedies : for calomel, opium, purgatives, colchicum. 

Yet, looking to my own practice in acute rheumatism, I find that although I 
am in the almost daily habit of treating it — for it is a disorder from which our 
wards are never perhaps entirely free — I rarely prescribe phlebotomy. Many of 
the patients come under our care at an advanced period of the disease ; when the 
time for bleeding, with any prospect of benefit, has gone by. Some have been 
bled before their admission. Others, in whom the rheumatic diathesis has become 
inveterate, are suffering recurrences of the malady : and neither does the recurrent 
disease require, nor would the system bear, active and repeated depletion. In 
many instances, again, the constitution has been battered and broken by a London 
life : while in others there is no great intensity of febrile disturbance from the 
first. So that the cases in which I am tempted to employ the lancet are really 
few and far between. At the same time I can well believe — what I have often 
heard — that in the country, in young persons of unimpaired vigour, in the first 
attacks of the disorder, and when the inflammatory symptoms run high, venesec- 
tion may be of much service in mitigating the sufferings of the patient, and in 
facilitating his cure. 

I believe few persons now adopt the plan of forced perspiration for the cure of 
acute rheumatism. Formerly it was the fashion to give powerful sudorifics: 
Dover's powder, or antimony, in large doses ; and the patient was " accinctus ad 
sudorem covered up in bed between thick blankets, with a hot bottle or brick 
at his feet. But in the severe, unequivocal fibrous form of rheumatism the per- 
spiration is profuse without any artificial means being used to excite it, and it is 
not accompanied by the smallest alleviation of the pain: nay sometimes the patients 
will tell you that they are worse, in that respect, while the sweating continues. 

The preparations of colchicum have sometimes, whether venesection has been 
premised or not, an almost magical effect in quelling the disease. Frequently, 
when most successful, (though that is by no means a necessary condition of their 
success,) they exercise some marked influence upon the stomach and bowels. 
Colchicum is very apt to occasion deadly nausea and vomiting, griping, and diar- 
rhoea, and when these consequences ensue from its use, the inflammation of the 
joints often subsides entirely. At any rate, if the rheumatism does not give way 
when the stomach and bowels become thus affected, you may be certain that to 
push the colchicum further would be useless. 

Our wishes, however, and our expectations, from colchicum, are often doomed 
to be defeated. I believe that in proportion as the synovial symptoms predomi- 
nate, or mix themselves distinctly with the fibrous — in proportion as the disease 
approaches in its characters to gout — you may expect to be successful with col- 
chicum. Large doses are not requisite. Twenty minims of the wine or of the 
tincture may be given every six hours, until some result is obtained. Or a grain 
of the inspissated juice, or of the acetous extract of colchicum, every four hours. 
Under this treatment the disease sometimes vanishes within three or four days; 
the medicine producing sickness and purging, and the rheumatism, or the rheu- 
matic gout, rapidly declining. Occasionally the same favourable event takes 
place, although there has been no disturbance of the stomach or bowels. 

There are some cases which yield readily to calomel and opium : and in the 
fibrous disease I think that calomel and opium are the remedies to which, after 
sufficient bleeding, you will do well to trust. For it is under this character that 
the extension of the disease to the membranes of the heart is so liable to happen: 
and if anything can protect the patient against this fearful complication of a malady 
which, previously attended by no danger, becomes by this addition almost neces- 
sarily fatal — or if anything can arrest the carditis before it leaves indelible mischief 
imprinted on the heart — it is (in my opinion) mercury. 

Dr. Hope has lately (1837) published an account of a particular mode of using 
calomel and opium in this disease, which mode he learned from Dr. Chambers, 



ACUTE RHEUMATISM. 



929 



and which is followed, more or less closely, I fancy, by many other physicians. 
It is said to be so successful that even the details of it ought to be known. The 
plan is described as follows : — After a full venesection, or even two, in the robust, 
but without any bleeding in the feeble and delicate, eight or ten grains of calomel, 
with a grain and half of opium, according to the age of the patient and the severity 
of the case, are administered every night ; and followed every morning by a strong 
black dose, sufficient to ensure four or five stools at least. With this treatment is 
combined, thrice a day, a saline draught containing from fifteen to twenty minims 
of the vinum colchici, and five grains of Dover's powder. When the pain and 
swelling are greatly abated, if not almost gone (which Dr. Hope affirms to happen 
often within two days, and almost always within four), the calomel is omitted ; 
or it is omitted sooner if the gums become at all tender. The opium, however, 
is continued to the amount of a grain or a grain and, half at bed time ; and in severe 
cases a grain also at noon is added ; and the colchicum, and the black dose, are 
still given as at first. Dr. Hope considers it a case of exception if the patient be 
not well in a week. 

The following are stated by Dr. Hope as being the great advantages of this plan 
of procedure: — 1. That the patient is generally sound, well and fit for work, in 
a week or ten days after the pains have ceased. 2. That the gums are rarely 
affected, especially if you previously ascertain that the patient has not a morbid 
susceptibility of mercury. 3. That it is rare to see inflammation of the heart if 
the treatment is early begun ; not oftener, he thinks, than in one of a dozen cases. 
4. If the slightest symptom of endo- or peri-carditis does supervene, a few extra 
doses of calomel and opium, given every four or six hours, will generally affect 
the constitution in twenty or thirty hours, which, with two or three cuppings or 
leechings on the region of the heart, almost always place the patient in a state of 
safety. 

Now, believing that some such plan as this, made up of blood-letting in some 
cases, purging, calomel and opium, and colchicum, is as good as can be pursued ; 
and indeed that, with individual modifications, it is very much pursued, especially 
in London at present; still I cannot help feeling great doubt — doubt which I 
would willingly not entertain — about all the advantages just enumerated. Too 
often we do not see the patient till there is such disease of the heart present as is 
manifest to the ear; and then, as I stated in a former lecture, perfect recovery 
and repair seem scarcely within the scope of possibility. Too often, when the 
patient is seen early, the system refuses to admit of the specific protection of the 
full mercurial action. There is a practical objection also to the exaction of four 
or five motions from the bowels of these rheumatic patients every day ; I mean 
the inconvenience, the increase of pain, and the fresh exposure to cold, occasioned 
by frequently going to stool ; and this is a disadvantage likely to be particularly 
felt in hospitals. 

Bark used to be highly thought of for the cure of acute rheumatism ; but it is 
only beneficial, or safe, during the convalescence. Where the system has been 
much reduced or broken by the complaint, or by the discipline the patient has 
undergone, I think that the decoction of cinchona is of service in fortifying the 
body against the renewed agency of those causes on which the original attack 
depended. 

Cases frequently occur which are neither absolutely acute, nor absolutely chro- 
nic. The inflammation, without being intense in any one joint, lingers in many ; 
and the fever, though not entirely absent, is moderate. The joints are hot and pain- 
ful, and the skin is dry, and there is some thirst. To this intermediate character 
the term subacute is sometimes applied ; and it will serve our purpose of distinction. 

In this form of the disease, as well as in the more active form, the urine is 
almost always loaded with lateritious matters, and strongly acid. Looking upon 
this as an indication of treatment, I have prescribed alkalies, and with much suc- 
cess : the liquor potassae, for instance, to the amount of a drachm daily, for seve- 
ral davs together; keeping the bowels free by laxative medicine. Under this 
59 



930 



CHRONIC RHEUMATISM. 



plan, more surely in my experience than under any other, the urine clears, the 
pain abates, and the joints are liberated. Nitre has been praised of late as being 
eminently successful against rheumatism: I have not had much opportunity of 
trying it, but I should think it likely to do good in these subacute cases. 

There are two kinds of chronic rheumatism : one attended with local heat and 
swelling, although the constitution at large sympathizes very little or not at all 
with the topical inflammation; the other characterized rather by coldness and 
stiffness of the painful joints. In the former of these the pains are increased by 
pressure, and by movements of the limbs, and by external warmth ; the warmth 
of a bed, for example; and there may be even some slight degree of pyrexia at 
night. In truth this form of chronic rheumatism claims a near relationship with 
the acute, into which it sometimes passes, and of which it is frequently the 
sequel. It accordingly requires antiphlogistic remedies, only less vigorously 
applied. It is important for you to know that, in these cases, you may, with less 
hesitation, less fear I mean of driving the inflammation to some more vital part, 
apply leeches, and cold washes, to the painful joints. Otherwise, the principle 
of treatment remains unchanged. The complaint is, however, often obstinate, 
and lingering, and prone to recur. It frequently involves and cripples the smaller 
joints, especially those of the knuckles and fingers ; rendering them knobby, and 
distorting their form and position. The fingers take a permanently oblique 
direction, slanting outwards towards the ulna: and Dr. William Budd has drawn 
attention to the curious fact that the corresponding joints of the two sides of the 
body are always affected exactly in the same manner. To use a paradoxical 
expression, the deformity is symmetrical. One crooked joint is just the copy of 
its fellow. Surely this indicates the constitutional origin of the disorder. 

In the other form of chronic rheumatism, what some call passive, the remedies 
that answer best are of a different kind. The pain is alleviated by friction of the 
joint, and the patients are most comfortable when they are warm in bed, and 
especially when moderate perspiration is present. They are singularly benefited 
also by summer weather. Persons who are much troubled by this wearing com- 
plaint, and who can afford to live where they please, would do well to take up their 
residence in a warm climate. Wherever they maybe, such patients should be pro- 
tected against atmospheric vicissitudes by warm clothing: they should be cased in 
flannel from the neck downwards. Warm bathing is of great service; and espe- 
cially baths of salt water, of a temperature not less than 100°, that they may act 
as a stimulus to the cutaneous circulation; warm douches; the vapour bath; or 
the hot-air bath, of which, as I said before, the patient may receive the benefit 
lying in bed. And to warm clothing, and warm bathing, may be added friction, 
with some stimulating liniment, and what is called shampooing. It is in these 
cases that stimulating internal medicines are often of use. Turpentine ; some of 
the animal oils, the cod-liver oil, for instance ; guaiacum. Opiates, too, are fre- 
quently remedial of the pain : and there can be no better form for their adminis- 
tration than that presented to us in the celebrated Dover's powders ; the pulvis 
ipecacuanha compositus of the Pharmacopoeia. 

There is a remedy which has recently come into extensive use, for the relief of 
chronic rheumatism ; I mean the iodide of potassium. It is most certain of acting 
beneficially when that fibrous part, the periosteum, is principally affected. Its 
virtues in the case of venereal nodes {i. e., in venereal inflammation of the perios- 
teum), were first distinctly pointed out by Dr. Williams, of St. Thomas's Hospital. 
I believe it is equally effectual upon whatever cause chronic inflammation of the 
same part, with nodes and thickenings, may depend. 

Some of you probably saw a woman who was lately my patient in the hospital, 
and who had been worn down to a skeleton by the pain she had endured from 
chronic periostitis giving ris.e to nodes, which did not appear to be traceable to 
syphilis. She had been in the habit of lulling the pain by large opiates at night, 
and begged to have them after her admission, J gave only the iodide in the 



GOUT. 



931 



ordinary dose (five grains thrice daily), and she slept without opium ; and in a 
week or two lost her nodes, and was perfectly well. 

Closely allied to acute rheumatism, and yet distinct from it, is the singular 
disease which in this country is popularly called the gout: which Cullen, in the 
first instance, was disposed to term arthritis ; but as arthritis would imply inflam- 
mation of all or any of the joints, he afterwards adopted the ancient name of poda- 
gra (foot-pain). 

The same author has given, in his First Lines, an excellent account of the 
phenomena which constitute a paroxysm of gout. It is copied from Sydenham, 
who drew from nature: for he had himself suffered frequent and severe visitations 
of the disease during a period of thirty-four years. 

The attack begins, most commonly, an hour or two after midnight. The pa- 
tient, who had gone to bed and to sleep in his usual health, and without suspecting 
what was about to happen, is awakened by a pain in one of his feet, mostly in the 
first joint or bait of the great toe ; but sometimes in other parts of the foot — the 
heel, the instep, the ankle. With the coming on of this pain there is generally 
more or less of a cold shivering, which gradually ceases as the pain gets worse, 
and is succeeded by heat. The pain grows more and more violent and intolera- 
ble ; and is spoken of by those who suffer it, as amounting to torture. It is a 
grinding, crushing, wrenching pain; or a burning sensation as if a hot iron were 
pressed into the joint. Some humorous Frenchman described it in this way. 
" Place (said he) your joint in a vice, and screw the vice up until you can endure 
it no longer. That may represent rheumatism. Then give the instrument another 
twist, and you will^ obtain a notion of the gout." The pain is attended with great 
restlessness and misery, and exquisite tenderness. The patient cannot bear the 
weight of the bed-clothes upon the affected limb ; nor the jar of a heavy foot-fall 
in his chamber. In a vain search after comfort he is perpetually shifting his foot 
from place to place, and from posture to posture. At length, about the ensuing 
midnight, the pain remits; sometimes gradually, sometimes so suddenly that the 
patient attributes the relief to his having at last found an easy position. He falls 
asleep in a gentle perspiration, and when he wakes the next morning he finds the 
part, which had been so painful, to be red, swelled, tense and shining, surrounded 
by more or less oedema, and by turgid veins. The same series of symptoms recur, 
in a mitigated degree, for some days and nights; and then the disease often goes 
entirely off, not to return till after a long interval. 

As the oedema subsides, and the redness fades, the cuticle of the part that has 
been inflamed peels off; and this process of desquamation is generally attended 
with troublesome itching. 

Such is a picture of an attack of gout, occurring in an adult subject, for the first 
time, and in its most regular and genuine form. 

Attacks of this kind are preceded, in most instances, by some marked disorder 
of the functions of the stomach; diminished appetite, flatulence, heartburn, nausea 
perhaps. And during the paroxysm the urine is very high-coloured, and acid, 
and turbid ; depositing a copious pink, or brick-dust sediment. The stools, also, 
are unnatural ; pale, or of a dark green, and very offensive. After the fit, when 
the complaint has ceased entirely, it generally (says Cullen) "leaves the person 
in very perfect health; enjoying greater ease and alacrity in the functions of both 
body and mind, than he had for a long time before experienced." 

But the disorder, which has thus departed, is very apt — nay, unless extreme 
care be taken to prevent it, and even in spite of all care, it is almost sure — to 
return. At first, perhaps, it recurs not oftener than once in every three or four 
years; but after some time the intervals are shorter, and the attacks become 
annual, happening about the same time of the year: afterwards they come twice 
every year; and at length they return several times during the course of the 
autumn, winter, and spring. And as the fits are more frequent, so also are they 
more protracted, till, in the advanced state of the disease, the patient is hardly 



932 



GOUT. 



ever free from it, except perhaps for two or three months in summer. I do not 
mean that all this occurs invariably in all cases alike; but this is a sketch of the 
general course of the complaint. 

There are other phenomena also to be noticed as time advances, and as the 
disease is repeated. At first, I say, it commonly appears in one foot only ; after- 
wards every fit includes both feet, the one after the other : and as the disease 
continues to recur, it not only attacks both feet in succession, but after having 
ceased in the foot which was secondly visited, it will return again into the foot 
first affected, and perhaps a second time also into the other. It passes, too, into 
other joints, both of the upper and lower extremities, large as well as small; so 
that there is scarcely a joint that may not, at one time or another, be seized upon. 
But as the disease proceeds, and the fits get to be more numerous, the pains are 
commonly less violent than they were at first; the patient is, however, more 
affected with sickness, and suffers more in his general health. 

Again, after the earlier attacks, the joints usually recover entirely their former 
strength and pliancy; but when the disorder has returned again and again, they 
are not so readily nor so completely restored to their previous condition, but 
remain weak and stiff: and sometimes they lose at length their capacity of motion 
altogether. 

Also, in many gouty persons, but not in all, after the disease has frequently 
recurred, what are called chalk-stones form ; concretions that look exactly like 
chalk take place around and outside the joint, filling up the areolar tissue, and 
lying, in general, immediately beneath the skin. The material of these curious 
concretions is deposited at first in a half fluid state, and resembles soft mortar; 
but the more watery ingredients being afterwards absorbed, it^becomes dry and 
hard. Of course when this stuff is deposited in any quantity on the outside of a 
joint, it must limit in a great measure, or entirely prevent, the motion of that joint. 
And sometimes matter of the same kind is effused into the joint itself; as I have 
once seen in a gouty patient who died in the Middlesex Hospital. 

Gout is a disease that was well known, and well observed, by the ancients. In 
its genuine form it could neither be overlooked nor mistaken. Many very interesting 
facts relative to this painful disorder have accordingly been ascertained : and I pro- 
ceed to notice the chief of these; but must do so with as much brevity as I can. 

First, then, gout is an hereditary disease. I do not mean to say that the dispo- 
sition to it is always a transmitted disposition; but that the complaint is much 
more likely to occur in persons in whose pedigree it can be traced, than it is in 
other persons. It may, I believe, be generated by certain habits of life ; and, on 
the other hand, in spite of an inherited predisposition, the disease may be staved 
off and averted. Let the son of a rich and gouty nobleman change places with 
the son of a farm-servant, and earn his temperate meal by the daily sweat of his 
brow, and the chance of his being visited with gout will be very small. Granting 
this, we see reason, independent of the general analogy of hereditary disorders, 
why the gout may be expected sometimes to leap over a generation, just as family 
likenesses are known to intermit ; while yet the disposition may descend to the 
children of those who, in their own persons, have never suffered the disease. 
Among 522 gouty persons, concerning whom Sir Charles Scudamore had collected 
information, 332 could trace their disease to the father, mother, grandfather, grand- 
mother, uncle, or aunt. In the remaining 190 the disease was not known to have 
existed in either upward branch of the family-tree. 

2. There is a pattern of body which is believed to be favourable to the acquisi- 
tion of gout. •* It attacks (says Cullen) especially men of robust and large bodies, 
men of large heads, of full and corpulent habits, and men whose skins are covered 
with a thicker rete mucositm, which gives a coarser surface." 

3. Whether, in a given individual, there be an inherited tendency to the disorder 
or not, its access is promoted in a remarkable manner by a full and luxurious mode 
of life, and by sedentary or inactive habits. 

4. It is observed of gouty persons, that they are usually subject to nephritic 



gout. 933 

complaints also, to fits of the gravel, to renal and vesical calculi. These disorders 
of the urinary organs commonly begin to manifest themselves after the gout has 
plagued the patient for some time. They do not coincide with the paroxysms of 
gout, but the two happen alternately : or (what is equally expressive of the con- 
nection between the two forms of disease) the children of gouty and nephritic 
parents inherit often the one or the other of these maladies ; but " whichever may 
have been the principal disease of the parent, some of the children have the one, 
and some the other. In some of them the nephritic affection occurs alone, without 
any gout; and this frequently happens in the female offspring of gouty ancestors." 

The urinary concretions to which gouty people are so subject, and the morbid 
states of their urine generally, belong to the lithic diathesis. Dr. Prout holds 
that "the lithic acid, developed principally during the mal-assimilation of the 
albuminous textures, may be considered as the characteristic feature in gout." 
And the chemical composition of the chalk-stones which sometimes accompany 
gout, is in accordance with this statement; and illustrates strongly the connection 
between gout and gravel. The so-called chalk-stones consist mainly of lithic acid 
combined with soda ; of the lithate or superlithate of soda. Sometimes this very 
lithate of soda, perfectly white, is deposited in large quantities in the urine. Dr. 
Prout says that he has seen it copiously secreted of the consistence of mortar, 
so as to block up the urethra in its passage outwards. Now this is just the stuff 
which is deposited around, and sometimes within, the joints, and which hardens 
as it collects. I may mention here again that many persons have the gout long, 
and severely, without having any of these concretions. They are incidental to 
the more chronic forms of the disorder, in which the pain and the fever, though 
of long duration and frequent recurrence, are slight in degree. The cuticle at 
length gives way, and the earthy matter lies bare. A namesake of mine, Mr. 
Henry Watson, describes, in the first volume of the Medical Communications, 
the case of a Mr. Middleton, who was accustomed, when playing at cards, to 
chalk or score the game upon the table with his gouty knuckles. 

5. Gout attacks especially the male sex. Some few women, however, suffer 
it, in its regular and decided form ; and generally these women are robust and 
plethoric. Cullen noticed its occurrence in " several females whose menstrual 
evacuations were more abundant than usual." But the disease chiefly happens 
in women after the catamenia have ceased to appear. Heberden knew a female 
who had numerous sores from chalk-stones. 

6. Cullen observes that the gout does not usually come on till after the age of 
five and thirty. Heberden, who in his long and extensive practice among the 
higher classes of society in this town saw as much of this disease as any physician 
ever did, says that he never met with a case which he could decidedly pronounce 
to be gout, before the age of puberty. Sir Charles Scudamore has collected a 
statistical account of 515 examples of gout, in which the period of the first assault 
had been noted. Of these, 142 began between the ages of 20 and 30; 194 between 
30 and 40; and 118 between 40 and 50. The greater number, you will observe, 
was between 30 and 40. 

However, I believe that where the inherited disposition is strong, and the habits 
of living are such as to foster that disposition, gout may show itself, occasionally, 
even prior to the age of puberty : but this is, certainly, the exception to a very 
general rule. 

7. Gouty persons are subject to various ailments, which spring from the same 
fountain as the well-marked paroxysm : derangements in the functions of the di- 
gestive organs, of the heart and lungs, of the brain and nerves. 

The most familiar of these ailments is indigestion, with its various circumstances 
of impaired appetite, sickness, vomiting, flatulency, heartburn, acid eructations, 
gastrodynia. Pains and cramps occur in several pans of the trunk, and shoot 
thence into the upper extremities, and are relieved by the extrication of wind from 
the stomach. The bowels are irregular; colicky diarrhoea being sometimes the 
prevailing fault, but more commonly costiveness. With all this the patient is 



934 gout. 

• k 

apt to be excessively dejected and hypochondriacal, morbidly attentive to every 
bodily feeling, disposed to exaggerate his sufferings, and apprehensive of the 
worst event. 

When the viscera of the thorax are affected, the patient has palpitations, fits of 
dyspnoea, faintings, or even pangs like those of angina. 

In the head occur pain, giddiness, transient affections of the vision and of the 
hearing, threatenings of palsy and apoplexy. 

All these, you may say, are feelings and ailments to which any and all persons 
are liable. True: but the remarkable peculiarity which connects them, in some 
men, with gout is this; — that they often all clear away and disappear upon the 
breaking out of a paroxysm of that disease in the foot. 

Hence such symptoms are regarded as indicating one variety of irregular gout. 
Cullen, led by a questionable theory, classes them under the head of atonic gout. 
Sometimes the patient so affected is said to have lurking gout; or masked gout. 

In another variety of irregular gout, the complaint commences, in the ordinary 
way, in a joint; but the pain and inflammation do not reach the ordinary degree 
of intensity, or at any rate do not continue for the usual time and then recede gra- 
dually in the accustomed manner, but they disappear abruptly and entirely, while 
symptoms of severe and alarming disorder arise, as suddenly, in some internal 
part. This Cullen names relrocedent gout. It affords an example, as I conceive, 
of true metastasis. The internal part most commonly attacked is the stomach. It 
becomes affected with a peculiar feeling of anxiety and distress; with sickness, 
vomiting, or violent pain which the patient calls spasm, and which, probably, is 
of a spasmodic character. More rarely the retrocession is to the heart, when 
syncope or urgent dyspnoea ensues; or to the head, when it may terminate in a 
stroke of apoplexy, or of paralysis. 

In a few cases the disorder, thus alighting on some other part than a joint, is 
plainly inflammatory. The most common example of this is gouty inflammation 
of the urethra, with scalding and a puriform discharge; stimulating very exactly 
an attack of gonorrhoea. So also there is a gouty form of ophthalmia, or gout in 
the eye ; gout in the testicle ; and a year or two ago an eminent physician of my 
acquaintance suffered a violent and dangerous attack of what was considered to be 
gout in the throat. Dr. Cullen speaks of these inflammatory affections under the 
title of misplaced gout : but they may well enough be ranked under one of the pre- 
ceding heads of masked, or retrocedent gout. 

The disposition to gout may be engendered, and when inherited will infallibly 
be strengthened and developed, as I have told you already, by certain habits of 
life : by sensual indulgences, and (but in a less degree, I believe) by want of 
bodily exercise. Of this we have the strongest negative evidence in the remarka- 
ble immunity from the disease enjoyed by the working poor in our rural districts. 
One never hears of the gout among agricultural labourers. Sir Gilbert Blanc 
states that, during ten years in which he was physician to St. Thomas's Hospital, 
although in his private practice he reckoned 130 patients who had gout, being 
about one in twenty-six of the whole number, he had not a single case of it among 
2406 patients in the hospital. This I think strange, for in the London hospitals 
it is not very uncommon for us to meet with gout; but then it is in persons 
who have lived fully and inactively: in the servants of wealthy families for in- 
stance, butlers, coachmen, porters — men who often live more luxuriously, and 
more idly a great deal, than their masters. And among the rich, those who are 
most subject to gout are notoriously those who indulge most in what are called 
the pleasures of the table ; who eat largely of animal food, and drink much wine, 
especially if they are indolent withal. Such men generate for themselves the 
litliic acid diathesis ; and if the gouty tendency happens to have been born with 
them, they incur the disease, under these habits, with more or less readiness, 
according to the degree of that innate disposition. Strong exercise certainly 
remedies, in some measures,, the evil effects of this mode of life, by promoting the 



GOUT. 



935 



excretions of the body: but gout used to be exceedingly common in the old- 
fashioned fox-hunter, who "rode hard," while he also "lived hard." Mere 
sedentary habits do not produce gout, as we learn from the comparative exemp- 
tion of females, and of the poor, who, following sedentary employments, are 
yet compelled by their poverty, which is so far a blessing to them, to be temper- 
ate. Men who eat much meat generally indulge themselves in drinking also : the 
two causes go together, and it is difficult to estimate their separate influence. 
Butchers, who live fully upon animal diet, are said to be rarely affected with gout, 
but then they necessarily take a great deal of exercise. It appears that the use 
of wine, and of malt liquors, fosters the disposition to gout much more than the 
abuse of distilled spirits. The paucity of gouty patients among the lower classes 
in this gin-drinking town suffices to show this. I have been told that gout is very 
little known in Glasgow, where the commercial men live richly, and lead seden- 
tary lives, but do not drink much wine, their favourite beverage being rum-punch, 
of which they are not at all sparing. Dr. William Budd says that the disease is 
common among the " ballasters" on the Thames ; that, although they are not a 
numerous body, many are admitted with gout every year into the Dreadnought. 
Now these men being much exposed to inclemencies of weather, and using great 
bodily exertion, which is attended with profuse sweating and much exhaustion, 
think themselves warranted in drinking (besides spirits) two or three gallons of 
porter daily. This shows the effect of malt liquor in producing the gouty habit 
of body. 

On the other hand, the inbred gouty tendency may be so strong, as to be 
scarcely kept in check by the most abstemious regimen. 

A fit of the gout may be brought on by various circumstances : in other words, 
the possible exciting causes of gout are many. A paroxysm has been frequently 
known to follow immediately upon an unusually severe debauch. Strong mental 
emotion has sometimes the same consequence, especially emotion of a depressing 
kind. Excessive fatigue — more particularly fatigue produced by too much walking 
exercise on any one day — is another exciting cause. And this is unlucky, for it 
often discourages a patient from again making use of a proper and even a necessary 
amount of exercise of that kind. Another exciting cause which frequently ope- 
rates is external injury. The first attack of gout often fixes upon the seat of an 
old hurt: and a very slight recent injury is sometimes enough to determine a 
paroxysm — a trifling bruise, or sprain, the pressure of a tight shoe ; nay, Dr. 
Heberden tells us that he verily believes he has seen an attack of gout brought on 
by the bite of a flea ; showing how easily the disease may be excited, when there 
is a strong predisposition to it. This it is which makes us so often doubt the 
accuracy of gouty persons, when they tell us that they are lame from a sprain. 

Dr. Cullen enumerates sundry debilitating circumstances, which, as such, 
appear to operate in calling into action the gouty disposition. And there can be 
no doubt that a state of weakness does often favour the eruption of the malady. 
A friend of my own had lately a most serious attack of continued fever, in the 
course of which he became hemiplegic, and his life was despaired of. Soon after 
the fever had left him, and while he was yet extremely feeble, he had three 
attacks of gout in quick succession. 

Pains have been taken by several writers, especially by Heberden, to lay down 
the distinguishing characters between gout and rheumatism. A first assault of 
gout can scarcely be confounded with an attack of acute rheumatism. The limi- 
tation of the inflammatory redness to one foot, and the restless distress of the gouty 
patient, contrast strongly with the helpless and motionless condition of the rheu- 
matic, who is pinioned, so to speak, in many limbs. There may be more room 
for doubt and mistake in the advanced state of gout, when many joints have at 
length become involved ; but even then you may generally decide by inquiring 
into the history of the patient, and learning the circumstances of his early attacks. 

The main points of distinction may be broadly and generally stated thus. 

In gout the small joints are first and chiefly affected, especially the joint of the 



936 



GOUT. 



great toe: in rheumatism, the large. The redness of the gouty inflammation is 
more blight and vivid than that of the rheumatic; and the fluctuations between 
agony and ease are greater and more frequent. Gout usually affects one joint 
only at a time: rheumatism often many at once. The inflammation in gout is 
attended with more oedema than in rheumatism ; and is followed, in the majority 
of instances, by desquamation and itching, phenomena which we do not notice at 
the close of rheumatic inflammation. Gout is not attended with those drenching 
acid sweats which are so characteristic of acute fibrous rheumatism. The gout 
is decidedly hereditary: rheumatism, if hereditary at all, is much less distinctly 
so. The gout occurs rarely or never, whereas rheumatism is not very uncom- 
mon, before the age of puberty. In gout, though many functions suffer, there is 
no tendency to carditis : in rheumatism, with far less general disturbance, that 
tendency is very marked. Gout is the punishment (some have thought it the 
privilege) of the rich, of persons who live fully, luxuriously, and idly: rheu- 
matism is most frequently the appanage of the poor, and of those who toil. 



LECTURE L X X X 1 1 . 

Pathology of Gout. Prognosis. Prejudices respecting the disease. Treatment : 
during the paroxysms ; during the intervals. Cutaneous Diseases. 

I yesterday described the phenomena of gout, from its primary outbreak to its 
crippling consummation. I told you what observation has collected concerning 
its causes ; and I pointed out the circumstances which distinguish it from rheu- 
matism. Let us look a little closer into the essence of this curious malady. 

The pathology of gout has been the theme of endless controversy. Humoralists 
and solidists contend alike for the triumph of including the disease within the pale 
of their respective theories. The very name, gout, derived through the French 
goutte from the Latin gutta, expresses summarily the doctrine of those who im- 
posed it: and we trace the same, or a similar idea, in the appellation of the kindred 
disorder, rheumatism. 

" The opinion (says Cullen) which has generally prevailed, is, that gout depends 
upon a certain morbific matter, always present in the body; and that this matter, 
by certain causes thrown upon the joints or other parts, produces the several 
phenomena of the disease." 

You will find this doctrine at the bottom of all Sydenham's speculations on the 
subject. But Cullen doubted it, and even endeavoured, in an elaborate argument 
which you may read in his First Lines, to disprove it. He held gout to be an 
affection of the nervous system. I shall not trouble you by detailing his argument, 
for I consider it an utter failure. I am satisfied that the ancient doctrine, which 
asserts the humoral origin of the disease, is the true one. " Morbific matter" (it 
may well be called a poison), is generated, or detained, under certain circum- 
stances, within the body, and silently collects in the blood ; until, after obscure 
threats, perhaps, and prelusive mutterings, it explodes in the foot; and then the 
bodily economy, like the atmosphere after a thunder-storm, is, for a while, un- 
usually pure and tranquil. To some such conclusion as this the result of all 
modern research seems clearly and unfailingly to tend. Dr. Holland, for exam- 
ple, in his thoughtful and thought-exciting volume, recently published, expresses 
his belief in "a materies rnorbi, which, whatever its nature, is capable of accu- 
mulation in the system, of change of place' within the body, and of removal from 
it.',' In this, and in several other propositions relative to gout, enunciated in dis- 
tinct terms by this learned writer, I fully concur. Some speculations still more 
lately put forth by Dr. William Budd, in a communication to the Medical and 
Chirurgical Society, throw a, strong light upon this perplexed subject; and bring 



GOUT. 



937 



the phenomena, not only of gout, but also of many other important complaints;,, 
within the operation of one general, comprehensive, and intelligible law. I shall 
take leave to refer, in a very cursory manner, to some of Dr. Budd's positions. 

I need not remind you of the various ways in which extraneous matters find 
entrance into the blood. Poisons, under their proper shape and name ; medicines, 
which misapplied become poisons ; our natural food and drink, which the folly of 
man converts into poison ; the products or dregs of the secondary assimilative 
process ; these are common sources of impurities, more or less hurtful, which 
mix and circulate with the vital fluid. Some of these extraneous matters escape 
harmlessly by one or more of the waste-pipes and emunctories of the body, 
Some are entangled in its solids : but not indiscriminately ; for different substances 
have their special or their favourite resting-places. All this is well known to» 
persons conversant with toxicological researches. 

Now this doctrine, of the elective affinity between certain tissues or parts of 
the body, and certain morbific principles conveyed to them by the blood, is applied 
by Dr. Budd to elucidate the very curious' fact of the symmetrical local manifesta- 
tions of many disorders ; which disorders are themselves so far general that they 
derive their origin from the circulating fluids. This symmetry he finds the most 
exact in chronic constitutional complaints, wherein the local morbid changes are 
effected in a manner which approximates closely to the processes of healthy 
nutrition. He shows good reason for believing (what, if the whole theory be 
true, we should expect) that the same symmetrical phenomena are modified by 
the amount of the poison collected in the system. If there be a certain quantity 
only, it may settle in some favourite or congenial spot, on one side of the body. 
If there be more than enough to saturate that part, it goes next to the correspond- 
ing spot upon the opposite side ; or, perhaps, to an analogous part of the other 
limb of the same side. If there be more still of the poisonous material, it flies 
to, and occupies, other parts also. He further shows that the elective affinity is 
more exclusive, and the bond of union stronger, in respect to some morbid prin- 
ciples, than to others: and in proportion as the affinity is weak, so is the local 
manifestation of the disease apt to shift, by metastasis, from place to place. When 
the matter which has thus entered, or combined with, a certain tissue or organ, 
is any how loosened and released from that union, or repelled from the part, it 
is again set afloat in the blood, to "break out" elsewhere; to tease various 
organs, perhaps, or to derange the whole economy. The alternation so often to 
be noticed between certain cutaneous eruptions and internal disorders of function, 
is a striking and familiar example of this. The eruption affords presumptive 
evidence of the detention of some peculiar morbid principle in that part; and the 
internal affection which succeeds the disappearance of the eruption, denotes that 
the morbid principle has re-entered the blood. Some of these peccant or poison- 
ous matters fix permanently in the affected spot or spots ; and some of them may 
even be recovered in substance from the dead tissue by chemical means ; the 
poison of lead, for example, from the symmetrically palsied muscles. Others 
appear to be expended gradually in the part, and so eliminated from the system. 
Dr. Budd observes, that the regular arrangement of these local tokens, whether 
they be outward or internal, is disturbed by the presence of fever. Probably the 
febrile tumult may itself be owing to the quantity of the noxious matter in circu- 
lation within the body. He states, also, that, cseteris paribus, this morbific 
matter is most apt to pounce, in the first instance, upon parts which have been 
previously hurt, or which are mechanically irritated at the time. For which 
reason a part that has once been affected by it is more likely than other parts to 
suffer again. 

Now, see how thoroughly the ascertained phenomena of gout accord with this 
theory. Certain habits of life p r oduce fullness, and richness, and impurity of 
blood ; the same habits which breed the lithic acid diathesis. We may even con- 
jecture this acid, or some of its compounds, to be the actual materies morbi. 
Lithates are poured forth with the urine, and sometimes deposited in vast masses 



938 



GOUT. 



around and within the gouty joints. At first, after obscurer intimations of the 
presence of the poison in the system, it thunders in the foot ; and there, perhaps, 
is all discharged and spent. The chemist, Berthollet, found that the skin of a 
part affected with gouty inflammation communicated instantly to litmus paper a 
deep red colour: a large quantity of acid was evidently passing off by exhalation 
from the inflamed surface. If the poison be too copious to find sufficient vent in 
one joint, it attacks another, or more than one. " Quandoque etiam primis morbi 
diebus, cum materia peccans adeo exuberat ut ei capiendae pes unus impar sit, 
utrosque simul pari vehementia fatigat : sed ut plurimum pedes successive, uti dixi- 
mus, adgreditur." These are Sydenham's words. A chain of repeated parox- 
ysms at length purifies the blood : " Donee tandem materia peccante prorsus ab- 
sumta, aeger pristinam obtinuerit sanitatem." The descent of the disorder upon 
a particular joint is often determined by a recent blow or sprain, or by the chronic 
weakness consequent upon an ancient hurt. If the inflammation, after thus set- 
tling, be repelled from the foot, the poison, being driven again into the blood, 
may light upon some vital organ, and place the patient's life in immediate jeo- 
pardy. The late Dr. Parry, of Bath, had at one time under his care two patients 
who had attempted to cut short or to ease a paroxysm of gout by plunging the 
affected foot into cold water. This gave instant relief to the pain, and in both 
instances the inflammation presently abated ; but in both, also hemiplegia occurred 
a few hours afterwards. 

If these views respecting the pathology of gout be true, it can scarcely be 
doubted that they are applicable, mutatis mutandis, to the cognate disorder — acute 
rheumatism. Dr. Prout, indeed, considers the lactic acid, developed chiefly 
during the secondary mal-assimilation of the gelatinous tissues of the body, to 
have the same relation to rheumatism which the lithic acid, derived from the mal- 
assimilation of the albuminous textures, has to gout. 

The prognosis of gout may be gathered, without much further suggestion 
on my part, from what has already been said. The inflammation which befalls 
the joints has no worse event than the thickening, or, perhaps, the chalk-like 
deposit, which it produces ; so that gout in the extremities is not a mortal disease. 
But as it is not always confined to the extremities, the life of a gouty person is 
justly held to be insecure. "La goutte articulaire (says some French author) 
est celle dont on est malade; et la goutte interne estcelle dont on meurt." You 
will find that all insurance companies exact, cseteris paribus, a larger premium 
from those who have had the gout. When it proves fatal, it is by translation of 
the disease, or rather of the gouty virus, to some vital part; to the stomach, the 
heart, the lungs, the brain. 

As the early visits of gout are generally followed by a striking change for the 
better in the health and feelings of the patient, it is not to be wondered at that the 
disease, in its genuine and decided form, should have sometimes been wished for, 
and even courted. It is commonly thought that a fit of the gout clears the system 
of all other disorders. It does, indeed, clear it, for the time, of those disorders 
which resulted from the poison of gout. But this fact has led to great practical 
mistakes. First, to the error of looking on inertly, and doing nothing to remedy 
the ailments which are supposed (often very wrongly) to depend upon lurking 
gout, and to require a fit of the gout for their cure ; and, secondly, to the more 
dangerous experiment of endeavouring to force on such a fit by excess and intem- 
perance. Men forget, or do not know, that the enemy thus reinforced, instead of 
evacuating the fortress by its outports, may retreat triumphant into the citadel. 
To drop metaphor, such a course of living may, indeed, determine an attack of 
the disease in the extremities, but involves the fearful peril of some fatal internal 
seizure. Besides, the benefits expected' from external gout belong to its earlier 
returns alone. The more numerous the fits, the faster does the general health 
break, and the more stubbornly do the associated symptoms cling to the patient: 
and many persons linger on, martyrs (as they say) to the disease, long after they 
have ceased to be fit for any of the business of life, or capable of any of its plea- 



GOUT. 



939 



sures. Nevertheless, as Heberden observes, " people are neither ashamed nor 
afraid of it ; but solace themselves with the hope that they shall one day have the 
gout; or, if they have already suffered it, impute all their other ails, not to having 
had too much of that disease, but to wanting more. The gout, far from being 
blamed as the cause, is looked up to as the expected deliverer from these evils." 

And this mistaken ambition is heightened, no doubt, by the notion, still more 
absurd and ridiculous, yet very generally prevalent, that it is a creditable thing to 
have the gout: a notion which evidently originated in the fact of its being pecu- 
liarly incidental to the wealthy and the great, to men of cultivated minds, and 
intellectual distinction. Nothing can show more strongly the power of fashion 
than this desire to be thought to possess, not only the tone and manners of the 
higher orders of society, not their follies merely and pleasant vices, but their very 
pains and aches, their bodily imperfections and infirmities. All this is more than 
sufficiently ludicrous and lamentable : but so it is. Even the philosophic Syden- 
ham consoles himself, under the sufferings of the gout, with the reflection that it 
destroys more rich men than poor — more wise men than fools. " At vero (quod 
mihi aliisque licet, tam fortunae quam ingenii dotibus mediocriter instructis, hoc 
morbo laborantibus solatio esse possit) ita vixerunt atque ita tandem mortem obie- 
runt magni Reges, Dynastae, exercituum classiumque, Duces, Philosophi, aliique 
his similes haud pauci. Verbo dicam, articularis hicce morbus (quod vix de 
quovis alio adfirmaveris) divites plures interemit quam pauperes, plures sapientes 
quam fatuos." 

The treatment of a gouty patient naturally divides itself into that which is pro- 
per during the paroxysm, and that which is proper during the intervals between the 
paroxysms. 

It was maintained by the great physician, whose words I have just been quot- 
ing, that all artificial evacuations during a fit of the gout are useless or hurtful. 
He, therefore, discountenanced blood-letting, purging, and the use of diaphoretic 
medicines. It was nature's prerogative, he said, to exterminate the peccant matter 
in her own way; namely, by depositing it in the joints, whence it might be dis- 
persed by insensible transpiration. Evacuant remedies had no other effect than 
that of recalling into the blood this peccant matter, which nature had already 
thrust forth to the extremities of the body; whereby it happened that the virus, 
which should have been eliminated through the joints, fell upon some of the vis- 
cera ; and so the patient, who was in no danger before, became in peril of his life. 
I mention all this to show you how entirely identical was Sydenham's theory of 
the gout with that which is now rapidly regaining its lost ground in this country, 
and which I firmly believe to be the true one. After his time, and upon his 
authority, the treatment of gout lapsed into an inert expectancy. Even Cullen 
came to the conclusion that the best thing to be done is to commit the sick man to 
" patience and flannel alone." Here and there, indeed, an advocate of more active 
measures sprang up. Dr. Rush thought that venesection was always safe, and 
generally serviceable : and some persons, following the bad example of the illus- 
trious Harvey, were for extinguishing the inflammation by immersing the affected 
joint in cold water. Heberden, however, had clearer and juster views upon the 
subject. He perceived that one Teason why physicians did nothing to check the 
paroxysm was, that they did not know what would check it. He agreed with 
Cullen in thinking " that no medicine for curing the gout had yet been found; 5 ' 
but he did not partake of his belief in " the impossibility of a cure by medicines." 

" The itch (he observes) is supposed to be wholesome in some countries, where 
it is endemical ; and an ague has been considered as a minister of health, whose 
presence and stay ought by all means to be courted. These opinions are now 
pretty generally exploded in England ; and I hope the time will come when a 
specific for the gout, as certain as those which have been discovered for these two 
disorders, will ascertain the equal safety and advantage of immediately stopping 
its career, and preventing its return." 

That time has come: for the colchicum, judiciously employed, may fairly be 



940 



GOUT. 



accounted a specific for the gouty paroxysm. And it is remarkable how long this 
truth has been seen, though not distinctly or steadily. The hermodactyl of the 
ancients is the modern colchicum, and was in high estimation among them for its 
efficacy in the same forms of disease as are benefited by the colchicum now. It 
bore, with some, the name of anima articulorum, the soul of the joints, because 
(as Quincy states) it prevented " the lodgment of such gritty matter as occasions 
the gout and arthritic complaints." And I think there can be no doubt that the 
active principle of the quack medicine so much in vogue for the cure of gout some 
years ago — I mean the eau medicinale — was either the same with that of the 
meadow-saffron, or derived from the same family of plants which Decandolle has 
associated together under the title " Colchicaceee." 

This drug has certainly the property of easing, in an almost magical manner, the 
pain of gout. How it operates is not so clear. It is apt to produce nausea, faint- 
ness, and diarrhoea; but its curative influence is not conditional upon the occur- 
rence of these symptoms. Sometimes the rapid disappearance of the gouty 
inflammation is its only perceptible effect. The patient may be in helpless agony, 
with a tumefied red joint, to-day; and walking about, quite well, to-morrow. The 
colchicum is, therefore, plainly an anodyne. It also sensibly modifies the con- 
dition of the urine, rendering it less acid, and even alkaline; and increasing its 
quantity. These effects are consequent, I presume, upon changes in the blood 
wrought by this substance, which thus, and there, proves somehow an antidote to 
the poison of gout. 

There are, as you are aware, various preparations of colchicum in use : the 
wine of the bulb : the wine of the seeds ; the vinegar of colchicum ; the acetous 
extract, made by evaporating that vinegar; the inspissated juice of the plant itself. 
These are all of them active and valuable medicines ; and I should pretend to more 
knowledge than I possess, if I undertook to tell you which of them is the best. 

The mode of administering the remedy, in a regular fit of the gout, is simple 
enough. For example, you may give forty or sixty minims of the vinum colchici, 
in a saline draught, at bed-time; and half a drachm more,' in a warm black dose, 
the next morning ; and you may repeat this sequence if the gout continues. Some 
persons give twenty minims every six hours, with a drachm of Epsom salts, and 
a drachm of syrup of poppies in the draught, till the symptoms yield ; but I prefer 
the other plan. In this way the pain is usually calmed, and the swelling reduced 
in a few days ; or even, as if by a charm, in a few hours. 

But you must not be satisfied with thus quelling the pain and inflammation. 
A strong prejudice at one time existed, and still exists among some practitioners, 
against the colchicum. It was said that it had indeed the power of cutting short 
the paroxysms, but that it cut short the patient's life also: that they who trusted 
to it for getting 1 rid of the gout, very seldom lived more than two or three years 
afterwards. How far this was true I cannot tell : but even admitting it to be true, 
it was not, I conceive, so much the fault of the medicine as of the patient, or of 
the medical man who did not properly admonish the patient. Men were very 
glad to get rid of their gout on such easy terms ; and they will sometimes say to 
us now : " I have, as you see got the gout. This is Monday. I must be in the 
House of Commons, or attend such and such a meeting, or be at the head of my 
regiment, on Wednesday: and I expect that you will enable me to do so." Or 
even sometimes the reason may be that they are engaged to some good dinner 
two or three days afterwards. Now if patients are content, or are suffered to be 
content, with expelling the gout from their toe, without observing abstinence more 
than a day or two, and without any depletion or further medication at the time, 
we can easily perceive the probability of their being soon attacked by some for- 
midable internal complaint. I apprehend that the proper way to eradicate the 
lurking residue of the mischief is to continue to give small doses of the colchi- 
cum; five minims of the wine, for instance, two or three times a day, for a while. 
Moreover, purgatives must be employed, if that remedy does not prove aperient. 
Not violent purgatives, however, which, by weakening the patient, seem to 



GOUT. 



941 



strengthen the power of the gouty virus. With mild cathartics, moderate doses 
of mercury will generally be advisable, to correct the subsisting disorder of the 
hepatic functions; and the patient must adopt and pursue abstinent, or at any rate 
strictly temperate habits, in respect to meat and wine. 

And as 1 think that the dregs, if I may so speak, left behind it by a gouty 
paroxysm, may be dispersed by the continued use of what, in the usual accepta- 
tion of that word, I may call alterative doses of colchicum (doses, that is, which 
produce the desired purpose gradually, and by insensible operation) so I think it 
probable that many a fit of the gout might be averted, if the remedy were given 
in the same way upon the first occurrence of the ordinary premonitory troubles. 
Many of those troubles never appear to reach the crisis of a fit. There are 
headaches, attacks of asthma, derangements of the digestive organs, which, oc- 
curring in a gouty person, are presumed to be fainter intimations of the presence 
of the gouty poison in the blood: and if such symptoms yield (as unques- 
tionably they often do) to colchicum, the presumption draws near to proof. Dr. 
Holland has well remarked that the meadow-saffron, by its curative effects, may 
bring sundry maladies, hitherto thought anomalous, under the same law of mor- 
bid gouty action; just as the Peruvian bark has reduced many complaints, that 
were previously vague in their nature, within the same category of aguish dis- 
tempers. The same author conjectures that as hypochondriasis is certainly often 
symptomatic of the gouty poison in the male, so may sometimes the kindred dis- 
ease, hysteria, be in the female. 

Strange stories are recorded — strange, but I believe true — of instantaneous cures 
of the gout by strong mental emotion ; by sudden terror, by violent wrath. Dr. 
Rush relates an instance of this. An old man who for several years had suffered 
an annual attack of gout, was lying in one of these paroxysms, when his son, by 
some accident, drove the shaft of a wagon through the window of his room, with 
vast noise, and a great smashing and destruction of glass. The old man leaped 
out of bed, forgetting his crutches; and his wife, on entering the apartment, was 
surprised to see him walking up and down, and exclaiming angrily against the author 
of the mischief. The late Professor Gregory, of Edinburgh, was in the habit of 
mentioning another example to the same effect, authenticated to him by a naval 
surgeon. It occurred in the person of an officer who was freed from an attack of 
gout, when at sea, by an alarm of fire. Whether this influence of certain states 
of the mind be rightly alleged or not, it is clear that we can never hope to make 
any practical use of such a remedy. Indeed, a fit of the gout has been sometimes 
brought on by a mental shock. 

The treatment of a gouty patient in the intervals between his attacks of gout, 
whether regular or irregular, must be chiefly regimenal. The instances are not 
few of men of good sense, and masters of themselves, who, being warned by one 
visitation of the gout, have thenceforward resolutely abstained from rich living, 
and from wine and strong drinks of all kinds, and who have been rewarded for 
their prudence and self-denial by complete immunity from any return of the dis- 
ease ; or upon whom, at any rate, its future assaults have been few and feeble. 
On the other hand, many who are liable to gout are taught by sharp experience 
that a single debauch, a casual glass or two of champagne, even an unusual 
indulgence in the use of animal food, may suffice to bring their enemy suddenly 
upon them. I am sure it is worth any young man's while, who has had the gout, 
to become a teetotaller. But the case is different with the old, and with those whose 
health has been broken by the inveterate disease. They must be allowed a cer- 
tain quantity of their accustomed good cheer, or they become an easier prey to 
the disease. In such cases you must trim, as well as you can, between opposite 
dangers; between the Scylla of excess, and the Charybdis of debility. 

It is the same with respect to exercise. The young and the hearty can scarcely 
take too much : the old and the dilapidated, by one act of over-exertion, may incur 
the penalty of an attack. Although I can do little more than point out general 
principles for your guidance, I may remark, in reference to exercise, that it should 



942 



GOUT. 



never be violent, lest it excite a paroxysm by straining any part, or by causing 
great fatigue : that it should be habitual, daily — not used by fits and starts, and 
interrupted by long periods of indolence or inaction : and that it should be active 
muscular exercise, as distinguished from passive exercise or gestation. No mode 
of exercise is so good as that of walking ; and with this may be agreeably and 
beneficially conjoined riding on horseback. 

Early and regular hours are also of much importance; and the avoidance of 
severe mental application. Sydenham relates that one of the most atrocious 
attacks of gout he ever underwent was induced by intense thought and study, in 
the composition of his medical works. - 

The regimen which I have been recommending may require some power of 
self-control; yet in reality it implies no severity of mortification. It is perfectly 
compatible with life's best enjoyments; but to be effectual it must be adopted 
early, as soon as the disease threatens ; and steadily persevered in. Gouty per- 
sons, however, do not like these restraints. They are ready to believe that an 
attack of gout will do them good ; or if they are disabused of that error, they are 
desirous that some medicine may be found which will avert the disease, without 
their being obliged to forego their accustomed indulgences. " To gratify this 
desire (says Cullen) physicians have proposed, and to take advantage of it empi- 
rics have feigned, many remedies." One of these was the famous Portland pow- 
der, of which Heberden remarks: " Unum est ex multis quae vocantur remediis 
specificis, quorum ortum, et splendorum, et occasum vidi." It consisted chiefly 
of bitters and aromatics, and had descended, with some slight variations in its 
composition, from the times of Galen. Another preventive has recently been 
praised by Dr. Graves, of Dublin, as being highly serviceable, although (what is 
a suspicious circumstance) it had, like the Portland powder, fallen out of fashion. 
These are its ingredients : — Two ounces of orange peel, an ounce of powdered 
rhubarb, and two ounces of the pulvis aloes cum canelld of the Dublin Pharma- 
copoeia, steeped for a week in a quart of brandy. A tablespoonful of the strained 
infusion is to be taken, mixed with two or three spoonfuls of water, night and 
morning. Sir Henry Halford recommends what I think a better form of prophy- 
lactic remedy ; viz., a few grains of rhubarb, with double the quantity of magnesia, 
every day; or some light bitter infusion, with tincture of rhubarb, and about fifteen 
grains of the bicarbonate of potass. 

Now what has been observed respecting preventive remedies of this kind is, 
not so much that they are inefficacious, as that, when exclusively trusted to, 
they are unsafe. I believe that they are often useful by improving the digestive 
process ; but they are dangerous substitutes for a course of temperance and exer- 
cise. 

When gout attacks the stomach, either by retrocession or primarily, it often 
proves rapidly fatal. The gastric affection is not, in general, inflammatory; so 
we judge, at least, from the juvantia. The attack, which consists of violent pain, 
and a sense of weight or of constriction in the epigastrium, with sickness, vomit- 
ing, and a disposition to faint, is often relieved by the employment of stimulants. 
But such remedies would be likely to aggravate inflammation. It will always be 
well when symptoms like these occur, to inquire whether any indigestible food 
has been lately taken; for gout (so called) in the stomach has sometimes turned 
out, under the test of an emetic, to have been nothing more than pork in the sto- 
mach. In the true gouty seizure, antacids will frequently remove the pain; mag- 
nesia, in full doses, with rhubarb. If this does not succeed, opium may be 
resorted to ; and if it should be vomited, opiate enemata may be injected. Dr. 
Heberden thought that opium, and hot spices, were more efficacious and less 
inconvenient, in these cases, than wine and spirits ; but when they fail, a glass of 
brandy will often allay the pain completely. The mustard poultice, or the tur- 
pentine stupe, applied over the epigastrium, has been followed by strikingly good 
effects. And it is in these emergencies, contingent upon retrocedent or misplaced 
gout, that we are justified in the endeavour to induce gout in the extremities ; not, 



CUTANEOUS DISEASES. 



943 



however, by internal stimuli, but by enveloping the feet in a mustard poultice, and 
so enticing or provoking the foe to quit his hold of the interior, and to appear in 
the outposts. And this expedient should be practised, whatever may be the inter- 
nal organ upon which the gouty disorder has settled. 

Sometimes, but much less commonly, actual gastritis does seem to ensue ; and 
therefore all these cases are anxious and alarming cases. I do not know how the 
inflammatory affection can be discriminated from the non-inflammatory, unless it 
be by the occurrence of tenderness with the pain, and of fever. You must treat 
such cases as you would treat an ordinary case of gastritis, taking no further heed 
of the gout, except by the application of stimulating cataplasms to the feet. 

This concludes what I proposed to say respecting gout and rheumatism : dis- 
eases of which the local seat is not exactly external, nor yet do they belong strictly 
to the interior of the body, except in their accidental complications. They form 
a link of connection between the internal and external disorders which fall to the 
care of the physician ; and I proceed, in the next and last place, to speak of those 
complaints which either concern the integuments alone; or which, at any rate, 
are attended with some notable affection of the skin. 

Under the general head of cutaneous diseases, are included maladies of very 
different kinds, and of very different degrees of importance. Some are attended 
with fever, and run a definite course, and are often dangerous to life. Others are 
chronic, irregular in their progress, troublesome perhaps, and obstinate, and dis- 
figuring, yet implying no peril to the existence of the patient. Some again are 
contagious, while many are not so. But before I enter upon any further account 
of these diseases, I wish to make you acquainted with the names by which the 
various morbid appearances presented by the skin have been known, since the 
time of Dr. Willan. 

That author — whose works have been augmented by Dr. Bateman, so that per- 
haps I ought to say those authors — divides cutaneous diseases into eight orders, 
distinguished from each other solely by the appearances upon the skin. I shall 
omit the last of these orders, the order of maculae, such as freckles and congenital 
spots and discolorations, because in fact these are not diseases at all. 

The first, then, of the appearances described by Dr. Willan are papulse; pim- 
ples. These are little elevations of the cuticle, of a red colour, and solid; not 
containing, I mean, any fluid. They are of uncertain duration, and often termi- 
nate in scurf. They are supposed to denote inflammation of the papillae of the 
skin. If you wish for an example of a papular eruption, look at that of small- 
pox, at its very earliest outbreak. 

The second are squam.se; scales. These are small, hard, thickened, opaque, 
whitish patches of unhealthy cuticle. The subjacent surface is red. They are 
well seen in lepra and psoriasis ; and are very common in syphilitic eruptions. 

The third are exanthemata; rashes. They consist of superficial red patches 
on the skin, variously figured, and irregularly diffused, and of all sizes. We have 
examples of them in some of the most important febrile cutaneous diseases ; 
scarlet fever, measles, and others. 

It is a pity that some other technical denomination was not chosen to express 
these rashes ; for the term exanthemata has long been familiar to the profession 
as the title of an order of diseases in Cullen's Nosology. 

The fourth are bull^; blebs, miniature blisters. Large portions of cuticle are 
detached from the subjacent skin, by the interposition of a thin transparent liquid; 
with inflammation beneath them. Such occur in erysipelas sometimes, and in 
pemphigus. 

The fifth are pustulse; pustules. Circumscribed elevations of the cuticle, con- 
taining pus, and having red inflamed bases. We have instances of these in com- 
mon boils; and in the eruption of small-pox when at its height and maturity. 

The sixth are vesiculse; vesicles. Small elevations of the cuticle, covering a 
fluid which is generally clear and colourless at first, but becomes afterwards 



944 



EXANTHEMATA. 



whitish and opaque, or pearly. These are exemplified in the eruption of cow- 
pox, and in the chicken-pox. You will observe that these vesiculse differ very 
little, except in size, from the bullae or blebs. They often terminate in small 
scabs. 

The seventh are tuberculse; tubercles. This also is an unlucky appellation, 
since the word tubercle is almost appropriated, in the present day, to the scrofu- 
lous deposits which infest the lungs, and other parts of the body, in pulmonary 
phthisis. However, these cutaneous tubercles are small, hard, superficial tumours, 
circumscribed and permanent ; or, if they suppurate at all, the suppuration in them 
is partial. Sometimes they slowly ulcerate at the summit. The imperfectly sup- 
purating pustules of the modified small pox, and certain red spots which are apt 
to haunt the face, particularly of young persons, furnish examples. 

Now it is very convenient, for the purpose of distinguishing different diseases, 
and of describing them, to know these outward marks when you see them, and 
to use these names. But they form a very unfit basis for the classification of 
diseases. Maladies may usefully be classed according to their causes; according 
to their intimate nature ; according to the general plan of treatment they may 
require. But the superficial markings of disease have no definite relation to any 
of these heads. Besides, a complaint which is papular to-day may be vesicular 
to-morrow, and pustular next Saturday. Yet the classification most commonly 
followed in this country, and in France, is that of Willan and Bateman. Here 
we find collected under one and the same division maladies which nature has 
stamped with broad and obvious marks of distinction; the febrile with the non- 
febrile ; contagious complaints with those which have not that property : ailments 
that are local and trivial, with diseases of grave import and deeply rooted in the 
system at large. And, on the other hand, distempers which nature has plainly 
brought together, and connected by striking analogies and resemblances, this 
methodical arrangement puts widely asunder. I point out, without professing to 
remedy, these imperfections. I cannot even undertake to give you any full or 
systematic account of the many disorders comprised in this classification. There 
is, however, one group so remarkable, so important, and so highly interesting, 
that I shall consider it as much in detail as I can. I allude to the group which 
Cullen comprehends under the title exanthemata. With this exception, the ad- 
vancing year warns me that I must contract what I have to say respecting dis- 
eases of the skin within very narrow limits. 



LECTURE L XXXIII. 

Exanthemata. They are contagious ; sometimes epidemic. Period of the 
eruption; period of incubation. Theory of contagious Febrile Diseases. 
Continued Fever. 

Of the numerous complaints which are ranked among the diseases of the skin, 
some, I observed in my last lecture, are attended with fever, and some are not. 
Among the former there is a highly interesting group, distinguished by other and 
more important characters than the mere presence of fever, or peculiar marks 
upon the skin; characters that enabled Cullen to collect these diseases into a 
separate order, to which he gave the name of exanthemata. This is his descrip- 
tion of them. " Morbi contagiosi, semel tantum in decursu vitae aliquem affi- 
cientes ; cum febre incipientes ; definito tempore apparent phlogoses, saepe plures, 
exiguae, per cutem sparsae." Contagious diseases ; attacking a person once only 
in his life; beginning with fever. At a definite period small eruptions appear, 
often numerous, scattered over the skin. These, you will allow, are very re- 
markable characters. They are not all strictly and universally true, perhaps, of 



EXANTHEMATA. 



945 



all the forms of disease which I propose to bring now under your notice ; but 
they apply with more or less exactness to continued fever, to the plague, to small- 
pox, chicken-pox, measles, scarlet fever, and erysipelas. 

Hooping-cough, and the mumps, might be placed in the same catalogue, al- 
though there is no specific eruption on the skin in them : but I have already 
spoken of these two disorders. 

Before I take up the consideration of any one of these diseases in particular, I 
shall premise a brief survey of certain circumstances that are more or less common 
to them all. This preliminary examination of the exanthemata as a class, will 
give you, I trust, clearer ideas respecting them : at any rate it will enable me to 
dispense with much needless repetition afterwards, and so to save both your time 
and my own ; a matter of some consequence at this advanced period of the session. 

In the first place, then, the diseases comprehended in this group are contagious 
diseases. You will hear persons disputing about the term contagion; but such 
disputes can only arise from the want of a distinct definition of the sense in which 
it is employed. I understand a disorder to be contagious, when it is in any way 
communicable from one person to another. Some would restrict the word con- 
tagion to the cases in which there must be absolute contact of the healthy body 
with the sick body, or with its visible offscourings. When the disease can be 
conveyed through the medium of the atmosphere, or by means of other interme- 
diate substances called fomites, they would call it infectious. And there is no 
objection to such a distinction, provided it is understood by the reader, or hearer, 
as well as by the writer or speaker. But since in all cases the disease is conveyed 
to the person of the recipient by particles of matter proceeding from the person of 
the sick, and since it seems very unimportant whether those particles are in a 
solid or in a gaseous form, whether they are imparted by direct contact of the 
two human bodies, or by being wafted through the air, or carried upon articles of 
clothing, I shall include both and all these modes of communication under the 
single term, contagion. This, in fact, is what is done in common discourse: all 
disorders that are " catching," I shall take leave to consider contagious. 

In this sense I believe that all the diseases just now enumerated are contagious; 
some, no doubt, much more strongly and distinctly than others. Some of them, 
indeed, are undeniably contagious. For example, we are privy to, and sometimes 
willing agents in, the communication of small-pox from one individual to another. 
There are others concerning the contagious nature of which medical opinion is less 
settled and unanimous. Many persons deny that continued fever is communica- 
ble from person to person. The evidence from which I conclude that it is so, I 
will lay before you when I have described that disorder. Even they who admit 
that it is contagious, are of opinion, many of them, that it sometimes breaks out 
spontaneously, without the intervention of any specific virus. No one questions, 
I fancy, the contagious properties of measles ; or of scarlet fever. Whether the 
plague, and whether erysipelas, be always or ever so produced, has been thought 
more doubtful. There is every reason for believing that the small-pox, at least, has 
now no other source than contagion. How it first arose, it may be difficult to 
conjecture; but it is never known to originate spontaneously now-a-days. 

Small-pox may in truth be regarded as the Tta^absiy/na^ or type, of this group of 
diseases. I shall, therefore, take by anticipation, some well-ascertained facts in its 
history, for the sake of illustrating the general subject. It is a malady vvhich could 
scarcely be mistaken for any other; and of which the horrible aspect and fatal 
tendency are so strongly marked, that its appearance has always been watched 
with affright by mankind in general, and with intense interest by the philosophic 
physician. 

In the acme of this disease, when it is severe, the whole surface of the body is 
covered with innumerable little pustules. A minute portion of the matter con- 
tained in any one of these pustules, just so much as may suffice to moisten the 
point of a lancet, is inserted, we will suppose, beneath the cuticle of a healthy 
man, who has not been near the sick man. What follows this engrafting? No- 
60 



946 



EXANTHEMATA. 



thing, apparently, for several days: but then febrile symptoms burst forth: and 
by and by a crop of papulse appear sprinkled over the skin : and these gradually 
ripen into pustules precisely resembling that from which the engrafted drop was 
taken. 

The very same phenomena ensue, if a healthy man enters the chamber of a 
small-pox patient, and breathes, for a certain time, an atmosphere tainted with the 
emanations from his body. 

The points to be noticed here are — 1, the manifest introduction of the virus into 
the system : 2, its dormancy for a while, in other words, the occurrence of a 
period of incubation : 3, the breaking out, at length, of a disease identical in its 
symptoms and in its character with that of the first patient: and 4 (most surprising 
of all), the enormous increase and multiplication of the poisonous matter. 

I say the history of small-pox leads to the settled belief that this disorder, of 
which few persons are not readily susceptible, never occurs, except from conta- 
gion. It was quite unknown in Europe till the beginning of the eighth century. 
No mention of any such malady is to be found in the Greek or Roman authors of 
antiquity. Now whatever may have been the deficiencies of the ancient physi- 
cians, they were excellent observes, and capital describers of disease : and it is 
impossible that a disorder so diffusive, and marked by characters so definite and 
conspicuous, should have escaped their notice, or have been obscurely portrayed 
(if known) in their writings. 

On the other hand, Mr. Moore, in his learned and interesting History of Small- 
pox, has shown that it prevailed in China and Hmdostan from a very early period; 
even more than 1000 years before the time of our Saviour. That it did not sooner 
extend westward into Persia, and thenee into Greece, may be attributed partly to 
the horror which the complaint every where inspired, and the attempts that were 
consequently made to check its progress by prohibiting all communication with 
the sick, partly to the limited intercourse which then took place among the eastern 
nations, but principally to the peculiar situation of the regions through which the 
infection was diffused ; separated as they were from the rest of the world by im- 
mense deserts and by the ocean. 

The disease is said to have broken out in Arabia at the siege of Mecca, in the 
year in which Mahomet was born; i. e., in the sixth century. It was widely 
propagated by his wars, and by those of the Arabs afterwards ; and, as I said 
before, it is generally believed to have first found entrance into Europe at the 
time of the overthrow of the Gothic monarchy in Spain by the Moors ; when to 
ayenge the well-known outrage upon his daughter, ii Count Julian called the in- 
vaders." Whensoever and wheresoever it came, it spread with fearful rapidity 
and havoc. 

What I wish you to remark is this: that while almost all men are prone to take 
the disorder, large portions of the world have remained for centuries entirely 
exempt from it, until at length it was imported ; and that then it infallibly diffused 
and established itself in those parts. 

Of the more modern history of the disease our knowledge is more precise and 
sure. It tends uniformly to the same conclusion. 

There was no small-pox in the New World before its discovery by Columbus 
in 1492. In 1517 the disease was imported into St. Domingo. Three years later, 
in one of the Spanish expeditions from Cuba to Mexico, a negro covered with the 
pustules of small-pox was landed on the Mexican coast. From him the disease 
spread with such desolation, that within a very short time, according to Robert- 
son, three millions and a half of people were destroyed in that kingdom alone. 
Small-pox was introduced into Iceland in 1707, when 16,000 persons were car- 
ried off by its ravages ; more than a fourth part of the whole population of the 
island. It reached Greenland still later, appearing there for the first time in 1733, 
and spreading so fatally as almost to depopulate the country. 

Evidence to the same effect is furnished by the results of vaccination in some 
countries. In Mr. Cross's History of a Variolous Epidemic which occurred at 



EXANTHEMATA. 



947 



Norwich in 1819, it is slated, upon good authority, that vaccination was adopted 
in Denmark, and made compulsory, in 1800. After the year 1808, small-pox 
no longer existed, and was a thing totally unknown. Whereas during the twelve 
years preceding the introduction of the preventive disease, 5,500 persons died of 
the small-pox in Copenhagen alone. Statements corroborative of this account 
have been made to me in the present year (1838) by Dr. Blick, an intelligent 
Danish physician, who was on a visit to London. 

Now it is a very instructive fact respecting this disease, thus rankly contagious, 
and arising from no other source than contagion, that when it is epidemic in any 
places, many instances of it occur which we can by no means trace to contagion. 
Dr. Gregory tells us that of the numerous cases received into the smali-pox 
Hospital (to which he has long been physician) not one in twenty is capable of 
being referred to any known source of infection ; the disease being ascribed by the 
patient to cold, fatigue, change of air, or some other innocent circumstance. A 
prisoner shut up in solitary confinement in the Penitentiary at Milbank was seized 
with small-pox. Surely this should warn us against inferring of analogous dis- 
orders (of continued fevers, for example) that they are necessarily not contagious, 
because we often fail to discover any way in which the poison could have been 
applied. If small-pox be produced by contagion alone, and yet the mode in 
which the contagious matter has been communicated eludes sometimes our closest 
scrutiny, then we must conclude that the same thing may happen in other con- 
tagious diseases, of which the contagious property may not be so strong or 
so obvious. Nay, the argument from analogy will lead us a step further. If 
once a disorder of this kind is decidedly proved to be sometimes the effect of con- 
tagion (and this I think I shall be able to prove to you of continued fever) — we 
cannot help entertaining a doubt whether the disorder in question really ever has 
any other cause. It is chiefly with a view to the light which they throw upon the 
obscurer subject of continued fever, that I am thus anticipating some points in 
the history of the contagious nature of small-pox. 

Again, it is noticed of small-pox — and it is the same with the other diseases in 
this group — that the human body is not always equally susceptible of its con- 
tagious influence. Some individuals are more readily affected by it than others : 
and the same individual more so at one time than at another. There are even 
some who seem to be incapable of taking the small-pox — just as some, who are 
quite as much perhaps in the way of it as their neighbours, never become infected 
with the great pox. Of 215 persons who had not been vaccinated, nor had the 
small-pox, and who were living at Norwich in the same houses with persons ill 
of that disease, fifteen did not become affected with it; and of these fifteen it was 
ascertained that ten had escaped under similar circumstances of exposure before. 
I mentioned, on a former occasion, the fact that a certain dog, in Paris, could not 
be made to take the contagion of rabies. 

It is not at all uncommon for persons to resist the influence of contagion at one 
period, and to yield to it at another, even when the exposure has appeared to bo 
jess complete. Mr. Cross gives a striking example of this. A man, who believed 
that he had had the small-pox, lived for twelve years as a nurse in an establishment 
for the reception of persons inoculated with that disorder. At the end of that 
time he caught the small-pox, which proved fatal to him. Now this might have 
been, and probably was, as the man supposed, a second attack. The late Mr. 
Lockley told me an instance still more remarkable, as being free from that ambi- 
guity. Nearly the first patient he ever attended, if not the very first, was an old 
woman, who for years had been in the habit of going from village to village as a 
nurse ; and of nursing a great number of persons labouring under small-pox, which 
she had never had, and against which she (naturally enough) believed herself 
proof. At length she was takgn ill, and died of small-pox, under Mr. Lockley's 
observation, at the age of eighty-four. 

In many cases we can assign no reason for these variations and differences. 
Age seems to have something to do with them. Infants are but little susceptible 



948 



EXANTHEMATA. 



of the operation of contagions. Debility, howsoever produced, certainly augments 
the disposition to be affected by this, as by other causes of disease. The dose 
and strength of the poison must also be taken into account. As some men can 
drink a much larger quantity of wine (which is an alcoholic poison) than others, 
without being intoxicated, and are differently influenced by the same quantity at 
different limes, so is it also with the animal poisons we are now considering; so 
is it, as I showed you before, with the mineral poison of mercury. 

This fluctuating power to resist contagion is most conspicuous, perhaps, when 
viewed in reference to scarlet fever. After the very earliest periods of life, children 
catch infectious disorders of all kinds readily enough ; more readily than in mature 
age. The poison of scarlet fever operates with less certainty upon adults than 
the poisons of small-pox, or of measles. Some medical men escape scarlet fever 
altogether, although brought much into contact with it by their vocation. I do 
not know that I ever had scarlet fever. 

Another fact, well worthy of notice, is, that small-pox, which is so rankly 
contagious, and which has at present no other source besides contagion, has its 
alternate periods of slumber and of activity. This metropolis, and most of our 
large towns, are never entirely free from it. Scattered cases occur here and there ; 
and when thus thinly disseminated, the disease is said to be sporadic. But there 
are seasons in which it spreads rapidly and extensively, and assumes the form 
of an epidemic distemper. We are now living (1838) in the midst of one of these 
epidemics of small-pox. The same is equally true of the other complaints included 
in this group. Sometimes they are confined to single families; sometimes they 
pervade a whole district. 

Hence you can never infer that any febrile disorder is not contagious, merely 
because it prevails epidemically. Many epidemic diseases are not contagious. 
But the two properties may and do meet in the sar^e malady. They are not to 
be set in opposition to each other, or regarded as incompatible properties, as they 
have been by some ingenious writers. 

With respect to these epidemic visitations of the exanthemata, certain general 
facts have been ascertained, very useful and necessary to be known. 

1. The strength of the contagion, and the severity and fatality of the disease, 
vary at different periods of an epidemic. In general the contagion is the most 
active, and the disorder the most fierce, at the outset of the epidemic. By degrees 
its violence slackens, and it ceases to spread. This is partly to be explained by 
the circumstance that the number of persons who are susceptible of the disease, 
and who have not yet been attacked, are fewer and fewer as the epidemic proceeds. 
The fire languishes for lack of fuel. But this does not seem to be all. The 
disease dies out before it has affected all those who are capable of receiving it. 
We might I think expect, prior to experience, that ihe earlier cases would usually 
be the severer: for the weak, who are less liable to struggle with the complaint, 
and those who, by peculiarity of constitution, are most susceptible of the morbific 
influence, are likely 10 be the first to suffer. 

2. There are great varieties also in the general character of the symptoms that 
occur in different epidemics of the same disorder. At one time, or in one place, 
inflammatory symptoms run high ; in another place, or at another time, there is 
an early tendency to debility and sinking. One epidemic is more malign than 
another. And the practice varies accordingly ; so that these are facts of the greatest 
importance. The prevailing character of the malady is attributed to what is 
called the epidemic constitution of the season. And when we have made out, 
by observation, what this epidemic constitution is, we have obtained a clue to the 
proper management of the disorder. Thus continued fever, as it has appeared in 
London during the last twelve years, has required and borne far less depletion than 
it did for the preceding twelve years or more. 

You may learn from this how dangerous it is to apply indiscriminately in one 
epidemic the remedies that may have been found useful in another: and also how 
foolish and unfair it is to censure the practice employed and recommended by 



EXANTHEMATA. 949 

others, merely because it differs from that which we, in other epidemic visitations 
of the same disorder, have considered fitting and beneficial. 

These differences in the prevalency of the disease, and in the character of its 
symptoms, are not to be explained by any variation in the exciting cause, which 
is a definite animal poison; nor can they be reasonably ascribed to any appre- 
ciable quality or agency of the weather at the time. They must depend upon 
changes that have been slowly wrought upon the human body : and those changes, 
constituting an acquired predisposition, are probably due to previous conditions of 
the atmosphere, which have exercised a long and gradual influence upon all the 
individuals of a community. 

After stating, in the first clause of his definition, that the exanthemata are con- 
tagious diseases, Cullen announces, in the next place, the very curious fact, that 
they occur but once in a person's life. " Semel tantum in decursu vitse aliquem 
afficientes." In this they offer a remarkable contrast to inflammations, which, 
having happened once, are, for that very reason, more apt to happen again. 

You will take care to observe, that it is not the mere circumstance of the dis- 
ease being contagious that makes the difference. Those disorders which shield 
the system against their own future recurrence are, all of them probably, conta- 
gious; but the converse does not hold. It is not true that all contagious disorders 
protect the constitution from their own return. Syphilis, purulent ophthalmia, 
the itch : these not only do not secure a patient from a repetition of the disease, 
but perhaps they even render him more liable to it in future. 

Neither is the proposiiion absolutely and invariably true of any disease. Like 
most general rules, it admits of occasional exceptions. There is not one of the 
group enumerated in the beginning of this lecture, which has not been known to 
occur more than once in the same person. Small-pox has, in many instances, 
affected the same individual twice; even when the first attack had been so severe 
as to have engraved deep traces of its visit upon the skin? There are a few in- 
stances recorded of its third recurrence. It was believed, at one time, that when- 
ever the disease was thus repeated, it was always, in the first instance, severe, 
which, taken in conjunction with the repetition, was thought to indicate a strong 
natural susceptibility of the disorder. But it has since been noticed that the 
primary visit is sometimes unusually mild : and this fact (so powerful is the love 
of theory) has led to the supposition that the first attack was not sufficiently in- 
tense to affect the whole mass of blood, and to exhaust the inborn susceptibility. 
I believe that the two attacks have always been separated by a considerable inter- 
val of time. I have myself known one very striking instance, about which there 
could be no mistake, of the recurrence of measles in several children of the same 
parents. This proclivity to be again affected by the specific poison seems to run 
in families. It is less uncommon for scarlet fever to happen a second time in the 
same individual. No contagious disease therefore furnishes complete future pro- 
tection against itself. But that this privilege belongs, as a general rule, to small- 
pox, to measles, and to scarlet fever, there can be no doubt: and the validity of 
the rule is applicable in the order in which I have here mentioned them. It 
applies, also, though less uniformly, to the other exanthemata. A person who 
has suffered a well-marked attack of continued fever is far less liable than another, 
according to my experience, to have that disease again. The plague is said to 
afford a temporary safeguard against itself. Very few persons have it twice in 
the same season. During one epidemic Dr. Russell found that, among 4,400 
individuals who underwent the disease, only twenty-eight contracted it a second 
time. The singular property we are considering is less plainly visible in erysipe- 
las than in any other malady of the group. 

The next clause in Cullen's definition asserts the supervention of the cutaneous 
marks, in technical language of the eruption, at fixed times (definito tempore) 
after the commencement of the general fever. It is clear, therefore, that the cuta- 
neous inflammation cannot be the cause of the fever, but is itself an effect of the 
contagious poison. Here again we have a mark of distinction between febrile 



950 



EXANTHEMATA. 



exanthemata and inflammatory fevers, or what Callen calls the phlegmasia?, in 
which the local inflammation commonly precedes the pyrexia. 

In point of fact, the circumstance to which I have just referred shows the im- 
propriety of ranking these diseases under the head of cutaneous diseases. They 
would more rightly be called blood diseases. The disseminated cutaneous in- 
flammation is a curious and an important circumstance; and it is the symptom 
which, in the majority of cases, is most distinctive of the disorder : but it is not 
an essential circumstance. Thus, although there often is a manifest eruption 
(quite independent of common petechias) in the earlier stage of continued fever, 
a lenticular mottling, somewhat like that of measles, yet it is often absent alto- 
gether. And the very same thing happens in other diseases of the same group — 
diseases which all the world considers and calls cutaneous. A febrile affection, 
often a fatal one, but attended with no rash, proceeds sometimes from the conta- 
gion of scarlet fever. The fever — or rather the patient — is not scarlet. The 
worst form of cynanche maligna is of this kind. It is just the same in measles. 
Authors speak of morbilli sine morbillis; of scarlatina sine scarlatina; and even 
of variolae sine variolis. Catarrhal symptoms certainly occur sometimes in weakly 
children who have been fully exposed to the contagion of measles; and the com- 
plaint has proved fatal, without there having been any eruption at all. So in the 
plague: certain cases occur in which there are no buboes nor carbuncles, yet 
which undoubtedly originated from the common contagion of the prevailing 
epidemic. 

The time at which the eruption comes out differs in the different diseases; and 
even in the same disease, it is subject to occasional variation. The rule with 
respect to small-pox is, that the spots begin to be visible on the third day ; that on 
which the sickness and fever commenced being reckoned the first. As far as I 
have observed, this rule is a very constant one. It has been noticed, however, 
that when the disease* is confluent, and therefore severe, it occasionally shows 
itself in eruption on the second day; and when quite distinct and mild, sometimes 
not till the fourth. 

The regular period for the outbreak of the cutaneous affection in measles is the 
fourth day: it scarcely ever begins sooner; but it is often later — on the fifth or 
the sixth day, or even later than that. 

Cullen assigns the fourth day for the ordinary appearance of the rash in scarlet 
fever also. But in this he is decidedly wrong. Sometimes it is, I believe, per- 
ceptible on the first day ; but its most general period is the second day. In severe 
and unfavourable cases it may be postponed till the fourth day, or longer. 

The eruption, which is tolerably constant in some varieties of continued fever, 
observes less regularity in the time of its arrival. 

*The period which intervenes between the reception of the poison, and the 
supervention of distinct symptoms — the period during which the virus, though 
doubtless at work, seems to lie dormant in the system — the period (in one word) 
of incubation, differs also in the different diseases of this group, and varies even 
in different cases of the same disease. Although no marked changes occur during 
this period, I believe that some slight deviation from the usual condition and feel- 
ings of the patient might often be observed, if they were expected and looked for. 

The period of incubation in continued fever is very uncertain. In a paper 
upon this curious subject, published in the ninth volume of the Medical Gazette, 
Dr. Gregory states it as his opinion, derived from much inquiry, that ten days is 
the average period. Dr. Haygarth reckoned the minimum period at seven ; the 
maximum at seventy-two days. Sir William Burnett, in his Account of a Con- 
tagious Fever at Chatham, gives the history of a party of men belonging to the 
St. George, lying at Spithead, who were sent, on the 3d of January, 1811, to 
assist in navigating the Dolphin troop-ship; the crew of which were affected with 
typhus fever. On the 10th (seven days after exposure) fourteen of these men were 
sent to the Hospital-ship from the St. George, ill with the fever ; and many subse- 



CONTAGION, 



951 



quently, up to the 21st of January (the eighteenth from exposure), after which 
period no cases occurred. 

The period of dormancy is more definite, yet still liable to some variation, in 
most of the other exanthemata. «' At the Small-pox Hospital," says Dr. Gre- 
gory, " abundant evidence has been afforded that the period of incubation is 
usually about twelve days." It is a remarkable fact that, " when the small-pox 
is received into the system by inoculation, seven days only elapse between the 
insertion of the virus and the establishment of the fever." 

Dr. Bateman puts the period of incubation in measles at "from ten to fifteen 
days." I have known several instances in which the date of a single short expo- 
sure was exactly ascertained, and in which the disease commenced precisely a 
fortnight afterwards. In scarlet fever the average period is shorter ; not more 
than from four to six days, in the plague it is, I believe, more variable; but 
generally not exceeding a few days. Dr. Russell tells us that, among those in- 
habitants of Aleppo who shut themselves up after having been in the way of the 
contagion, no instance occurred of the appearance of the malady later than the 
ninth or tenth day. 

To say that a febrile disorder is contagious, is the same thing as to say that it 
is produced by an animal poison. Now there are many poisons, very deadly 
poisons too, which cause diseases that are not communicable from person to per- 
son. That particular poison, the malaria, is of this kind. 

Of the inorganic poisons some are taken into the blood, and emerge again from 
the body, unaltered, with one or more of the ordinary secretions; chiefly with 
the urine. They may induce changes in the body as they pass : and if these 
changes be salutary, the substances so inducing them become medicaments. If 
the changes be destructive or injurious, they are strictly poisons. 

Other of the inorganic poisonous substances do not find so ready an exit from 
the body. They enter into permanent chemical union with the constituent tis- 
sues of particular organs. In this way, to use the words of Liebig, they deprive 
the organs of the principal property which appertains to their vital condition, viz., 
that of suffering and of effecting transformations. If the organs of which the 
functions are thus destroyed be vital organs, these poisons are fatal. 

But the animal poisons, those at least with which we are now concerned, act 
in a totally different manner. They effect changes in the blood, whereby they 
are themselves abundantly multiplied or reproduced; and the eruptive disease 
that ensues seems to be the mode provided by nature for the escape or the expul- 
sion of this newly-formed morbid matter from the system. This is the old- 
fashioned humoral pathology ; founded on bold, unproven speculation: and it is 
most curious to see these very doctrines, which had sunk into universal discredit 
and contempt, now again assuming, their places, as scientific truths, upon the 
secure basis of organic chemistry. A wonderful specimen this of the sagacity of 
the older physicians — of the despised wisdom of our forefathers. 

The ancients attributed various disorders to a fermentation of the animal fluids. 
The cause of fever, according to Hippocrates, was some morbid matter in the 
blood. This matter, by a process of concoction, was brought, in a certain number 
of days, into a state in which it was ready for expulsion from the body. It was 
then thrown off by hemorrhage, by sweat, by alvine discharges; or deposited 
upon the surface in the form of abscess, or cutaneous eruption : and these erup- 
tions or evacuations constituted the crisis of each fever. 

The doctrine thus enunciated by the father of physic is very nearly the same 
with that which Liebig is teaching in the nineteenth century. This distinguished 
chemist ascribes the phenomena which succeed the introduction of certain animal 
poisons into the blood, to a process exactly resembling fermentation. Let me 
try, in a few sentences, to expound to you his views on this deeply interesting 
subject. 

You know that the brewer excites the fermentation of his sweetwort, by adding 



952 



THEORY OF CONTAGIOUS FEVERS. 



to it a small quantity of yeast. Wort is an infusion of malt, and contains sugar 
and gluten, with other vegetable matters, in solution. Yeast is putrefying gluten; 
and its component particles are, therefore, in a state of intestine motion or trans- 
position. When placed in contact with sugar in solution, it has the property of 
communicating a similar intestine motion to the elements of the sugar, whereby 
they arrange themselves into new and simpler forms ; namely, into alcohol and 
carbonic acid. If there were no gluten in the wort, this would be the whole of 
the process : during which the added yeast disappears. 

But the decomposition or fermentation of the sugar reacts upon the gluten in 
the wort, and converts it gradually into yeast, which, mingling with the liberated 
carbonic acid, rises and floats upon the surface of the fermenting liquid. So that, 
when the process is completed, there has been produced thirty times as much 
yeast as was originally added to the wort. 

Now this is but a type of what happens in other fluids under analogous circum- 
stances: and it may be laid down as an abstract proposition in Liebig's, or rather 
his translator's words, that "a substance in the act of decomposition, added to a 
mixed fluid in which its constituents are contained, can reproduce itself in that 
fluid, exactly in the same manner as new yeast is produced when yeast is added 
to liquids containing gluten." 

Thus the virus of small-pox (which virus is formed out of the blood) causes 
such a change in the blood as gives rise to the reproduction of the poison from 
the constituents of that fluid: and whilst this process is going on, the natural 
working of the animal economy is disturbed : the person is ill. The transforma- 
tion is not arrested until all the particles of the blood which are susceptible of the 
decomposition have undergone the metamorphosis. 

Liebig shows that similar processes may take place in mixed fluids (and, there- 
fore, in the blood) without the regeneration of the added substance : just as the 
fermentation of a solution of sugar is effected by the addition of yeast, without any 
reproduction of the yeast, if there be no gluten in the saccharine solution. In 
such cases, the disease, which accompanies, or results from, the transformations 
that occur in the blood, is not contagious : the poison is not renewed. It is thus, 
apparently, that certain miasms produce disorders which are not communicable 
from person to person. 

In order that a specific animal poison should effect its own reproduction in the 
blood, and excite that commotion in the system which results from the formation 
and expulsion of the new virus, it is requisite that a certain ingredient (analogous 
to the gluten in the brewer's sweet-wort) should be present in the blood : and this 
ingredient must have a definite relation to the given poison. 

If this ingredient be indispensably necessary to lffe, the poison, which trans- 
forms and destroys it, is inevitably a fatal poison. May not this be the modus 
operandi of the poison of hydrophobia? 

Again, if this ingredient be wanting, no reproduction of the poison takes place; 
nor, of course, any of those symptoms which are consequent upon such reproduc- 
tion. The poisonous qualities of the animal substance are not developed. It 
ceases to be a poison. 

And this ingredient, if naturally present, is exhausted and destroyed, for a while 
at least, by the operation of the poison. Hence, for a while at least, the same 
disease cannot be again produced by the agency of that poison. 

Supposing the ingredient to be one which is not essential to the composition of 
the blood, and to have been thus destroyed or exhausted, it may never be replaced. 
Or it may be replaced only after a long interval. In some persons it may never 
exist at all ; or it may exist at certain periods only of their lives. It may even be 
acquired by unnatural or peculiar modes of living. 

All this is not only very possible, but probable. A certain number of peculiar 
substances do certainly exist in the blood of some men which are absent from the 
blood of others. In childhood and in youth the blood of the same individual con* 



THEORY OF CONTAGIOUS FEVERS. 



953 



tains variable quantities of substances, which are not to be found in it at other 
periods of life. 

This theory of Liebig's offers, then, a reasonable explanation, the only expla- 
nation, indeed, that I have ever met with — of the curious facts, that certain conta- 
gious disorders furnish a protection, temporary or permanent, against their own 
return ; that they have a tolerably definite period of incubation, and run, for the 
most part, a determinate course ; that some persons are less susceptible than others 
of the influence of these animal poisons, or not susceptible at all ; and that the 
same individual may be capable of taking a contagious disease at one time, and not 
at another. 

Moreover, the light supplied by this theory gives distinctness to our conceptions 
respecting certain deviations from the regular course and type of these diseases ; 
which deviations are not uncommon. 

Thus the symptoms which precede and usher in the eruption are sometimes 
slow, halting, and irregular in their progress; appear, and then recede, and reap- 
pear, so that we are in doubt what is about to happen, until at length the disease 
declares itself in its decided and authentic form. 

We may suppose this to depend upon some tardiness or interruption of the 
process, whereby the virus is (to use the ancient term) concocted. 

Again, the series or combination of symptoms that marks the specific disease is 
sometimes, as I stated before, incomplete. We have the eruption of measles with- 
out the catarrhal symptoms : the sore throat without the rash of scarlet fever. And 
experience has found that, where the malady is thus imperfectly developed, the 
protection it confers against its own recurrence is also incomplete. To explain 
this double failure we may reasonably infer a corresponding defect in the series 
of changes which the poison tends to produce in the mass of the blood. 

Glandular enlargements and chronic abscesses are frequent sequelae of these 
exanthematous disorders. They may be considered to represent the dregs of the 
reproduced virus, which has been imperfectly eliminated from the system by the 
usual channels. 

Such is a brief exposition of Liebig's ingenuous theory. Do you ask whether 
I adopt it, with implicit credence in its truth? I answer, " By no means." Re- 
specting points so curious, it is scarcely possible to refrain from speculation altoge- 
ther. These views come recommended by the authority of a consummate che- 
mist. They furnish a plausible explanation of the main facts of the case: namely, 
that the disease is produced by an animal poison ; that the specific virus increases 
prodigiously in quantity within the body during the progress of the disease ; and 
that the susceptibility of its influence in that individual, is thereby somehow ex- 
hausted. I entertain the theory, therefore, until a better one is propounded. It 
has this incidental merit, that it involves no risk of practical error. 

The subtle contaminating effluvia which proceed from the bodies of the sick 
enter the blood of those who catch the disorder, chiefly, I imagine, by being 
inhaled into their lungs in breathing. The poison may, perhaps, be capable of 
being spontaneously absorbed through the skin: and upon this supposition oil 
lias been smeared over the surface with the view of shutting out the contagion of 
the plague. The virus may gain direct entrance into the blood ; we know that it 
sometimes does so, for we ourselves insert it, in inoculation of the small-pox. 
Dr. Francis Home imparted measles by engrafting some blood of a person ill of 
that complaint; and subsequent attempts to excite the disease in that way have 
been equally successful. Some rash and unfortunate trials have proved that the 
plague is communicable by inoculation with matter from the buboes. 

Endeavours have been made to estimate the distance to which the influence of 
different contagious emanations extends. The effluvia in small-pox, measles, and 
scarlet fever, are the most active ; operate, I mean, at the greatest distance. In 
continued fever they have a less range ; and in the plague the diameter of the in- 
fectious circle is probably very small. Some have even supposed that the plague 



954 



CONTINUED FEVER. 



is communicable only by actual contact; but the opposite opinion seems the mors 
likely, namely, that you may touch plague patients with impunity (as Bonaparte 
is known to have done on a memorable occasion) if you avoid inhaling their breathy 
or the effluvia proceeding from their bodies. 

The most important practical result of the experiments made by Dr, Haygarth 
and others, for determining the absolute distances to which the power of the con- 
tagion extends in different disorders, was, that where ventilation is complete, in 
other words, where the gaseous poison is freely diluted with atmospheric air r the 
sphere of its operation is very limited. 

It is an interesting subject of inquiry, worth glancing at for a moment, how far 
the power of different contagions is modified by differences of temperature. Small- 
pox is readily propagated either in hot or in cold regions ; in Mexico near the 
equator, in Greenland towards the pole. The plague does not spread when the 
temperature is below 60° or above 90° Fahrenheit. The vaccine matter loses its 
property of producing the cow-pox if it be exposed for a certain time to extreme 
cold, or to a heat of 95°. Typhus fever, measles, and scarlet fever, are said to 
be of extremely rare occurrence in the intertropical regions. Dr. Henry has turned 
these facts to useful account by proposing to decompose and destroy certain con- 
tagions lurking in fomites, by the operation of artificial heat. 

Having thus pointed out many circumstances of interest, which are common to 
all, or nearly all, the diseases grouped together under the title of exanthemata, I 
may now proceed to a more particular account of those diseases in succession. 
And I shall begin with continued fever; because, although it does not afford the 
best-marked example of the collection of symptoms that compose Cullen's defini- 
tion of the order, yet a right understanding of the practical points concerned in 
the management of this febrile disease will assist us materially towards a just con- 
ception of the modifications of treatment that may be required by the rest. 

We hear continually, both in and out of the profession, different species of fever 
spoken of. By the public, typhus fever, brain fever, bilious, putrid, low, nervous. 
And systematic writers are to the full as particular: mucous fever, ataxic, adyna- 
mic, gastro-enteric, and so forth. Now, admitting that fever shows itself under 
various forms, I am persuaded that the effect upon the mind of all this subdivision 
is bad and hurtful. It encourages a disposition, already too prevalent, to prescribe 
for a disease according to its name. There is no line of genuine distinction 
between continued fevers, that can be relied on. They run insensibly into each 
other, even the most dissimilar of them ; and are traceable often to the same con- 
tagion. I shall in the first place, therefore, attempt to describe this disease of 
continued fever as it occurs in its most ordinary and simple form ; and then point 
out its principal varieties. 

Continued fever does not always commence in the same way. It often happens, 
that for several days before the disease assumes its distinct and proper aspect, and 
before the patient is rendered unable to pursue his usual occupations, he is affected 
with certain morbid symptoms, which may be considered premonitory of the 
fever; so that it is sometimes difficult to mark the precise beginning of the disease. 
These preliminary symptoms result apparently from an altered condition of the 
nervous system. The poison in the blood disturbs the functions of animal life 
before it causes any palpable derangement in the mechanism of the circulation. 
The expression of the patient's countenance alters; he becomes pale, languid, and 
abstracted. Those about him observe that he is looking very ill. He is feeble, 
and easily tired ; reluctant to make any exertion of mind or body ; listless, and 
apprehensive often of some impending evil. He loses his appetite; his tongue 
becomes white and inclined to tremble ; the bowels are irregular, often confined, 
sometimes affected with diarrhoea ; his senses lose their natural delicacy. He has 
uneasiness or wandering pains in various parts of the body; and occasionally there 
is some giddiness: drowsiness, perhaps, during the day, and unsound and unre- 



SYMPTOMS. 



955 



freshing sleep at night. To collect all this into one expressive word, the patient 
evidently droops. 

In other cases these preliminary movements are altogether wanting. Chomel 
gives the following comparative account, deduced from the exact observation of 
112 patients in this particular. In 73 of these cases the invasion of the disease 
was sudden, without any warning, in the midst of apparent good health. In 39 
there were prelusive circumstances. 

The regular onset of the fever is, very frequently indeed, marked by a shivering 
fit. Another common phenomenon at the period of the invasion is severe head- 
ache; pain or aching across the forehead. According to Chomel, the headache is 
usually first experienced by the patient when he gets up in the morning. But 
this certainly is not a constant symptom. There is sometimes a sense of heavi- 
ness and vertigo rather than headache. Another symptom which sometimes, but 
not so often, sets in with the fever, is diarrhcea; and this is an important circum- 
stance when it does occur. It is attended, perhaps, with pain or uneasiness in the 
abdomen. You will also perceive, even when there have been no premonitory 
circumstances, that symptoms arise, even thus early, which belong to the nervous 
system, and denote some disturbance and alteration in the functions of sensation, 
thought, and voluntary motion. They are comprised under the general phrase, 
"febrile oppression, 1 '' and they are different from what we notice when pyrexia 
supervenes upon inflammation. You will obtain a clearer notion of what this 
term, febrile oppression, means, by watching at the bedside of one patient in this 
disease, than by any description I can give you. There is great inaptitude for 
exertion of the power of thought, or of motion. The expression of the face is dull 
and heavy, absent, puzzled. The patient presents very much the appearance of 
a person made stupid by drink ; and he staggers a little if he attempts to walk. 
The muscular power is sensibly enfeebled: sometimes the patient will struggle 
against this ; but in a few hours, or in a day or two at furthest, he takes to his bed. 

These are the symptoms which mark the outset of the disease we are about to 
consider. They occur sometimes in other disorders of the class in which I have 
placed continued fever. In the plague, for example. The patients appear like 
people who are drunk. Now these symptoms result, no doubt, from changes which 
are going on in the blood, and which make an early and a strong impression upon 
the nervous system. And there is another circumstance which, when it is observa- 
ble, denotes a depressed state of the nervous power. Practitioners sometimes 
are in doubt whether the case may not be one of some visceral inflammation : or, 
perhaps, knowing it to be continued fever, they still think it expedient to bleed the 
patient. Now faintness or actual syncope is much more easily produced by the 
abstraction of blood, in continued fever, than it is in inflammation: and this fact 
may occasionally be the means of distinguishing between incipient continued fever, 
attended, for instance, with catarrhal symptoms, and pure incipient pneumonia. 

In order the more clearly to describe the course of continued fever, I shall divide 
it, as others have done, into periods; weekly periods. Not that there is any such 
period of seven days'allotted to particular symptoms; but that in the simplest 
forms of the disease, when it runs its course most evenly and favourably, and 
therefore, we may suppose, the most regularly also, there is a succession of dif- 
ferent sets of symptoms, which occupy each about that space of time; nearly 
enough to allow of my taking it, I say, as a help to the better describing the 
disease. 

Many of the symptoms which occur during the first stage of the disorder — dur- 
ing the first week, we will say — are such as belong to the sanguiferous system. 
The pulse becomes more frequent than in health, .there is increased heat of skin, 
and thirst; headache, and throbbing of the temples. The pulse varies consider- 
ably in different cases. Generally, I say, its frequency augments; but sometimes 
it is even slower than natural. The acceleration of the pulse is greatest [cseteris 
paribus) in those constitutions which are the most irritable. In young persons, 



956 CONTINUED FEVER. 



in females, and in weak or delicate males, it will often rise, soon, to 120: while 
in stronger adults, it does not so early attain its maximum of frequency, and per- 
haps does not exceed 100 throughout the whole course of the disease. Should the 
pulse in any instance reach 130 or 140, the disease is severe: and the majority 
of such patients die. The absolute frequency of the pulse is not, however, of so 
much importance in this disorder, as its steadiness. If it shifts from one number 
to another, that affords a worse prognostic even than its being very frequent; pro- 
vided it keeps at the same standard. The skin, during this period, is generally 
hot and dry, and it feels to a bystander very hot and pungent. The actual heat, 
however, is not so great as the sensation given to the hand might persuade us it 
was. Dr. Bateman found that, in a majority of the cases treated by him, the heat, 
as ascertained by the thermometer, was about 100°; and he never observed it 
higher than 104°. The thirst is usually troublesome for the first few days. The 
tongue becomes clammy or dry; sometimes it is clean and smooth ; more often 
furred ; its edges and tip will, perhaps, be red, then a white fur will begin, which 
either covers the central part of the tongue, or is divided by a straight brown 
streak which occupies its middle portion. This brown streak is often the first 
step to dryness and blackness of the tongue. 

During the same period a careful examination of the abdomen will detect indi- 
cations of diseased action there. Sometimes diarrhoea is an early symptom; 
generally it is postponed, I think, to the next period ; or to the latter part of the 
first. When it does occur, the stools are, for the most part, loose and frequent; 
and either of a dark colour, and fetid, or of a yellow-ochre appearance, like pea- 
soup somewhat. K you make pressure upon the abdomen, you will find it un- 
naturally hard and resisting, as though its walls were made of pasteboard ; slightly 
tympanitic, as you learn by making percussion. Frequently, uneasiness is mani- 
fested when pressure is made on the belly, particularly over the caecal region ; and 
Chomel remarks that another symptom, not commonly met with in other diseases, 
is usually noticeable in the first stage of this, viz., a little gurgling movement, 
evidently from the intermixture of liquid and gas within the bowel, which move- 
ment becomes audible, or palpable to the hand, upon pressing the same region. 
This symptom is still more common in the more advanced stages of the disorder. 

There is evidence, frequently, of a slight affection in the membrane lining the 
air-passages, from nearly the first: some notable quickness of respiration, and 
some diffused rhonchus and sibilus, audible through the stethoscope. 

And among all the indications of increased action in the circulating system, the 
symptoms that relate to the nervous centres remain perceptible. The aspect of 
the patient is peculiar: the features are fixed and inexpressive; or expressive 
merely of apathy and indifference. If he is spoken to briskly, he responds ; and 
although his sensibility seems blunted, his answers are, as yet, rational, and to 
the purpose. Delirium does not come on, in general, till towards the end of the 
first week. The muscular power is greatly depressed. The patient lies on his 
back, motionless ; he sleeps but little, waking often ; and the short snatches of 
repose which he seems to get, are disturbed, apparently, by uneasy dreams : and 
he fancies, and says perhaps, that he does not sleep at all. Sometimes, even 
during the first stage of the disorder, when the bowels are relaxed, the prostration 
of strength is so great, or the tendency to stupor and indifference is so marked, 
that the stools are passed under him as he lies in bed, without any apparent en- 
deavour on the part of the patient to prevent it ; and without any notice of his 
wants being made to his nurse. The urine, during the same stage, is scanty, 
and high-coloured, and ill-smelling often. Towards the very end of the first 
weekly period, the eruption which is peculiar to continued fever sometimes 
begins to show itself: but this is commonly postponed to the next stage; and I 
shall describe it in connection with the other symptoms that are apt to occur in 
the second week of the disorder. 

It is seldom, except in very malignant forms of continued fever, that death takes 



SYMPTOMS. 



957 



place during its primary stages. Of forty-two cases treated by Chomel, one alone 
was fatal in that period. 



LECTURE LXXXIV. 

Continued fever, continued. Phenomena of the second week; Delirium, an 
Eruption, Diarrhoea; of the third week; Recovery, or death in the way of 
Coma, of Jlpnoza, of Asthenia. Symptoms that usher in those modes of death; 
morbid changes found after them. 

In the last lecture I commenced the consideration of that important disease, 
which is best known, in this country, under the name of continued fever. I told 
you my opinion that there is but one species, although there are many varieties, 
of continued fever. Sometimes this disease is preceded by symptoms of a slighter 
disturbance of the system; and sometimes it sets in suddenly, in the midst of ap- 
parent health. Whatever premonitory symptoms may take place, they indicate 
some alteration in the functions of the nervous system, upon which many patho- 
logists have supposed that the first and most direct impression is made, by the 
exciting cause of the fever. But the exciting cause, in many cases, probably in 
all, is a specific poison received into the blood : and all analogy is in favour of the 
belief that the primary change is wrought upon the blood itself. The whole mass 
of the blood is gradually vitiated ; and the first evidence of the circulation of this 
altered fluid, is depression of the powers and functions of animal life. Among 
the earlier symptoms of the declared disease, shivering, headache, and occasion- 
ally diarrhoea, take the lead. 

For the convenience of description I divided the course of the disorder into 
three weekly stages : not that it necessarily runs its course in three weeks, but 
because the sets of symptoms which succeed each other while the disease is in 
progress, occupy, in the cases which seem to proceed the most regularly, about 
the space of seven days each. 

Now the symptoms present during the first week are expressive of disorder 
both of the sanguiferous and of the nervous system. The patient is hot, flushed 
perhaps, and thirsty, and he has a frequent and hard pulse. Besides this he 
manifests indifference and stupor; his senses are blunted; his intelligence is di- 
minished. His muscular strength is reduced in a remarkable manner; so that he 
cannot sit up; in many cases he cannot even lie on his side, or turn himself about 
well in bed, but remains in the supine position : and if he be purged by medicine, 
or spontaneously, the stools are apt to pass from him into the bed, without his 
knowing it, or without his taking any care to prevent it. This, however, is more 
common, and more marked, in the second period or week; the phenomena of 
which I next go on to sketch. 

In the first place, in mild cases, and in some epidemics, the patients begin to 
improve soon after the first week. Dr. Welsh, in his account of fever as it oc- 
curred some years since in the Queensbury-House Establishment in Edinburgh, 
says that of 743 patients, 373 (that is, fully one-half) had passed the worst, or 
had begun to get better, by the ninth day ; and several of the physicians who 
witnessed the fever that prevailed in Ireland in the earlier part of the present 
century, concur in declaring that, in a vast majority of cases, the disease had 
" taken the turn," and the patient began to mend, by that time. But the epide- 
mics, in these cases, were undoubtedly mild. In general no change for the better 
takes place at the end of the first seven or eight days; but what are called the 
typhoid symptoms develop themselves more distinctly. 

The changes that occur are usually the following: — The pulse becomes more 
frequent, weaker, and more compressible. The tongue grows drier and browner. 



958 



CONTINUED FEVER. 



More sordes, and of a darker colour, accumulate on the teeth and lips : and it is 
in this period that delirium is most apt to ensue ; and that certain eruptions are 
most often observed. But the symptoms that relate to the nervous system are 
often still the most prominent. The patient generally loses his headache. ' His 
voluntary movements, however, become very much weakened, and are sometimes 
exercised irregularly. The posture which the patient in this stage almost always 
assumes is, I say, indicative of this weakness; he lies on his back, and he sinks 
down in the bed, slips towards the foot of the bed. He is unable to make or bear 
that degree of voluntary exertion which would be necessary to place him upon 
his side. Hence we hail it as a good omen — because it is an indication that the 
patient still retains some strength — if we find him on his side, or even on his back 
with his knees drawn up. Other proofs of muscular debility, approaching to 
palsy, are apt to present themselves. The voice becomes feeble ; the patient can 
scarcely utter an audible sound. Perhaps he is unable to swallow. This is a 
very bad symptom, though it is one that has been recovered from. Sometimes 
it seems that the power of deglutition is not lost, but the sick man is too listless 
to try to swallow ; or the dry and parched state of his tongue and throat renders 
it difficult and painful for him to attempt to do so. The patient is apt to lie with 
his mouth open: and breathing thus through the mouth tends to dry the tongue. 
Hence it is well to desire the sick person to swallow a mouthful or two of water, 
and so to moisten his tongue, before you decide upon the state of that organ, or 
upon his facility of deglutition. Often, in bad cases especially, there are little 
convulsive startings of the tendons, [subsultus tendinum is the technical name of 
the symptom,) and other irregular and involuntary actions of the muscles : tre- 
mulous movements, especially of the tongue and of the hands; and sometimes the 
patient is unable to put out his tongue at all. There are two symptoms which 
present themselves in the majority of instances in the second week of the fever, and 
which deserve your particular attention: I mean delirium, and the eruption which 
belongs to the disease. 

The delirium is peculiar. The patient wanders, at first, in the night only ; and 
the delirium commonly appears on his awaking from disturbed sleep. Sometimes 
he is desirous of getting up, and talks incessantly and earnestly in a loud voice, 
and can only be kept in bed by the imposition of some restraint. Usually, how- 
ever, his rambling is of a tranquil kind, and without agitation. His mind seems 
elsewhere : he is inattentive to all that passes around him ; but he lies still, mut- 
tering disjointed words or sentences, like a man talking in his dreams. From 
this state of typhomania the patient may sometimes be roused by loud speaking 
addressed to him, or by the sight of a strange face ; so that, though incoherent and 
delirious just before, he may become collected when his medical attendant enters 
the room. But he presently relapses. During the delirious state there is a great 
deficiency of sensation, and insensibility to impressions. The patient is deaf. 
This deafness you may hear spoken of as being a good omen, or favourable sign; 
but it is so only by comparison : it indicates a condition of brain less perilous than 
its opposite, in which the sense of hearing is morbidly acute. Imperfection or 
loss of vision is much rarer, and much more dangerous, than deafness ; yet the 
eye is generally dull — unlike the brilliant eye of acute phrenitis; it corresponds 
with the expression of the countenance, which is perplexed rather than wild. 
Sometimes, however, as the disease advances, black spots, like flies on the wing, 
rnuscse, volitantes, appear before the patient's eyes : in consequence, it is presumed, 
of partial insensibility of the retina. The patient attempts to grasp or catch these 
in the air, or to pick them from the bed clothes. This is called floetitatio. After 
these symptoms recovery is not common. The mouth and tongue are dry ; yet 
the patient no longer complains of thirst. The taste, the smell, the sense of touch, 
are all impaired ; even external inflammation may take place, especially about the 
hips and sacrum, and go on to gangrene, without any complaint of pain from the 
patient. He seems altogether careless about the issue of his disorder. If, at this 
period of the fever, you ask him how he does, he will probably declare that he is 



# 

SYMPTOMS. 



959 



quite well. I have already alluded to the involuntary passage of the feces: this 
may depend, in part, especially in the advanced stage of the disorder, upon debility 
or paralysis of the sphincter muscles. The urine also dribbles away frequently : 
and these are points which must always be looked after; first, for the sake of 
keeping the patient as clean and dry as possible, the irritation of the urine and 
fecal matters tending to produce sloughing ulceration; and, secondly, with the 
view of preventing the bladder from becoming unduly distended. Retention of 
urine, and all its bad consequences, may otherwise occur. It is a good general 
rule, therefore, to examine the hypogastric region every day with the hand ; and 
also to ask to see the urine, not for any purposes of prognosis, but to ascertain 
that it is regularly discharged. 

It is also, I repeat, iu this stage of the disorder that the rash or eruption, which 
so often accompanies it, very frequently shows itself. Sometimes it is noticed 
earlier. It consists of -small rosy blotches, of a roundish or lenticular shape; 
scarcely raised, if raised at all, above the general surface of the skin on which they 
appear. Chomel states that they vanish under pressure ; but it is not so. I have 
again and again observed that they diminish or become fainter under the pressure 
of the finger; but they are not effaced even for an instant. They are sometimes 
few ; sometimes so numerous as to dapple the whole surface of the abdomen, or 
of the thorax, or of both. Upon the limbs they are less common, and less closely 
set. I believe that they often besprinkle the back, although they are seldom looked 
for there. They vary in intensity of colour, and, therefore, in distinctness. The 
whiter the skin, the more obvious do the spots become. In brunettes they may 
easily eseape notice. In this form of disease the entire skin is often unnaturally 
dusky. 

The eruption does not come out all at once: nor is its duration always the same. 
Sometimes it disappears entirely after two or three days. Sometimes, on the other 
hand, it lasts a fortnight, or more. In the latter case it is probable that successive 
crops of the spots continue to arise. 

The rash now described stamps continued fever with one of the most striking 
characters of the exanthematous group of febrile diseases : but it certainly is less 
constant than the cutaneous phenomena of small-pox, measles, or scarlet fever. 
It occurs much more regularly in some epidemics than in others. Fever is very 
rife in St. Giles's, and in other crowded parts of this town, just now (1838). Our 
wards at the Middlesex are full of it; and scarcely a case presents itself without 
these spots. We speak of it familiarly as the spotted fever ; or, (from the resem- 
blance which the rash bears to that of measles, hereafter to be described) as the 
rubeoloid fever. 

You cannot well confound this mottled rash with petechia;, which are little 
specks, or dark circular spots, resulting from a minute extravasation of blood 
beneath the cuticle. The specific rash and these petechias are, however, some- 
times mingled together. 

It may not be superfluous to caution you against mistakingjta-foVes, which are 
common to nearly all our hospital patients, for this specific eruption, which is 
peculiar to the fever patients. The round red stain, with a dark point for its centre, 
sufficiently distinguishes the mark of the insect from the rose-coloured blotches of 
the disease. 

There is another eruption described by the French as occurring in this disease 
without being pecidiar to it. In this country it is now very rare ; but it used, 
when the hot plan of treatment was in vogue, to be very common indeed here, 
in various febrile complaints ; and it was, and is, occasioned by profuse sweating. 
Sudamina, the vesicles composing the eruption are called. They are small, 
hemispherical, transparent elevations of the cuticle, containing a clear watery 
fluid. The vesicles are from a quarter of a line to half a line in diameter; they 
have no red bases; and they are so perfectly pellucid, that when you look upon 
them in a direction perpendicular to the skin on which they stand, they may 
readily elude observation. Viewed sideways, they present bright surfaces, and 



960 



CONTINUED FEVER. 



look like so many drops of water, and yon may feel with your hand that they 
roughen that part affected with them. These sudamina are mostly met with on the 
thorax, along the sides of the neck, and about the axillae. By degrees, the limpid 
fluid disappears, and they shrivel up; the cuticle becomes wrinkled, and dries 
into a whitish powder. 

Diarrhoea is anoiher marked symptom observed in many cases of continued 
fever, though not in all, at this period of the disease. When the stools are invo- 
luntary, when they are passed in bed without notice on the part of . the patient, 
they add materially to his danger, by the irritation and the sores, which are liable 
to result from their contact with the skin. There is seldom much pain of the 
abdomen complained of by the patient; but if you make pressure, especially 
about the situation of the caecum, you may often remark that he winces, or that a 
transient expression of suffering passes across his features. The character of the 
evacuation remains the same, and is almost distinctive of the disease: thin yellow- 
ish, ochrey, like pea-soup. When in fever, such stools persist day after day, 
and several of them every day, you may safely infer that there is ulceration of 
the bowels, although there should be no pain complained of, even when the abdo- 
men is pressed. 

And the same conclusion will become still more certain when hemorrhage from 
the bowels occurs, as it is apt to do, in this stage of the fever. It often takes 
place unexpectedly, sometimes in considerable quantities, and rapidly exhausts 
the patient: or it recurs at intervals to a smaller amount, wasting his strength as 
effectually, though more slowly. The bleeding is probably owing, in general, to 
the division or opening of some of the mesenteric veins, by the ulcerating process 
which I shall more fully describe by and by. This is not, however, a necessary 
consequence of the ulceration ; for the vessels are usually obliterated previously 
to their erosion. Sometimes blood may be thus poured into the bowel without 
being voided. Andral relates a case in which a man died suddenly, and unexpect- 
edly, at an advanced period of continued fever. Large clots of black blood filled 
the lower two-thirds of the small intestines, which were crowded with patches of 
ulceration. No part of the blood had passed the valve of the caecum. 

Hemorrhage from the bowels occurs also in continued fever sometimes in 
another way ; in connection with other putrid symptoms, as they are not unaptly 
called : petechias, purple spots, bruise-like blotches, and extreme depression of the 
vital powers. In these cases the hemorrhage is strictly of the passive kind, and 
it is a symptom of the worst omen. Like those effusions of blood from the same 
parts that happen in scurvy and purpura, it depends upon a morbid condition of 
the blood. This is no matter of speculation, for by this time the sensible quali- 
ties of the blood are manifestly changed: its natural tendency to coagulate when 
withdrawn from the body is diminished, the crassamentum is large and loose, and 
fills the cup, and sometimes is rather an incoherent sediment than a clot. When 
these putrid symptoms are strongly marked, a peculiar fetor is exhaled by the 
patient's body ; his tongue becomes dry, black, and fissured ; his teeth are covered 
with dark sordes ; sloughs form from the mere pressure of the bed on which he 
lies ; in extreme cases the toes have mortified; and Dr. Roupell relates one terri- 
ble instance in which both legs rotted away to the bones, which it became neces- 
sary to saw through : yet this patient recovered. 

Death may take place in this, the second period of continued fever. Of forty- 
two patients who died under his care, Chomel counted nine in which the fatal 
event occurred between the eighth and the fifteenth days. 

The phenomena belonging to the third period of the fever vary considerably 
according as the disease is about to terminate in death, or in recovery. Among 
Chomel's forty-two fatal cases, I have already mentioned that one death took place 
in the first week, and nine in the second ; the remaining thirty-two all occurred 
in the third period. And the tendency of the fever to terminate during this period 
is equally well-marked in the cases which recovered. Of twenty-four such patients, 
one alone began to be convalescent in the first week ; and of those whose symp- 



SYMPTOMS. 



961 



toms were at all serious, not one showed marks of convalescence before the end 
of the second. 

When the disorder is about to end favourably, the more formidable of the symp- 
toms diminish and abate. The patient begins again to attend to questions that 
are put to him ; the air of stupor which had hung over his countenance clears 
away; he once more shows an interest in what is going on around him; the 
temperature of his skin becomes more natural, the tongue moist and cleaner at its 
edges, and the frequency of the pulse is less. The evacuations from the bowels 
are less numerous, more consistent, and more healthy; and the patient is aware 
when the necessity for passing them arrives, and he gives notice, or asks for assist- 
ance. Generally, at the same time with these tokens of improvement, the ema- 
ciation which has taken place becomes remarkably conspicuous ; perhaps it is the 
more observable on account of the patient's resuming a more natural expression of 
countenance. 

In many instances, the amendment is so gradual that we can scarcely say when 
it begins. In other cases the favourable crisis is preceded by an aggravation of 
most of the former symptoms, and a marked increase of the general distress. This 
is a very curious circumstance ; and it did not escape the notice of our great 
dramatist. 

Before the curing of a strong disease, 
Even in the instant of repair and health, 
The fit is strongest. Evils that take leave, 
In their departure most of all show evil. 

Certain evacuations are also sometimes observed to accompany or to be conr 
nected with the favourable change ; and the most common of those is the evacua- 
tion of sweating. 

On the other hand, when the disease is about to terminate in death, that event 
may take place in different ways; in either of those modes, in short, which I took 
some pains to distinguish in the earlier part of this course of lectures. I told you 
then that I had been taught the importance of studying the tendency to this or that 
mode of dying, in reference especially to fever, by Dr. Alison. My own expe- 
rience has since sufficiently approved to me the wisdom of his teaching. Cullen 
inculcates the necessity of " obviating the tendency to death." To do so, we 
must ascertain the direction of that tendency. We do not so much cure these 
exanthematous maladies, as keep our patients alive while they recover. If we 
would prevent their dying we must know in what manner they are in danger of 
dying. 

The most common mode of death in continued fever is certainly that of coma. 
The organic life survives the animal life. The muttering, half-conscious, dream- 
like stupor, from which the patient may be roused for a while, becomes, by 
degrees, more profound, and deatfi begins in the head. This mode of death, 
occurring in the second or third week of the fever, is associated, frequently, with 
the symptoms of putrescency already described. But as the stupor deepens, the 
pulse generally grows weak, and the extremities become cold. So that death does 
not come purely in the way of coma ; but we have a compound of coma and 
asthenia, in which the coma takes the lead. 

Now coma may result from at least two different kinds of cause. One cause 
is pressure, which is mechanical. Another, which is probably chemical, is the 
circulation of some noxious or narcotic substance (such as opium) in the blood. 
And there are, doubtless, many physical conditions of the nervous mass itself 
which are capable of arresting the cerebral functions, and producing coma. To 
which kind of cause are we to ascribe the stupor that supervenes during the pro- 
gress of fever? That is an interesting, and in reference to practice, an important, 
question. 

Physicians have diligently attempted its solution, by examining the dead brain. 
I cannot tell you how often I have looked, and looked in vain, for some palpable 
disorganization, or some effusion implying pressure. All who are familiar with 
61 



962 



CONTINUED FEVER. 



the dead-house of a hospital are aware that this fruitless search for some physical 
explanation of the comatose state, after death by fever, is of very common occur- 
rence. 

Chomel— -one of the latest, and a very able and accurate French writer on fever 
— gives the following statement in respect to 38 fatal cases, in which the brain 
was carefully and minutely inspected by him. In 15 of the 38, no morbid ap- 
pearance at all was perceptible: in 12 there was some serous fluid, from a tea- 
spoonful to a tablespoonful, in the ventricles: in 7 there was what he calls oedema 
of the meninges, effusion, that is, in the meshes of the pia mater: in 6 general 
but slight diminution of consistence: in 2 some alteration of density: in 5 a 
speckled appearance of the cerebral substance. Now to what conclusion do these 
facts lead us ? Why, in the first place, to the conclusion that those pathologists 
are in error who maintain (as Dr. Clutterbuck does, for whose experience and 
talents I entertain a sincere respect), that the essence of continued fever is inflam- 
mation of the brain. Not only do we fail to discover, in many instances, any 
traces of inflammation, upon inspecting the dead brain, but we find that, during 
the life of the patient, measures which would be likely to aggravate any inflamma- 
tory mischief — strong stimulants, for example, wine or brandy, — do actually and 
obviously, in cases innumerable, relieve the comatose symptoms, and benefit the 
patient. The inference seems unavoidable, that the coma, in such cases, has 
some other cause than that mechanical pressure which arises sometimes from the 
effusion of fluid upon the surface of the brain, or within its ventricles ; and that 
other cause is supplied by the poisoned blood. Here again we may adopt the 
pathology of Shakspeare: 

The life of all his blood 
Is touched corruptibly: and his pure brain 
(Which some suppose the soul's frail dwelling-house) 
Doth by the idle comments that it makes 
Foretel the ending of mortality. 

In some malign epidemics the nervous system is overwhelmed at once, in the 
very outset, by the force of the poison. The patient becomes stupid or bewil- 
dered ; his surface is cold, clammy, purplish, and his pulse feeble: the coma 
rapidly augments, and death may ensue within twenty-four hours. We some- 
times see this fearful train of symptoms in small-pox; and still more often and 
more strikingly in the worst forms of scarlet fever. I believe that in these cases 
there is no deviation, cognizable by our senses, from the healthy texture and 
appearance of the parts within the skull. 

Nevertheless, there may be, and there often is, in these fevers, actual inflam- 
mation of the brain or its membranes : but this is an incidental complication. We 
conjecture that, in addition to the influence of the poison upon the nervous system, 
there may be a low degree of inflammation go # ing on within the head, when we 
find it externally hot, when the patient has flushed cheeks, and a vascular eye, 
and complains of dull headache. And there are some instances in which we 
recognize more distinctly the outward signs of encephalitis — severe pain in the 
head, high and fierce delirium, intolerance of light and of sound, with much heat 
of skin, and a hard pulse. When coma succeeds such symptoms as these, we 
naturally ascribe it, in part at least, to the effects of the inflammation : and rightly, 
for we find traces of inflammation after death ; serous effusion beneath the arach- 
noid and in the cerebral ventricles; shreds of coagulable lymph; and more rarely 
suppuration. I suspect that genuine encephalitis, which is, of course, attended 
with pyrexia, is sometimes mistaken for continued fever with intercurrent inflam- 
mation of the brain. Great attention, and some skill and judgment, are required 
for discriminating those cases of fever in which such inflammation occurs, and for 
directing the appropriate treatment. 

The death in fever by apnosa is certainly much rarer than that by coma : yet it 
is not very unfrequent. It often mingles itself with the death by coma. From 
the earliest period of the fever we may, in most cases, notice some increased 



MORBID APPEARANCES. 



963 



quickness of respiration, which is not entirely owing to the mere fever, or to 
acceleration of the circulation ; for the ear, when applied to the parietes of the 
chest, discovers rhonchus, and sibilus, at least. Frequently there is considerable 
dyspnoea for some hours, or for a day or two, before death: and this may be appa- 
rent only, in consequence of the stupor; or it may be real, and proceeding from 
a low degree of pneumonia, which, by interfering with the due arterialization of 
the blood, may aggravate, or even give rise to the coma: and such pneumonia is 
apt to be masked by the fever; declaring itself by none of the ordinary symptoms 
of cough, rust-coloured sputa, or pain in the thorax. The inflammation, thus 
latent, is discoverable, however, by the sense of hearing. 

Now what does dissection teach us with respect to the condition of the lungs 
after death from continued fever? Why, the most common unnatural appearance 
met with in the pulmonary substance is engorgement : a state similar to that which 
occurs in the first stage of pneumonia. But here the engorgement is probably in 
a great measure mechanical, and takes place during the last few days of the pa- 
tient's life. As the vital powers diminish, the laws which govern the physical 
world resume their empire. The fluids, and the blood especially, accumulate in 
the most depending parts of the viscera; and the lower and posterior portions of 
the lungs in particular become loaded. But besides this, it is not unusual to find 
large portions of the lungs in a state of hepatization, and even inriltered with pus: 
and the bronchial tubes clogged up by viscid and frothy mucus. 

The mode of death by asthenia or syncope is not very common as existing by 
itself; but it is often combined with one or both of the two other modes. In 
some cases of fever, however, death does appear to take place from mere debility 
of the heart; there having been no pulmonary embarrassment, and the head having 
remained clear. Death, in such cases, is preceded by those symptoms of debility 
which have been already described. The pulse becomes small and weak, and 
like a thread ; the patient lies on his back, and sinks clown in the bed ; the fea- 
tures sharpen; the eyes are hollow and dim, as though glazed; the sphincter 
muscles fail to contract; the extremities grow cold; cold sweats appear on dif- 
ferent parts of the body : and at length the heart ceases to beat, and the patient 
to exist. 

Death occurring in this manner does not occur early. It happens at an advanced 
period of the disease. It is noticed sometimes in persons who have been largely 
bled, or too actively depleted at the commencement of the fever: and in those 
who have suffered a good deal from diarrhoea. In short, as the two previous 
modes of death are connected, often, with morbid conditions of the head and chest 
respectively, so death in fever occurring purely or chiefly by asthenia, connects 
itself with morbid conditions existing within the belly. 

And we trace the vestiges of disease much oftener in the abdomen than either 
in the brain or in the thorax; and the mischief which we there discover is more 
constant and definite than elsewhere. It is proper, therefore, to inquire some- 
what more closely into the morbid appearances observed in the abdomens of those 
who die of continued fever. 

I need scarcely remind you that the intestinal canal is largely furnished, on its 
inner surface, with glands, or follicles, which consist of little more than crypts, 
and of which the precise office has not yet, I think, been accurately determined. 
Some of these glands are sprinkled (one may almost say at random) over the 
whole tract of mucous surface. These are accordingly called solitary glands. 
Till I was better instructed by Professor Todd, I used to speak of them as being 
the glands of B runner ; whereas the glands discovered and described by that 
anatomist are limited to the duodenum. Other glands or follicles are collected 
into groups, and are named glandulx agminatsz, or often the glands of Peyer, 
who has given a capital description of them. Now the arrangement of these 
glands of Peyer is peculiar: and, in reference to the morbid anatomy of con- 
tinued fever, very necessary to be known. They are met with in the ileum alone : 
they are, mostly, oblong in form : and they occupy that part of the bowel which 



964 



CONTINUED FEVER. 



is opposite its mesenteric attachment They are largest, and most numerous, and 
consequently most thickly set, in the lower end of the ileum, which, in some 
instances, is almost entirely covered with them : they are found also upon the 
ileo-ccecal valve: but beyond that they do not go in that direction. Ascending 
from the caecum towards the jejunum, these groups or patches become smaller, 
shorter, more circular, and less numerous; they are separated by longer and 
longer intervals, till at last they cease to be visible at all. Where there are val- 
vulae eonniventes, there the situation of these patches is very obvious; for the 
valvules eonniventes are interrupted, and never run across them. This fact has 
sometimes led to curious mistakes. I have seen in the museum of the College of 
Surgeons a preparation put up by Mr. John Hunter (but not labeled, I presume, 
by him), professing to be an example of the destruction of portions of the valvulae 
eonniventes by ulceration. It is nothing more than one of these natural patches, 
rather more plainly developed than usual. 

These glands, in their healthy state, are much more conspicuous in some bodies 
than in others. You may see, if you look at them attentively, that they are made 
up of a eongeries of mucous follicles, of which the orifices are obscurely apparent. 
Now the main alterations met with in the abdomen after death, in continued fever, 
are alterations of these very glands : of the solitary glands, to wit; and still more 
constantly and remarkably of the agminate glands. 

The changes which these glands undergo are of the following kind. In the 
first place they become enlarged, and more perceptible than they are in the natural 
state. They then present a grayish transparent surface, dotted over with black 
points ; which black points mark, I conceive, the excretory mouths of the several 
follicles. Then, as the inflammation, for such it is, advances, the patch becomes 
reddish perhaps; and the follicles burst or ulcerate, or slough away: not alto- 
gether, but partially and by piecemeal ; so that an irregular ragged ulcer is gene- 
rally left, having thickened edges. Sometimes, however, the follicles disappear 
without there being much redness or thickening : the mucous membrane imme- 
diately adjacent, and even the remaining part of the patch of follicles, being pale, 
and level. Sometimes the patch puffs up into a sort of fungous swelling, in 
which all trace of the follicular structure is lost. The colour of the ulcerated sur- 
face is various, as well as its form and appearance. Sometimes it is pale and 
gray ; sometimes red ; oftentimes yellow, as if the exposed cellular and other 
tissues were stained by the ochrey fluid which had been poured from the bowels 
during life. What I have hitherto stated relates to Peyer's glands ; but the soli- 
tary glands participate, usually, in the change. They become, in the first place, 
large and hard, and present a whitish-coloured projection from the surface, which, 
by a mistaken analogy, has sometimes been called a pustule. At length a loss of 
substance takes place in these also; beginning at their summit, and producing a 
small, but sometimes a deep ulcer. 

And of these changes it is further to be observed, that they are more common, 
more numerous, more extensive, more advanced, in proportion as we approach 
the caecum. It is natural that we should meet with more uleers near the caecal 
valve, because there are more glands there; but undoubtedly the ulcers are (in 
general) further advanced there than higher up in the bowel. 

Going along with this ulceration of the mucous glands of the intestines, and 
above all of the aggregate glands of the ileum, you will frequently find inflamma- 
tion (& e., redness, hardness, and swelling) of the corresponding mesenteric glands. 
This would seem to be a consequence of the inflammation and ulceration of the 
mucous glands. The inflammation of the mesenteric glands is, I conceive, secon- 
dary ; and bears the same relation to the ulcers seen in the bowel, as a bubo in 
the groin bears to a chancre on the glans penis. 

These alterations are extremely interesting, because they afford a plausible ex- 
planation of many of the symptoms of continued fever. They account for the 
diarrhoea; they account for one form of occasional hemorrhage from the bowels; 
they account for the uneasiness or pain which is experienced when the abdomen; 



MORBID APPEARANCES. 



965 



is pressed, and*teach us why that uneasiness is greatest in the situation of the 
caecum. Nay, we can even understand why, although these ulcerations exist, 
there may be no pain occasioned by them. This may be partly owing to the 
general insensibility to impressions and sensations of all kinds, produced by the 
stupor; but partly, also, it probably depends upon the depth to which the ulcera- 
tion goes. The mucous tissues are possessed of but little sensibility even under 
inflammation; but if the muscular and peritoneal coats become involved in the 
inflammatory process, then pain begins to be felt. I remember, a few years ago, 
attending a young lady ill of fever, with a very well-informed practitioner, but one 
of the old school, for he had not turned his attention much to the state of the 
intestines in that disease. One day we learned that our patient had had hemor- 
rhage ; from the uterus her friends supposed; but when I saw the discharge, I 
was certain, by its appearance, and by its odour, though it was not mixed with 
any feces, that it had come from the bowels; and I stated my conviction that 
there was ulceration in the lower portion of the ileum. But she had no pain in 
the abdomen. You might press any part of it without exciting the smallest un- 
easiness. So, distrustful of my opinion, they called in an eminent accoucheur, 
who also pressed and examined the belly : but neither could he detect any tender- 
ness or undue sensibility. He next examined the uterus per vaginam ; but could 
discover nothing wrong there. Some few nights afterwards the general practitioner 
was called out of his bed to this patient. He was told that the hemorrhage (or 
flooding as they called it, for they persisted in believing that \\ was uterine), had 
returned ; and before he arrived at the house the patient was dead. We next day 
opened the body together. The uterus was perfectly natural; there was no ves- 
tige of discharge or bleeding in the vagina; but the ileum, for about a foot above 
its entrance into the caecum, was in a state of superficial but ragged ulceration, and 
universally red and smeared with blood. I mention this as a strong fact in illus- 
tration of the possibility of there being much disorganization of the inner surface 
of the intestines, without any pain to reveal it. 

Now the alterations I have last been sketching — the thickening, redness, tume- 
faction, and ulceration or sloughing of the glands of Peyer, and also of the solitary 
glands — are so common in fever, particularly in some epidemics, that many 
pathologists are of opinion that fever is essentially inflammation of these glands, 
and nothing else. But this, I am sure, is an error. In the first place, if this 
doctrine were true, it would almost follow of necessity that the severity of the 
case, and the intensity of the symptoms, should be in proportion to the number, 
depth, and extent of the ulcerations. But this is far from being so. In cases in 
which the symptoms have been of the worst kind, there have been found very few 
ulcerations, and those small and apparently insignificant. On the other hand, 
when the complaint has run a moderate course, but at length has terminated fatally, 
it is not uncommon to discover a frightful amount of disorganization in the ileum. 

But what is more conclusive is, that the occurrence of this inflammatory con- 
dition of the mucous follicles of the intestines is not constant, in continued fever. 
If one well-marked instance of the disease should occur, without any trace of a morbid 
action having been going on in the mucous follicles, that instance would, of course, 
suffice to overturn the theory. But scores of such cases have occurred. I have 
seen many such myself; and other persons have seen more. Since attention has 
been drawn to the subject, the patches of glands, and the whole tract of mucous 
membrane, from the stomach to the rectum, have been diligently explored : and 
the result seems to be that, at certain times and places (in other words, in certain 
epidemics), the ulceration of the inner surface of the intestines is far less common 
than at others. It was comparatively rare in an epidemic of which I witnessed 
some part in Edinburgh. Then I came to London ; and for several years I never 
saw a body opened after death by continued fever, without finding ulcers in the 
bowels. More recently, however, and especially during the present epidemic 
(1838), I have looked for them, carefully, in many cases that have proved fatal in the 
Middlesex Hospital, and have discovered neither ulceration nor any other apparent 



966 



CONTINUED FEVER. 



change in the follicles of the intestines. Still, in my own experience, such ulcers 
have been vastly more often present than absent. Chomel, during five years' 
investigation of this matter in the Hotel Dieu, never met with an exception to the 
general rule of their occurrence ; or of some degree or form of that kind of alter- 
ation in the mucous glands, of which the ulcer is the last stage. 

We must conclude, upon the whole, that although an inflammatory state of the 
solitary and aggregate glands, which strew the surface of the mucous membrane 
of the alimentary canal, is not the essence of fever, yet that it is a very frequent 
companion of continued fever. 

But when it does occur, is this state of things always, or necessarily fatal ? 
By no means. It may be fatal, in more ways than one. It may lead to death, 
by exhausting diarrhoea, in the way of slow asthenia ; it may kill by laying open 
a large mesenteric blood-vessel, and so producing copious hemorrhage and mortal 
syncope ; it may, and often does, destroy the patient, by perforation of the bowel ; 
the ulcer penetrates the mucous and muscular coats, and reaches the peritoneum: 
and sometimes that membrane gives way, and sometimes it does not. The conse- 
quences of its rupture or perforation — the escape, I mean, of the contents of the 
bowel, and the supervention of intense and uncontrollable peritonitis — I need not 
again dwell upon. But the ulcers may, and doubtless often do, heal: and the scars 
which they leave behind them are frequently to be seen. The ulcerated surface 
seems to clothe itself afresh, by degrees, with a new mucous membrane; which 
is thin, however, and adherent to the subjacent tissues, and does not slide over 
them when pressed between the finger and thumb, as the healthy portions of the 
coats of the bowel will do upon eacli other. And in the place of the cicatrix there 
is usually to be seen a manifest puckering, and a number of little wrinkles or lines, 
radiating from a common centre. 

The spleen — I may observe, before I conclude this lecture — is more frequently 
found altered in texture after death by continued fever, than any other part except 
the glands of which I was last speaking. It is usually enlarged, of a dark colour, 
and of soft, and sometimes almost rotten, consistence. 

To-morrow I shall endeavour to point out some of the most important varieties 
that have been found to occur in this disease of continued fever. 



• LECTURE LXXXV. 

Varieties of Continued Fever. Its Causes. Exciting and Predisposing. 

Prophylaxis. 

Having traced, in the last lecture, as clear an outline as I could, of the ordinary 
course and the different terminations of continued fever, I wish to touch, briefly, 
to-day, on some of its principal varieties; and then to inquire into its causes. 

Although fever is, as I have stated, a specific disease, it assumes divers forms ; 
and so dissimilar are some of its phases that they might seem to belong to totally 
different maladies. These variations relate not only to individual cases, but to 
whole epidemics. In some places and seasons, the inflammatory type predomi- 
nates, marked by excitement of the sanguiferous system ; in others, depression of 
the nervous system, characteristic of the typhoid type, is the prominent feature of 
the disease. Most generally of all, the disorder commences with inflammatory 
fever, and ends with typhoid symptoms. The distinctions drawn by Cullen,now 
well nigh obsolete, were founded in nature. To the inflammatory form he gives 
the name of synocha, which he thus defines : " Calor plurimum auctus ; pulsus 
frequens, validus, et durus; urina rubra; sensorii functiones parum turbatas." 
With this he contrasts his typhus. " Calor parum auctus ; pulsus parvus, debilis, 
plerumque frequens ; urina parum mutata; sensorii functiones plurimum turbatee ; 



CONTINUED FEVER. 



967 



vires mnltum imminutas." These forms I would have you bear in mind : not that 
you are likely to meet with many instances of pure synocha, nor of pure typhus, 
but because they furnish standards of comparison, towards which, in opposite 
directions, the fevers of different epidemics approach. The most usual variety of 
continued fever is represented by the synochus of the same author, which is a 
compound of the two others. " Febris ex synocha et typho composita: initio 
synocha, progressu et versus finem typhus." The unsoundness of many of Cul- 
len's theories, and the conceit of later and far inferior writers, have thrown his 
First Lines into undeserved neglect; but his clear, succinct, and faithful pic- 
tures of disease, will not easily be surpassed ; and are worthy of your attentive 
study. 

The difference is very striking between the kind of fever that I witnessed in 
London for ten years before the arrival of the spasmodic cholera in this country, 
and the kind of fever that has since prevailed, and is now (1838) so rife around 
us. During the first of these periods, the antiphlogistic regimen was indispensa- 
ble in the outset of the disease ; in most instances, bleeding, either general or 
topical, was required, and well borne ; there was no eruption to be seen upon the 
skin ; the glands of Peyer, according to my own experience of the fatal cases, 
were almost invariably affected; and the mortality was very moderate. This 
was an inflammatory phase. The present epidemic offers a marked contrast in 
all these points. A large per-centage of those who contract the fever die ; after 
death we seldom detect any disease of the agminate glands of the intestine ; the 
peculiar rash scarcely ever fails to show itself ; we are taught by experience to 
refrain as much as possible from blood-letting ; and almost from the beginning, or 
quite, we find it necessary to sustain our patients by a liberal allowance of strong 
animal broths. The typhoid is now the prevailing type. You might, I say, 
almost suppose that I have been speaking of two distinct maladies. But during 
each of the periods in question, some scattered cases have occurred, bearing most 
of the characters proper to the other period. Moreover, all acute diseases have 
assumed, within the last ten years, in this town at least, an unusually asthenic 
character. So that the differences observed in the aspect and phenomena of con- 
tinued fever, depend more, I conceive, upon an acquired disposition of the human 
body, produced by some obscure general influence, and therefore affecting the 
entire London community, than upon any change in the essential nature of the 
disease, or in the virus which (as I believe) occasions it. 

The inverse relation between the rash, and the intestinal ulceration, is remarka- 
ble. When the one is prevalent, the other is rare. It would seem, in conformity 
with Dr. William Budd's views, that the specific poison displays its elective 
affinities by settling sometimes upon the mucous glands, sometimes upon the 
cutaneous tissues, and sometimes by sharing itself, though unequally, between 
the two. 

I have incidentally alluded to the duration of the fever. In this particular, also, 
there is much variety: a fact which is apparent even to the vulgar, and expressed 
in their ordinary discourse. They talk of the one-and-twenty day fever, and of 
the fourteen-day fever, according as the disorder " takes the turn" in three weeks 
or in a fortnight. It appears from the report made some years ago to the govern- 
ment, upon the state of fever in Ireland, that the fever there generally began to 
depart on the fifth day ; wherefore it was called, in that part of the kingdom, the 
five-day fever. Of the fever patients whom I saw in the Edinburgh Infirmary, almost 
all were fairly convalescent, or dead, before the end of the third week. In this 
place, the disease runs out longer; lasting three, four, or five weeks. I observed 
also in Edinburgh that many of those who recovered had a tedious convalescence, 
in consequence of very troublesome sloughs and ulcers which formed upon the 
sacrum and hips. In London, these bed-sores are comparatively uncommon. 

The symptoms attending the fever seem to vary also, cseteris paribus, accord- 
ing to the season of the year, and the situation of the patient : whether, I mean, 
he be surrounded with pure and cool air, or with a foul and hot atmosphere. In 



968 



CONTINUED FEVER. 



the colder months there is greater risk of inflammatory complications, and espe- 
cially of pectoral affections : in the autumn we look more for diarrhoea or for 
dysenteric complaints, engrafting themselves on the disorder. Where the air is 
close and foul, the symptoms show a much greater tendency to the typhoid type, 
and the deaths are more numerous, than where it is pure. 

It is of great importance to hold correct notions as to the exciting cause of con- 
tinued fever ; respecting which there has been, and there still is, a perplexing 
contrariety of opinion among medical men. You are aware, from what has 
already been stated, that I consider the disorder to originate in an animal poison, 
and to be contagious; communicable, I mean, from one who is labouring under 
the complaint to another who is not. 

When the same disease attacks many persons in the same house or neighbour- 
hood, at about the same time, the popular suspicion soon arises that the disease 
is catching. Yet you know that disorders may be widely prevalent without being 
contagious. Agues, for example, engendered by malaria; ordinary catarrhs and 
sore throats, produced by vicissitudes of the weather. When an epidemic ma- 
lady affects large masses of the people suddenly and at once, it is presumably not 
contagious ; at any rate it must have some other source besides contagion. When, 
on the contrary, it begins in a certain spot, and gradually spreads thence as from 
a centre, the presumption is in favour of its propagation from person to person. 
In investigating this subject, if we trace the fever among persons who have had 
intercourse with the sick, and more frequently in proportion as that intercourse 
has been close and continued ; and if we find that other persons, living in the same 
place, and under precisely the same circumstances, except that they have had no 
known communication with the sick, escape the fever; we have in these facts 
convincing evidence that the disease has been spread by such intercourse ; in one 
word, that it is contagious. 

Have we, then, facts of this kind ? We have, in the amplest abundance. 

We find, even in hospitals, where cleanliness and ventilation are prized and 
enforced, that fever attacks many of the persons who come most often and most 
intimately in contact with those already ill of that disease ; chiefly the nurses, 
next the clinical assistants and the most assiduous of the students, and the medical 
officers ; rarely the other patients, even in the same ward. The separation of a 
few feet, if due regard be had to ventilation, is sufficient to render the poison in- 
operative, by diluting and diffusing it in the surrounding purer atmosphere. Three 
of our nurses in the Middlesex Hospital have fallen ill of fever during the epidemic 
now prevailing; and two of the three have died. I am now attending -a pupil of 
the Charing Cross Hospital, who is persuaded that he caught the fever while 
watching some bad cases of it there. It is only when our wards are unusually full 
of fever patients that these disasters occur ; but they happen very often, indeed, con- 
stituting the rule rather than the exception, wherever many fever patients are col- 
lected together: as in hospitals which are exclusively appropriated to their recep- 
tion, or in the fever wards of certain general hospitals. In such places the effluvia 
which proceed from the bodies of the sick are, in spite of all care, the most 
abundant and the most concentrated. 

Dr. Welch, whose book I have referred to before, has the following statement 
in point. " In this hospital (that is, Queensbnry-House in Edinburgh, which 
was opened for the sole use of fever patients during the prevalence of a severe 
epidemic in that city in the years 1817, '18 and '19), since it was opened (which 
was the year before the time when Dr. Welch was writing), my friends, Messrs. 
Stephenson and Christison, the matron, two apothecaries in succession, the shop- 
boy, washerwoman, and thirty-eight nurses, have been infected; and four of the 
nurses have died. With the exception of but two or three nurses, who have been 
but a short time in the hospital, I am now the only person who has not caught the 
disease, either here, or at the infirmary, within the last eight or ten months." 

I may quote a passage from Dr. Alison, in illustration of the same thing. He 



EXCITING CAUSE. 



969 



is speaking- of a more recent epidemic which occurred in Edinburgh in 1827 and 
1828. He says: "During this epidemic, as well as that of 1817-19, many of 
the clerks and nurses employed in the Royal Infirmary have taken fever. Since 
November last, six of the clerks employed in the clinical wards only, four of those 
employed in the ordinary wards, and twenty-five nurses or servants, have taken 
fever. All these persons had necessarily frequent and close intercourse with the 
fever patients in the house, having been employed more or less constantly in the 
fever wards, excepting only four of the servants. Of these four two had been 
employed in the laundry where the linen from the fever wards was washed ; one 
was a porter employed at the gate, who would of course have communication 
with the fever patients at their entrance or dismissal, as well as with their relations 
coming to visit them ; and one was a nurse employed in the servants' ward, but 
who was in the habit of visiting the fever wards." Now mark the contrast. He 
adds, that "in this very place and season, those of its inhabitants who have not 
had intercourse with fever patients have almost uniformly escaped the disease. 
Of the inhabitants of the ground floor of the house, (including patients in the 
lock-ward,) none but those already mentioned as having washed the linen from 
the fever wards, and the barber who shaved the heads of the fever patients, have 
taken the disease. Yet in the case of malaria" (to which I must apprize you 
that many medical men of great authority ascribe the occurrence of continued fever), 
" it is the ground floor of the house that is generally found the most dangerous. 
No one of the nurses, whose duty has confined them to the medical or surgical 
wards where no fever patients were admitted, has taken fever, with the single 
exception of the woman in the servants' ward above mentioned. And of the 
numerous patients in these ordinary wards, the only one who has taken the fever, 
within my knowledge, during the present year, was a patient in the men's general 
clinical ward, who lay in the bed next the door that communicates with the clini- 
cal fever ward. If there be malaria in this house, therefore, it would seem to 
restrict itself in point of space, as at Queensbury-House in point of time, to the 
immediate vicinity of fever patients." To understand this last remark you should 
know that, in ordinary years, the inmates of Queensbury-House escaped fever. 

We have similar testimony nearer home ; in this metropolis. " Every physi- 
cian connected with the London Fever House, with one exception (writes Dr. 
Tvveedie), has been attacked with fever; and three out of eight have died of it. 
Also the resident medical officers, matrons, porters, laundresses, domestic servants 
not connected with the wards, and every female who has performed the duties of 
nurse, have, one and all, invariably been the subjects of fever. And to show that 
the disease is capable of being engendered by fomites, or clothes, the laundresses, 
whose duty it is to wash the patients' clothes, are so invariably attacked with 
fever, that few women will undertake the loathsome and disgusting office." 

Now, it is in vain to attempt to escape from this kind of evidence, by saying 
that the situation of the Fever Hospital is infested with some local miasm ; for 
the inmates of the Small-pox Hospital, which is immediately adjacent to it, are 
not affected in this way with continued fever, but remarkably exempt from it, as 
Dr. Gregory testifies. 

Evidence of a somewhat different kind, but leading to the same conclusion, is 
to be found in the fact, that when persons, having the fever upon them, are trans- 
ferred to some distant spot that was previously free from fever, they frequently 
form centres from which the disease begins, thenceforward, to spread. It is im- 
parted, in this way, even in the country, from family to family, and from village 
to village. 

I was summoned home from Edinburgh on account of my mother's serious 
illness with continued fever. She was living in a village where there was little 
or no fever prevailing. While she was recovering my sister took the disease, and 
had it severely. It had evidently been introduced into the house by a man-servant, 
whose family lived in a neighbouring village. This family had the disease raging 
in their house, and he was in the habit of going thither occasionally, and always 



970 



CONTINUED FEVER. 



of sending his linen to be washed there. He first, in onr house, had the disorder, 
then two of the maid-servants, and next my mother. 

The cook of Trinity College, Cambridge, living in a street called the Petty 
Cury, had a daughter in London who fell ill with continued fever, and who in- 
sisted upon going home. At that time there probably was no case of fever in 
Cambridge : certainly none in the Petty Cury, as Dr. Haviland (who gave me 
the account) satisfied himself by inquiry. The girl was very ill indeed, after she 
reached her father's house ; but she ultimately recovered. Every inhabitant of 
that house, except an old, seasoned nurse, became affected with the fever; and 
three or four of them died. But no fever existed in the other houses of the same 
street. When one of the sick persons was convalescent, it was thought her reco- 
very might be accelerated if she were put into a lodging at Trumpington, a small 
village two or three miles from Cambridge, in which there certainly was then no 
fever. Here she and the old nurse were waited on by a servant belonging to the 
Trumpington House. That servant soon sickened of the fever, and was sent to 
Addenbrook's Hospital, where she died. 

Take one more instance to the same effect, related by Dr. Alison. " Some 
years ago, at a time when there was no great number of fever cases in Edinburgh, 
I met with a case in the son of a shoemaker, who was lying in a room in which 
his father and two apprentices were at work. I could not prevail upon the father 
to remove his son to the hospital, although I stated the danger of the apprentices 
being affected. Within two or three weeks after, I found that the two apprentices 
were lying ill of fever in their own houses : one of them two hundred yards, the 
other half a mile distant from the workshop, and widely distant from each other. 
These young men likewise lay at home during the fever; and each of their cases 
was speedily followed by a succession of others in the inhabitants of the rooms 
which they occupied, and of those immediately adjoining, who had never been at 
the workshop. In one of these houses seven, and in the other twelve, were thus 
affected. Now, on the supposition of the fever being contagious, all this was to 
be expected, and all corresponded to the predictions which were hazarded on that 
belief. But on the supposition of such succession of fever cases depending on 
miasmata, there must have been at least two, more probably three, separate and 
accidentally concurring miasmata to explain the phenomena here observed ; one 
at the workshop, and one at each of the houses of the apprentices : and there 
must have been this extraordinary coincidence, that at each of these last the ma- 
laria sprung up just at a time when a patient was lying ill there of fever, which 
he had apparently contracted elsewhere. Further, the three houses in which 
these successions of fever cases were observed, are in situations very different 
from one another; and all of them have been, to my knowledge, perfectly free 
from fever for years together, both before and since that time, notwithstanding 
that fever has been much more generally prevalent, and that they have been in 
..habited by successive families. What probability is there (continues Dr. Alison 
that three separate miasmata should have arisen in these three houses, just at th 
time when their presence was required in each to produce an effect which ha 
been foretold as the consequence of another cause undeniably operating on all?" 

If we contrast facts such as I have been advancing, with other cases, in whic 
all the circumstances appear to have been precisely the same, except the presenc 
of the alleged cause of the disease — making our observations always upon as larg 
a scale as possible — we approach, as nearly as the subject will admit of, to a de 
monstrative proof that continued fever spreads by contagion. 

The reports which were made by the accredited physicians, to a committee o 
the House of Commons, respecting epidemic fever in Ireland, contain abundan 
and valuable evidence on this point also.' Dr. Cheyne states that the farmers an 
householders in some parts of Wicklow, who would not harbour or admit int 
their houses strolling persons, nor go to wakes or funerals, remained free from th 
disease. In Ballytore a committee was formed of persons who took pains to in 
struct the inhabitants as to the precautions to be observed against infection: sue 



EXCITING CAUSE. 



971 



as refusing admission to wandering beggars, absenting themselves from wakes and 
other assemblies; and even, under certain circumstances, from places of worship. 
These precautions were so effectual that not a case of fever occurred. Four vil- 
lages in the neighbourhood of Lismore are stated by Dr. Barker to have been 
preserved from the fever, chiefly by the exertions of some Roman Catholic cler- 
gymen, who persuaded the inhabitants to avoid all communication with Lismore, 
and with another town in its vicinity, where the fever was rife. 

It was observed also that bodies of persons collected together, and fenced about 
by barriers which precluded intercourse between them and places infected with 
the fever, remained exempt from it ; children in charity schools, soldiers in bar- 
racks, and even prisoners in the jails. In the same parliamentary report you may 
see a letter from Dr. M'Donald, who had established a fever hospital at Belfast, 
which hospital alone, at one period, contained 190 cases of typhus. Very near 
the hospital was a school, containing 700 or 800 young persons ; a poorhouse 
with 300 inmates; and a barrack with 1000 soldiers. These places were never 
more free from fever than at that time. 

Facts to the same purpose abound in the medical reports of the army and navy. 
Those of the navy are especially valuable and instructive in this matter, because 
the whole of the circumstances in which the patients are placed come under the 
certain and immediate cognizance of the medical officers superintending them. I 
cannot go into particulars here, but must content myself with referring you to 
the writings of Dr. Lind, Sir Gilbert Blane, and Dr. Trotter. You will there 
find that ships which had, for a great length of time, been quite free from fever, 
have had that disease spread rapidly from one individual, recently imported, so as 
to affect almost all the crew. This was often the case when raw recruits were 
drafted from the receiving ships. It appears, from reports made to Dr. Trotter 
by different naval surgeons, and published in his Medicina Nautica, that the fever 
was conveyed to a great number of vessels forming the Channel Fleet, from the 
receiving ship called the Cambridge. 

It is, moreover, found, that when persons ill of fever are taken away from their 
own close and crowded houses, and when means of purification are employed, the 
fever ceases to spread in those houses. This well-ascertained fact it is which 
gives to fever hospitals their greatest, nay, almost their only value. Thgy would 
otherwise, as we have already seen, be detrimental or dangerous to all concerned 
with them, by concentrating the poison that produces the fever; without equiva- 
lent benefit. As it is, they cause, indeed, a certain amount of disease and of death; 
but by affording opportunities for cleaning an infected neighbourhood of the seeds 
of the fever, and by so preventing its diffusion among a large and healthy com- 
munity, they save many more lives than they sacrifice. 

You may be surprised that I should appear to labour this point ; and should 
take so much pains to prove what may seem to you, as I confess it seems to me, 
to be an undeniable proposition. But I do so because many have denied, and do 
still deny it ; and plausible reasons are given, by men of name and character, for 
discarding altogether the notion of continued fever being propagated by contagion. 
Some even, who have begun by expressing their belief that the disorder was con- 
tagious, have ended by becoming strong, ay, violent anti-contagionists. The late 
Dr. Armstrong was one of these ; and there are living men, of high and deserved 
repute, both in this country and abroad, who hold what I cannot help thinking 
erroneous — and if erroneous, then manifestly dangerous — opinions on the subject. 
Chomel informs us that not one in a hundred of the profession in Paris believes 
that typhoid fever is a communicable disease. Upon a subject so important it is 
right that you should be furnished with data for forming a correct and settled 
judgment. But I scarcely expect that the facts I have now brought forward will 
carry the same conviction to you all ; for I agree with Dr. Christison in believing 
that the discrepancy which exists upon this, as upon some other controverted 
questions, depends, in part, upon the different constitution of men's minds, and 
their peculiar habits of thought. Most of the anti-contagionists whom I have 



972 



CONTINUED FEVER. 



known have belonged to that party in this country which advocates what are called 
liberal opinions in politics and in religion. If this should prove to be generally 
true, it must be regarded as a curious psychological fact. 

I have laid before you some of the positive evidence which goes to prove the 
contagiousness of continued fever. You may naturally ask, and it is but fair that 
I should tell you, what are the arguments on the other side of the question. 

First, then, it is asserted that continued fever cannot be contagious, because 
some, nay many persons, who have intercourse with the sick, do not contract the 
disease. 

But the force of this reasoning is completely broken by the well-known fact that, 
in respect to diseases which are on all hands acknowledged to be contagious, and 
which are even propagable by inoculation, small-pox for example, the same kind 
of exemption notoriously happens. Some of those who so escape may have had 
the fever before; and have thereby become less capable of being re-infected by 
the poison. I believe it to be uncommon for a person to have genuine continued 
fever for a second time, unless he is exposed to the contagious matter in a very 
concentrated state, or for a long time together. Some may, by original peculiarity 
of constitution, be proof against its power; but probably in most cases, the im- 
munity arises from the circumstance that the person has been fortunate enough, or 
careful enough, to escape imbibing an effective dose v of the poison. You may 
breathe, for a good while, without much hazard, an atmosphere but faintly imbued 
with the contagious effluvia; and you may, though with somewhat more of 
hazard, breathe, for a short time, air which is strongly tainted by them, and yet 
go free. 

Allowance must also be made, in some cases, for the effect of habit in fortifying 
the system against contagion. Persons who are much and often exposed to these 
effluvia, are thereby seasoned, in some degree, to the noxious atmosphere : just as 
drunkards and opium eaters become at length impassive under such a dose of 
their customary stimulus as would intoxicate or stupefy a novice. Upon this 
principle has been explained the comparative immunity from contagious diseases, 
(under like circumstances of exposure,) of medical practitioners, and nurses; of 
the keepers of filthy lodging-houses, while the new-coming inmates suffer; and 
even of prisoners, who, without having had the disease themselves, may never- 
theless carry forth and communicate the infection: as is said to have happened at 
the celebrated " black assizes" in Oxford ; and again at the Old Bailey in the 
year 1750. 

This argument, that the fever cannot be contagious because many of those who 
come near the sick are not affected with it, has been happily ridiculed by com- 
paring an epidemic to a battle. A man might say, " I was in the battle of Water- 
loo, and saw many men around me fall down, and die, and it was said that they 
were struck down by musket balls ; but I know better than that, for I was there 
all the time, and so were many of my friends, and we never were hit by any 
musket balls. Musket balls, therefore, could not have been the cause of the deaths 
we witnessed." And if, like contagion, they were not palpable to the senses, 
such a person might go on to affirm that no proof existed of there being any such 
things as musket balls. 

It must not be forgotten that this same argument, whatever may be its validity, 
is equally potent against any other general cause : against local miasms ; against 
an undefined something in the air. 

Again, the disorder does not spread, say they, in the houses of the rich. But 
why should it not do so, if it proceeds from any cause which strict attention to 
cleanliness and ventilation does not disarm ? The fact, when rightly considered, 
is a strong circumstance in favour of the theory of contagion. 

But then the disorder often occurs when we can trace no contagion : and the 
full answer to this argument is to be found in the fact that the same difficulty 
applies to diseases which are not only confessedly contagious, but which are be- 
lieved to have, now, no other source than contagion ; even, as I showed you before, 



ALLEGED CAUSE. 



973 



to small-pox. All that the argument can amount to, is a presumption that the 
distemper may sometimes originate independently of contagion. A person may 
be exposed to the agency of the contagious matter quite unconsciously, by coming 
into contact with fomites, or by approaching another person who is just conva- 
lescent from the disease. A nobleman died here, in the prime of life, last year, of 
scarlet fever. The story goes that he had just come to town, and was dining out, 
and by his side sat a young lady who had just recovered from that complaint; 
and that from her he unwittingly received it. In such a place as this there are a 
thousand unsuspected ways in which contagion may be disseminated. It may 
lurk in a hackney coach ; you may catch the complaint from your neighbour in 
an omnibus, or at the theatre, or at church ; your linen may be impregnated with 
the subtle poison in the house of your laundress ; or your coat may convey it from 
the workshop of your tailor. So that, when continued fever occurs, it is very diffi- 
cult indeed to be sure that it has not arisen from contagion ; and it becomes a very 
interesting question whether the disease ever proceeds from any other cause. It 
is, however, of primary importance to determine whether it be, or be not, com- 
municable. By our belief in this matter the lives of our neighbours and clients 
may be saved, or lost. Even if we doubt about the contagiousness of the disease, 
we are bound to act as if we had no doubt upon the subject; and I would ad- 
monish you (although that is a lower ancl poorer motive) that your own reputation 
and success may be endangered by mistakes in this very thing. I have been told 
of one instance which may serve as a warning. A lady came from the country 
to London, to see a sister, who was ill of fever. She asked the medical attendant 
if there was any danger of infection. He happened to be a staunch non-conta- 
gionist; and he said "no danger whatever." Upon the faith of that assurance, 
the lady resolved to sit up with, and to nurse her sister; but she fell sick herself 
of the disease, and died. I believe this did not shake the medical man's opinion. 
He attributed the mischance to some local miasm. But he could not persuade 
the lady's friends of this. They maintained that her death lay at his door; and 
whether they were right or wrong, the affair was so much talked of, and was so 
injurious to him, that he was obliged to leave that part of the town, and to seek 
for practice elsewhere. 

Many sporadic cases occur of febrile disorder, which do not belong to the 
category of continued fevers, and yet are liable to be confounded with them. All 
the phlegmasiae are attended with pyrexia, and the local inflammation may be 
slight, or very obscurely marked, and easily overlooked ; but the febrile symptoms 
are much the same as those which constitute the more inflammatory forms of 
continued fever. In like manner severe bodily injuries, compound fractures, for 
example, sometimes give rise to constitutional symptoms precisely resembling the 
most prominent phenomena of its typhoid forms. Excluding all such spurious 
resemblances of the genuine disease, I confess my own opinion to be, that con- 
tinued fever, like small-pox and measles, originates, in all cases, from a specific 
poison. With respect to all these disorders, I conceive that, in every large com- 
munity, there is constantly kept up a sufficient stock of contagious matter, to act 
as a sort of leaven, whenever circumstances favourable to the development of the 
disease, as an epidemic, may chance to arise. 

Continued fever has been ascribed, by those who deny its origin in contagion, 
to certain other causes; some of which demand attention, not merely on account 
of the interest that belongs to the whole inquiry, but also because they really are 
important agents in the extension of the disease. 

First, then, it was, and is, a common belief, that continued fever may be gene- 
rated by the effluvia constantly proceeding from the human body, even when 
healthy, if these effluvia be accumulated and condensed by the crowding together 
of many persons in close, dirty, and ill-ventilated places. It is unquestionable 
that, when once introduced, the disease spreads, under such circumstances, with 
fearful rapidity ; but the point at issue is whether it be ever so caused de novo. I 
must refer you, for good evidence that it is not so engendered, to Dr. Bancroft's 



974 CONTINUED FEVER. 

book on the yellow fever. He shows that typhus fever does not spring up in 
places where it could scarcely fail to appear if that theory were true. He in- 
stances the natives of the arctic regions, who in order to shelter themselves 
against the extreme cold of their climate, live during the greater part of the year 
in close subterraneous dwellings, from which the fresh air is studiously excluded, 
and of which the atmosphere becomes so offensively foul as to be scarcely sup- 
portable by a stranger: yet continued fever is not known among them. A similar 
exemption from that disease is observed within the tropics, in the African slave 
ships, where " the poor wretches are crowded together below the deck, as close 
as they can possibly lie, in a sultry climate, barred down with iron to prevent in- 
surrection." Although many of them die from suffocation, and from fluxes, yet 
Dr. Trotter, who was himself, at one time, surgeon to a slave ship, declares that 
"contagious fevers are not their diseases." Dr. Bancroft quotes also a narrative 
of the sufferings of 193 Europeans, who, during the time of the French Revolution, 
were "deported" to Cayenne, in the Decade frigate. They were crowded, and 
even squeezed together, in so small a space, and for so long a time, that the sen- 
tinels, who were placed at the hatchways to guard them, and who were thus ex- 
posed to the hot and fetid air which came from their hole of confinement, demanded 
that their period of offensive duty might be shortened. Yet none of these miserable 
persons perished, nor did fever, properly** so called, arise among them. Neither 
did that distemper present itself in any of the survivors of the Black Hole at Cal- 
cutta ; the frightful account of which, by one of those survivors, Mr. Howell, is 
abstracted in an appendix to Dr. Bancroft's work. 

Fever used to infest our English jails ; but that it was always imported, and 
never engendered there by filth and defective ventilation, and by the accumulation 
of human effluvia, may be concluded from the fact that the benevolent Howard, 
when he visited the prisons on the continent, found, to his great surprise, that 
they were free from fever, although they were no less close, crowded, and impure 
than our own. He brings the result of his observations and inquiries concerning 
the cause of the jail-fever, to this pointed conclusion : — " If it were asked," says 
he, " what is the cause of the jail-fever, it would in general be readily replied, 
the want of fresh air and cleanliness ; but as I have found in some prisons abroad, 
cells and dungeons as offensive and dirty as any I have observed in this country, 
where, however, this distemper was unknown, I am obliged to look out for some 
additional cause for its production" — which additional cause can be no other than 
the contagious poison emanating from the bodies of those who have the fever. 
It is true that fever is most frequently met with, and most rapidly propagated, 
where men are crowded together, in jails, or in close and ill-ventilated places; 
but this affords no reason for supposing that it is ever generated there, any more 
(to use a homely illustration of Dr. Bancroft's) than the general prevalence of lice 
and other parasitic vermin in such places, proves that these vermin are generated 
by filth, by pent-up human effluvia, and want of ventilation, instead of being 
merely fostered thereby. 

Again, continued fever has been attributed, with great confidence, to a vitiated 
state of the air, from the putrefaction of dead animal and vegetable substances. 
Dr. Bancroft deals with and demolishes this error also: showing that neither the 
putrid atmosphere of dissecting-rooms (respecting which you must have some 
personal experience), nor the noisome effluvia from full and ill conducted burial- 
grounds, nor those to which tallow-chandlers, soap-boilers, glue and cat-gut makers, 
and the melters of whale-blubber are exposed, nor the foul air of sewers and privies, 
have ever been known to produce anything like continued fever. In some parts 
of Essex, near the coast, where the farmers are in the habit of manuring their 
fields with shoals of sprats, I have seen large tracts covered with these fish in a state 
of putrefaction. The stench they occasion is horrible ; but no disease results. 
Dr. Chisholm, in a paper to which I can only refer, but which I would recommend 
you to look at, in the sixth volume of the Edinburgh Medical and Surgical 
Journal, brings forward other, and very satisfactory, instances, to the same purpose : 



ALLEGED CAUSE. 



975 



from a bone manufactory, near Britton, in Gloucestershire ; from an establishment 
(now relinquished) on the banks of the Avon, for converting the flesh of dead 
animals into adipocire ; from manufactories for refining sugar, where the blood of 
slaughtered animals is kept for that use by butchers ; from the leather-dressing 
business ; — all tending, I say, to the conclusion, that air, contaminated by the 
decomposition of animal substances, is not necessarily noxious to life; still less 
productive of that specific disease which we are now considering. The old belief, 
therefore, was unfounded, that the exhalation from the dead and putrefying bodies 
of men and horses, lying unburied on the field of battle, is capable of producing 
a pestilence. Many instances to the contrary are on record : one, of an early date, 
is thus stated by Diemerbroek : — " Anno 1642, in agro Juliacensi maxima strages 
facta est, et ad minimum 8000 militum occisi fuerunt, praeter majorem adhuc 
famulorum, rusticorum, aurigarum, puerorum et mulierum numerum, atque equo- 
rum copiam innumerabilem ; corpora inhumata sub dio computruerunt, nulla tamen 
peslis insecuta est." 

It has been said that fever is produced by some unknown condition of the air, 
imperceptible by our senses, but distinct from contagion. I believe this is a very 
popular notion ; but it is perfectly gratuitous and untenable, and inconsistent with 
observed facts. You may have fever raging in certain parts of a town, and yet 
the parts in the immediate vicinity of these be quite exempt from it. Now this 
could hardly be, if there were some general property diffused through the atmo- 
sphere capable of engendering continued fever; and, as I stated before, this notion 
is severely pressed by one of the arguments which the non-contagionists them- 
selves are fond of employing. If the disease depend upon contagion, some persons 
in the community may come less near the sick, or imbibe a less dose of the con- 
tagious poison, than others, and so escape : but if the cause of fever were spread 
abroad throughout the whole atmosphere, all must be exposed to its influence, 
and few, we may suppose, could avoid suffering from its operation. 

Exposure to cold is another cause to which fever has been sometimes attributed. 
But this is an agency so widely prevalent that if it alone could excite fever, that 
complaint would be far more general than it really is, and we should be able to 
trace it oftener and more distinctly than we can, to the alleged cause. That, by 
its debilitating effect, cold will predispose the body to be affected by the contagion 
of fever, I well believe : and the same remark is applicable to another cause that 
has been assigned; namely, deficiency of nourishment. Dr. Alison, in his admi- 
rable essay On the Management of the Poor in Scotland, has clearly proved 
that the prevalence of contagious fever amongst the lower orders is always in direct 
proportion to their state of physical destitution. The association of pestilence 
with famine is proverbial. But we do not find that continued fever is ever created 
by the mere want of nutriment. In persons who have sought to starve themselves 
to death — among sailors who have of necessity been kept upon very short allow- 
ances of food — in cases of insulation by snow storms, or by the accidental closure 
of a mine — we find, indeed, that disease is produced by the privation of nourish- 
ment; but it is not continued fever. The condition into which the sufferers are 
brought is more like scurvy. So that although a want of sufficient aliment may 
be, and doubtless is, a powerful auxiliary in promoting the effect of the conta- 
gious poison, there is no ground for supposing that it ever primarily or solely 
occasions fever. 

In fact, all the circumstances which I have now been considering act as predis- 
posing causes. They render the human body an easier prey to the real exciting 
cause, which is a specific animal poison. You will remark that they are all debili- 
tating circumstances ; and where several of them co-exist, their joint influence in 
subduing the system, and bringing it into subjection to the contagion, is very 
great. For the same reason, depression of spirits, however produced, has a strong 
predisposing effect; as strong, perhaps, as any other single cause. Of this I have 
seen, if I mistake not, some remarkable examples. Upon this principle we may 
explain the fact, that continued fever is especially apt to attack those of the lower 



976 CONTINUED FEVER. 

classes who have recently come to reside in the metropolis ; who are often living 
anxiously, and with persons to whom they were not previously known. We have 
had numerous opportunities, in the hospital, of noticing this curious circumstance; 
and it is mentioned by almost all the French writers on fever. To the same prin- 
ciple also we must attribute the tendency to fall down in fever, observed in young 
soldiers and sailors. You will find statements to that effect in Dr. Trotter's 
works, and in those of Dr. Lind and of Sir Gilbert Blane. When fever appears 
in a ship, the raw sailors are always the soonest attacked by it: and it is the 
same with the recruits in the land service. In a defeated, dispirited, or retreating 
army, its ravages are often frightful. Here we have, combined, fatigue, a defi- 
ciency of wholesome food, and mental depression. 

However paradoxical the assertion may seem, a predisposing cause may even 
be applied, and operate, after the exposure to the exciting cause — and so render 
the latter effective when it might not, otherwise, have been so. Dr. Russell ob- 
served the plague sometimes to "hang ambiguously" about persons for several 
days. In this state, an overheated bath, or a sudden impression of fear, especially 
fear of the disease, has roused the lurking poison into activity. It is a suggestion 
of Dr. Henry's that atmospheric variations may call into action contagious poisons 
already admitted into the system, but not yet manifested by the usual phenomena; 
and, operating thus over a wide space, and upon numbers at once, may occasion 
those sudden and violent outbursts of epidemic disease, of which numerous exam- 
ples are on record. 

You must, I think, perceive the importance of distinguishing between the one 
exciting cause and the many predisposing causes of fever. The latter are gene- 
rally beyond our control. We cannot hope to remedy extensive destitution ; nor 
to separate it effectually from its concomitants of filth, and despondency of mind. 
But we may, by timely diligence, root out the specific contagion, or confine it 
within narrow bounds. When the sick can be at once removed from their crowded 
homes to a fever hospital, and their impure apartments ventilated, cleansed, and 
whitewashed, the disease may often be kept in check, if not entirely stopped ; and 
the yet healthy persons of the infected district be preserved from its grasp. For, 
as I stated before, there is reason to believe that the poison, unless pent up, does 
not remain active at any great distance from the person from whom it proceeds; 
not even many yards, or feet. It is very rare, I apprehend, to meet with instances 
of the disease being communicated in the open air. It is almost always caught, 
if at all, in the interior of houses. It is extremely uncommon for it to extend from 
one bed to another in our general hospitals, where great attention is paid to clean- 
liness and ventilation. The noxious qualities of the poison are diminished, and 
at length destroyed, by its dilution with common air, just as those of other gaseous 
poisons are: and hence, in private houses, in the better ranks of society, where 
the rooms are spacious and airy, and proper precautions are taken, the disease 
hardly ever spreads. 

What are those proper precautions ? They are simple, and may be stated in a 
very few words. 

Where choice can be made, a large apartment should be selected for the sick 
person. Unless the weather be very hot, there should be a fire in the room, for 
it acts as a ventilator. The air of the chamber should be kept fresh by having a 
window, or a door ^according to the weather) always open: or both window and 
door. Bed and window curtains, carpets, and all superfluous articles of furniture, 
should be removed. Great diligence should be used in keeping the patient clean, by 
the requisite ablutions, and by frequently changing his sheets and his body linen ; 
and these should be immersed'at once in water; and all discharges from the sick 
person's body should be instantly carried out of the room. 

All unnecessary intercourse with the patient, by his family and friends, should, 
for his sake as well as theirs, be forbidden. As life advances, the susceptibility 
of the disease appears to diminish : for which reason the nurses and personal 
attendants of the patient should not be very young: and all who do approach the 



TREATMENT. 



977 



sick bed should lake care to avoid, as much as possible, inhaling the patient's 
breath, or the emanations which proceed from his person. Friends who visit the 
apartment at intervals only, should never enter it fasting. 

And you may, if you please, employ the chloride of lime as a disinfecting 
agent, in aid of the simple measures I have just recommended ; but by no means 
instead of them. People hang a bag of camphor round their necks, and think 
themselves safe against infection. The mental confidence which that expedient 
is calculated to inspire, may perhaps afford some degree of protection ; but cam- 
phor has, in reality, no prophylactic virtue; and all these artificial scents are 
objectionable, inasmuch as they tend to conceal offensive odours which might 
otherwise reveal the actual danger. 

I shall speak of the treatment of continued fever when we next meet. 



LECTURE L XXXVI. 

Continued Fever, concluded. Treatment. Small-pox. lis essential symptoms. 
Distinction into discrete and confluent. Periods and modes in which it proves 
fatal. 

The treatment of continued fever has been, at all times, a stumbling block to 
young practitioners; and a subject of dispute even among physicians who have 
built it upon their own -experience. Before I attempt to trace out any plan, or to 
lay down any principles for your guidance, it may be useful to inquire how it 
happens that ihe practice in this disease has been so fluctuating and unsettled. 

In the first place, then, it is very difficult to estimate the value and efficacy of 
any particular plan of treatment, and still more of any particular remedial sub- 
stances, in this disease. Continued fever, like other disorders which run a defi- 
nite course, and have no direct or necessary operation in spoiling the structure of 
vital organs, has a strong natural tendency to terminate in health. We see this 
tendency when the disease is left entirely to itself, and it equally exists when 
remedies are employed to regulate its course, or to abbreviate its duration. No 
one can doubt, who has had much experience in fever, that this tendency is some- 
times thwarted by the nimia cura medici; and that patients get well in spite of 
the well-meant but mischievous interference of the doctor. This tendency to 
recovery is a constant source, therefore, of fallacy in our observations upon the 
behaviour of this disease under different plans of treatment; and upon the effects 
and utility of remedies. It leads us, too often, into the danger of ascribing to 
drugs what is really due to the workings of nature: of confounding antecedents 
and sequences with causes and effects ; of counting recoveries as cures. And 
this danger is increased by the circumstance .that continued fever, although it 
observes a certain definite course, is nevertheless liable, even when left altogether 
to itself, to sudden and remarkable changes in the symptoms, sometimes for the 
worse, and sometimes for the better; and often we cannot perceive any obvious 
reason for these fluctuations. But if this happen when no medicine is given, so 
also will it happen when the disease is submitted to treatment; and it requires 
more than a little care and discretion to avoid attributing the changes which so 
occur to remedy which was last employed. For example, the abatement or 
cessation of headache, after a few days have elapsed, is a natural phenomenon : 
whereas an inexperienced or a careless person might easily persuade himself that 
it had yielded to his method of treatment, and that it was a favourable omen : 
neither of which conclusions would, however, be warranted by the circumstance 
upon which it was founded. 

There is yet another source of difficulty connected with this subject. I have 
shown you that not only individual cases of fever, but different epidemics, vary 
62 



978 



CONTINUED FEVER. 



much in their character; so that a plan of treatment which was well suited to 
one epidemic, may be improper and even hurtful if indiscriminately applied in 
another. 

These considerations may serve in some measure to teach us how it has happened 
that so many different, and sometimes opposite remedies and modes of treatment 
have been recommended by different practitioners for the cure of this disorder. 
The tendency to a termination in health was very plainly visible in the epidemic 
fever in Ireland, to which I have more than once referred. The mortality among 
the patients who were placed in sheds upon straw, with very little medical care, 
and even without any great personal attention from others, was very small indeed. 
No one can form even an approximate judgment of this tendency, who has not 
s*een the disease under several varieties of practice. Doubtless one rule which 
we derive from a clear perception of the same tendency is, that we should not 
interfere unnecessarily . Aoxsiv rcspo vovc^/xata 5i;o,(says Hippocrates) q^exsecv, 
rj (ivi phartttw. There are two things to be considered in the treatment of diseases : 
first, that we do the patient good ; secondly, that at least we do him no harm. 
In all these exanthemata, he must be reckoned the safest and the best practitioner 
who knows when to abstain from acting, as well as when to act ; in other words, 
who has learned when, and to what extent, the case may be left to the salutary 
processes of nature. 

However, there is an opposite error to that of mischievous activity. The tend- 
ency to recover which manifests itself under different modes of treatment, and 
even in spite of opposite modes, has induced, in some minds, a degree of scepti- 
cism as to the utility of any remedies, that may easily be carried too far. It does 
not follow, because the majority of patients under continued fever would at length 
emerge into health, although no remedial measures were employed, that the dis- 
ease ought therefore to be abandoned to what Cullen calls the vis medicatrix 
naturae. It is not quite correct to say, with the older pathologists, that the whole 
disorder is merely an effort of nature to throw off something noxious to the sys- 
tem, and therefore is not to be interfered with. The true view of the matter I 
apprehend to be that which a toxicologist might take. The disease is produced 
by a poison of which the injurious impression upon the animal economy at length 
ceases, or passes off, of itself; in the same manner, only more slowly, as the 
influence of a dose of opium will spontaneously pass away. But during the natu- 
ral course of the fever, as in many other cases of poisoning, morbid processes are 
apt to be set up, which, if suffered to proceed unchecked, would inflict irreparable 
injury upon important organs, and which are fairly within the scope of remedial 
management. Our object must be, when the fever is once established, to conduct 
it to a favourable close ; to " obviate the tendency to death." Upon this point I 
agree most entirely with Pitcairn, who, being asked what he thought of a certain 
treatise on fevers, declared, " I do not like fever curers. You may guide a fever; 
you cannot cure it. What would you think of a pilot who attempted to quell a 
storm 1 either position is equally absurd. In the storm you steer the ship as well 
as you can ; and in a fever you can only employ patience and judicious measures 
to meet the difficulties of the case." 

When some immediate change ensues in the symptoms or in the feelings of 
the patient upon the administration of remedies that are generally followed by 
sensible effects, we are warranted in ascribing the change to those remedies. But 
even here comes in the fallacy already noticed, arising from the sudden and spon- 
taneous changes that are apt to occur in fever: and this fallacy is to be got over 
only by multiplying our observations. 

After all, the best guide that you can have in determining upon the general 
principle of treatment in a given epidemic, or even in an individual case, is that 
which Dr. Alison has so ably enforced in his lectures and in his writings upon 
this subject. I mean the observed tendency to this or that mode of dying. The 
manner and circumstances of the deaths are of more practical importance than of 
the recoveries. 



TREATMENT. 



979 



After briefly passing in review some of the principal remedies that have been 
employed and recommended for this disease, I propose to sketch the plan which 
I am myself in the habit of pursuing in the management of fever patients. 

It was once a favourite practice with physicians to attempt to cut short the fever 
at its outset: and the two expedients which were chiefly relied upon for that pur- 
pose were emetics, and the cold affusion. They have both of them, in this coun- 
try, gone very much out of fashion. In truth, neither reason nor experience 
encourages us to look for such a result from such measures. If fever depend (as 
I believe it does) upon a poison in the blood, it is not to be dislodged by the act 
of vomiting, nor washed out by the forcible descent of cold water upon the skin : 
and in the few instances in which the one or the other of these remedies may have 
seemed to arrest a fever, or to check its progress, that effect has always occurred 
at the very commencement of the complaint: so that we cannot be sure (and the 
probability lies the other way) that these were really cases of fever at all, or that 
they would not have ceased even if nothing had been done for them. Perhaps 
emetics may, in the present day, be too much neglected. I have no notion of their 
stopping the fever; but when given early, especially if gastric disturbance is a 
prominent symptom, they are sometimes followed by a marked abatement of many 
morbid sensations. " It is astonishing," says the observant Sydenham, " how it 
happens, that a vomit, which does not produce either a large or a morbid dis- 
charge from the stomach, should so materially relieve the nausea, restlessness, 
anxiety, and furred tongue of the patient." 

The cold affusion is not more effectual in cutting fever short than the treatment 
by emetics ; and it has these great disadvantages, that it fatigues and alarms the 
patient: and when the vital powers are naturally feeble, or are much depressed 
by the disease, the very shock of the affusion may be attended with injurious 
consequences. * 

A modification of this expedient is, however, often of great use in abating the 
morbid heat, and soothing the uneasy feelings of the patient. I mean the prac- 
tice of cold or tepid sponging of the surface. This is one of the remedies which, 
when the symptoms appear to indicate it, deserves to be tried ; and the propriety 
of continuing or of discontinuing it may be determined by a very simple test ; 
namely, the feelings and wishes of the patient himself respecting it. It is most 
adapted to the more inflammatory, and least adapted to the more typhoid types of 
the malady. 

Great controversies have been maintained in regard to the effect of blood-letting 
in fever. They who hold that the fever consists in a general disturbance of the 
system, growing out of some local inflammation, and they especially who believe 
that continued fever is nothing else than inflammation of the brain and its mem- 
branes, would naturally seek to cure it by the remedies of inflammation. But 
although local inflammation, and even itflammation of the brain, is very apt to 
spring up in the course of contined fever, there is no reason for thinking that in- 
flammation anywhere is essential to the fever; but very much reason for the op- 
posite opinion" The active use of blood-letting has been in favour and out of 
favour, with the medical world, again and again : and this very circumstance 
would of itself make us doubt the propriety of its indiscriminate adoption. 

The late Dr. Armstrong gave a strong and unfortunate impulse to the practice 
of free blood-letting in continued fever, by the publication of his well-known and 
ingenious treatise on the disease. I have no doubt that great mischief was done 
by that work. I may say so without scruple, since Dr. Armstrong is gone, and 
neither his feelings, nor his success, can be hurt by the expression of such an 
opinion : and I do so the rather, because it is well known here that Dr. Armstrong 
saw reason, as his experience increased, to qualify those views respecting the 
nature and management of fever, which his earlier observation of it in the country 
had led him to form. This change in his sentiments was probably justified and 
produced by a change in the character of the fevers that he witnessed; but it 
does not appear in his book. You have heard me state already that whereas the 



980 



CONTINUED FEVER. 



fevers which occurred in London for some time previously to the year 1831 or 
1832, not only bore, but required, the abstraction of blood, in some way or another, 
— since that period, and especially since the epidemic cholera visited us, it has 
been necessary to abstain, whenever we could with safety, from taking blood at 
all ; and stilt more necessary, even if we take away blood with one hand, to uphold 
the patient with the other: while, in the former period, wine and stimulants of all 
kinds seemed generally superfluous, if not pernicious. 

Dr. Williams, of St. Thomas's Hospital, has shown, very clearly I think, in 
his recent publication on " Morbid Poisons," that the evidence against the efficacy 
and the safety of bleeding in continued fever — of bleeding largely, I mean, from the 
arm — far outweighs that in its favour: and I venture to advise you, as the result 
of all that I have seen of the disease in London and elsewhere, not to draw blood 
from a vein, even early, merely because the disease is or appears to be fever; not 
to order venesection unless there be some other manifest reason for it — i.e., unless 
the febrile symptoms run unusally high, or unless some local inflammation is un- 
equivocally present: and, when you do bleed, do not take a drop of blood more 
than seems absolutely necessary to answer the desired end. Bleed your patient, 
therefore, if at all, in the upright posture. 

Purgatives. — What are we to say in general with respect to them ? This, I 
believe — that the intestines should be cleared by an active aperient in the outset; 
and that laxatives should be continued if the bowels do not act every day without 
them. When the typhoid type is strongly marked, and when the symptoms 
indicate ulceration of the intestinal glands, purgatives are not to be pressed. 

Much contrariety of opinion has prevailed also among practitioners, and does 
prevail, about the administration of mercury in this disorder. Without attempting 
to strike the balance between these conflicting judgments, it is my business and 
duty to state my own belief, to tell you what is the result of my own observation, 
upon this and other disputed points. I must repeat, then, that my practice has 
altered, in several particulars, within the last few years. In the fevers which I 
treated, or saw others treat, in London, prior to the breaking out of the present 
epidemic, mercury, in one shape or another, was almost constantly prescribed: 
and a great number of the patients were brought, sooner or later, under the spe- 
cific operation of that mineral: and in these patients (with one exception only, 
where the mercury appeared to do neither good nor harm) a decided improvement 
was almost immediately apparent upon the supervention of soreness of the mouth; 
and all such patients ultimately recovered. I am aware, however, and I wish you 
to be aware, of an alleged source of fallacy in this matter. The gums in that 
variety of fever to which I am at present referring, did not readily take on the 
mercurial action; and it might be ('hough such is not my own impression), it 
might be that the affection of the mouth by mercury was attributable to the mild- 
ness or to the .cessation of the disease, r§ ther than the cessation of the disease to 
the effects of the mercury upon the system : that the improvement was the cause, 
and not the consequence, of the mercurial action. v 

In the form of fever that is now epidemic (1838), I do not think mercury so 
proper. Last year the spotted fever broke out in a patient of mine while he was 
in the hospital, and while his gums were sore. I found, upon inquiry at that 
time, that of twelve fever patients who had been recently treated in the hospital, 
by my colleagues and myself, with mercurials in greater or less quantity, four had 
died, in all of whom the gums were affected : whereas, of sixteen others, who 
took no mercury, three only died ; and of these three, one was pulseless at her 
admission, from uterine hemorrhage, and the other two were so feeble and ex- 
hausted that they were scarcely able to swallow. I should give mercury very 
cautiously, therefore, if at all, in this typhoid variety of the fever. 

Besides a strict enforcement of the antiphlogistic regimen, my own mode of 
treating continued fever is somewhat of this kind. I am always desirous that 
the patient's hair should be cut off. The mere removal of it is often attended 
with benefit: the headache and confusion of thought are relieved, and the patient 



TREATMENT. 



981 



is calmed. We can then also, with much greater convenience and effect, apply 
cold washes to the head. Patients sometimes demur to this shaving of their heads : 
but they generally consent if you explain to them that their hair will at length fall 
off, in consequence of the fever; and that the head, if on that account only, had 
better be shaved at once. The head and shoulders should be somewhat raised, 
and thin strips of linen, kept constantly wet with some cold lotion, should be 
continually applied upon the forehead and scalp. It should be the business of one 
person to attend to this. You would be surprised at the rapidity with which the 
cloths sometimes dry. 

Now with regard to this remedial measure you need not have any difficulty. It 
will do good, and should be steadily employed, so long as it is grateful to the 
feelings of the patient ; and it will, generally, be pleasant and agreeable to him so 
long as the head remains morbidly hot. If the temperature of the scalp be not above 
the natural standard, and especially if the cold application make him shivery or 
uneasy, and give him annoyance instead of comfort, then it must be at once dis- 
continued. 

If the patient suffered intense headache, and his face were flushed, and the heat 
of the surface great, and he were wildly delirious, and his pulse were full and 
hard, I might perhaps deem it right to take blood from his arm, while he sat up. 
But even under these circumstances I should generally think it better to apply 
leeches to his temples, or behind his ears, or to remove a few ounces of blood 
from his neck by means of cupping-glasses, and at the same time to ply assidu- 
ously the cold lotion. 

If the bowels have not been already purged by nature, or art, it is right to give 
three or four grains of calomel at once, and to follow this up by a black dose. 
After that I was formerly in the habit of prescribing, in the early periods of the 
fever, unless the bowels were irritable, a pill composed of two grains of calomel 
with two grains of James's powder, every six hours ; washing it down with a 
common saline draught. In hospital practice I frequently omitted the saline 
draught; allowing the patient to drink toast and water, or barley water, as often 
as he wished. If there was diarrhoea, or early prostration, I gave, instead of the 
combination just mentioned, five grains of the hydrargyrum cum cretd. At the 
same time I carefully investigated the state of the abdomen ; and if I found ten- 
derness at the epigastrium, or in the caecal region, in both of which situations 
tenderness was common, I applied, over the tender spot, from six to ten leeches, 
and covered the leech-bites with a light poultice. If the diarrhoea ran on profusely, 
I added to the hydrargyrum cum crela a certain quantity of Dover's powder, or 
of the extract of poppy. 

In those forms of fever (whereof the prevailing epidemic affords you a well- 
defined specimen), in which there is a strong and early tendency to typhoid 
symptoms, a signal loss of strength, a confused and dusky countenance, a mottled 
state of the skin simulating the eruption of measles, a dark dry brown tongue, a 
feeble pulse — in these forms I begin very early to give the patient a full allowance 
of beef tea; and if the typhoid and nervous symptoms become more pronounced, 
I add ammonia, Hoffman's aether, and, what is better still, wine ; and I omit the 
mercury. 

Under this kind of management the patients will often go on, in a doubtful state, 
for some days, and at length begin to recover. Many of them, especially in the 
more typhoid varieties, sleep heavily, as the disorder passes slowly off. 

There is one point in the treatment of fever, of exceeding importance, and of 
some nicety : 1 mean the use of opiates. If they are given inopportunely, they 
are apt to puzzle and perplex the case. You do not know how much of the dis- 
position to coma is owing to the disease, and how much is the consequence of the 
remedy. Again, you may easily augment the natural tendency to coma, and lull 
your patient into a fatal stupor. But, when judiciously administered, opium will 
often save a patient who would inevitably sink without it. 

It is in that form of fever which the French call the fievre ataxique, — when the 

§ 



982 



CONTINUED FEVER. 



patient is affected with delirium, restlessness, wakefulness, and spasm, and the 
disturbance of the nervous system outruns the disturbance of the sanguiferous 
system, — that opium is so beneficial. The condition of the patient resembles that 
of a person in delirium tremens. It is said that these symptoms occur most com- 
monly among patients in those ranks of life that are above the lowest rank; and 
it probably is so : but they are apt to take place in any patients, high or low, rich 
or poor, who have had the mind over-wrought, and the nervous system unstrung, 
whether by dissipation and intemperance, or by anxiety of any kind. Sydenham 
was quite aware of the existence of this particular set of symptoms, and of the 
remedy for them. Of all these symptoms, sleeplessness is the most urgent. Dr. 
Grattan and Dr. Latham have both written in praise of the same opiate treatment, 
under such circumstances, as was recommended by Sydenham. Dr. Grattan 
observes, with great truth, that two or three nights, spent in restless delirium, are 
followed by the worst consequences; and that patients who pass three nights in 
succession in that way, almost invariably die. If the symptoms be well marked, 
the best mode of proceeding is to give a tolerably full dose of opium in the eve- 
ning; one-third of a grain of acetate of morphia is a common prescription with me. 
The amendment of the patient, on the following day, is often very striking. Un- 
less the same symptoms recur, it is better, I think, not to repeat the anodyne. 
But, as Dr. Latham cautions us, " there are cases, where the indications for the 
employment of opium are doubtful. Wild delirium, and long wakefulness, and 
a circulation weak and fluttering, seem to call for a considerable dose of opium. 
Yet, withal, there is a certain jerk in the pulse, so that we cannot help suspecting 
that the blood-vessels have something to do with the sensorial excitement. Under 
\ such circumstances, I have certainly seen (says he) twenty minims of laudanum 
produce tranquil sleep, from which the patient has awoke quite a new man. But 
I have also seen the same quantity produce a fatal coma, from which he has never 
been roused. Now, (continues Dr. Latham,) since it is a fearful thing to strike a 
heavy blow in the dark, where the alternative is of such magnitude, it is the safest 
and the best method to administer a small dose, at intervals of an hour or two : so 
as to stop short of actual mischief at the first glimpse of its approach, or to be led, 
by a plain earnest of benefit, to push the remedy to its full and consummate effect. 
Many doses may be required for this purpose ; but we shall see, after the first or 
second, whether to go on or to desist." 

When, as is sometimes the case, the stress of the disorder falls upon the thorax, 
and there is much dyspnoea, with the sounds that denote inflammation of the 
bronchial membrane, or of the pulmonary substance, leeches or cupping-glasses 
may be applied to the chest; and, in milder cases, a blister, or a mustard cata- 
plasm. 

These remedies — cold to the shaven head; the local abstraction of blood wher- 
ever there happens to arise evidence of local inflammation ; an active purge at 
first, and mild aperients afterwards, if the bowels are confined or sluggish ; mo- 
derate astringents, if there is much or urgent diarrhoea, a few grains of Dover's 
powder, for example, or of the extract of catechu ; opium in a more efficient dose, 
when the nervous symptoms are prominent, particularly sleepless delirium and 
restlessness ; in certain cases small and repeated doses of some preparation of 
mercury; and in certain cases, early support by animal broths, and even by wine 
— these remedies, adapted to the particular circumstances of individual patients, 
form the staple of the treatment of continued fever, according to the best of my 
judgment and experience. 

After what has been said, I need scarcely again admonish you to study care- 
fully, not merely the symptoms of any particular case to which you may be called, 
but the general character of the fevers that are at the same time prevalent, and the 
manner of dying in the fatal cases. If you find that they who die, die chiefly in 
the way of asthenia, that will be a strong reason for caution in respect to the 
removal of blood, and for the early employment of beef-tea, and other means of 
support. In the form of fever which has of late years been common in the most 



TREATMENT. 



983 



crowded and unhealthy parts of London, I am sure that the risk of beginning this 
sustaining treatment a little too early is much less than the risk of commencing it 
a little too late. If plenty of beef-tea does not suffice, you must give the patient 
wine, and that sometimes to a considerable amount, or even brandy ; the egg-flip 
of the Pharmacopoeia for instance, the mistura vini gallici. The object is to 
keep him alive, to keep the heart in motion, until the depressing influence of the 
exciting cause of the disease shall have passed by. If the wine should flush or 
excite him, or render the pulse hard, it must be diminished in quantity, given less 
frequently, or omitted altogether. If there be indications of local inflammation — ■ 
pain (for example) in the csecal region, increased by pressure — leeches may be 
used, and wine given at the same time. There is nothing inconsistent in such 
mixed practice. We seek to remove the local inflammation by unloading the 
capillary blood-vessels of the part, while we uphold the general powers of the 
constitution which are ready to sink. The great art of getting a fever patient 
through a bad attack, is to have him judiciously and perpetually watched, by night 
and by day. The remedy that is proper one hour may do harm if pushed during 
the next. And there is another reason, which I may mention en passant, why 
the sick person should never be left alone, even for a moment. I have heard of 
more than one or two instances, of patients, in the delirium which attends the 
disease, getting out of bed, and out at the window, during the temporary absence 
of their nurse, and perishing from the fall. 

If the patient relishes and wishes for the beef-tea, or the wine, that is no small 
warrant of the propriety and usefulness of its administration. 

A word or two more may be proper, even in this cursory sketch, respecting 
certain incidental points of practice that are apt to arise. 

Often, when there is no longer any detectible uneasiness produced by pressing 
the belly, the diarrhoea will persist, and meteorismus will come on ; a tympanitic 
distension of the intestines with gas. When this happens, especially in the latter 
periods of the fever, a large blister, laid over the abdomen, has often very happy 
effects, both upon the diarrhoea and the meteorismus. The diarrhoea, when very 
urgent and obstinate, may often be checked by opiate enemata. In some cases I 
have recently found catechu of great use, in these long-drawing forms of diarrhoea 
during fever. 

Again, if the patient sinks into profound coma, a blister should be applied to 
the shaven scalp. The sick man will sometimes awake from deep stupor while 
the blister is still rising. 

It is always a matter of importance, as I stated before, to inquire carefully, 
every day, into the condition of the bladder of these fever patients. In the state 
of stupor and indifference in which they often lie, they appear not to be sensible 
to the want of passing the urine, which collects in the bladder, and distends it 
enormously ; not only increasing the present hazard of the patient, but laying the 
foundation, sometimes, of future disease of the kidneys, in case he recovers from 
the fever. You must not take the assurances of the nurses upon this point. 
They will often tell you that the patient has made plenty of water, when in fact 
the urine has been dribbling away from him, overflowing, while the bladder is 
stretched to the utmost. Feel, therefore, with your hand, and percuss the hypo- 
gastric region, as well as that of the caecum, at every visit. 

It is requisite, too, that the under surface of the patient's body should not only 
be kept scrupulously dry and clean, but be looked at every day, or twice a day. 
If the projecting points, the hip bones, the sacrum, the shoulders, the elbows, 
should become red, that is a sign that they are likely to slough or ulcerate, This 
evil consequence of continued pressure upon parts of which the vital power and 
healthy tone are lowered, may often be prevented by washing the erythematous 
spots with brandy. Should the skin be already broken, the place may be covered 
with soap-plaster. An adjustment of pillows and of posture — or the water-bed — 
may sometimes supersede the necessity of these local expedients. 

When ulceration of the mucous follicles perforates the bowel, that catastrophe 



984 



CONTINUED FEVER. 



does not always so distinctly declare itself in fever, as in other cases. I have 
seen such perforation, and its resulting peritonitis, when no complaint of pain had 
been made by the patient, so great was his insensibility. In general, however, 
the accident is denoted by symptoms which cannot be mistaken. When it does 
occur, there is but little chance of the patient's recovery ; and that little will be 
best husbanded by the adoption of the plan of treatment which I formerly laid 
down: opiates, to check the peristaltic movements of the intestine; and a rigid 
adherence, for some days, to the horizontal posture. 

I have seen a few instances, in which an cedematous swelling of one leg and 
thigh has occurred in the advanced stage of fever, like that which is incidental to 
parturient women, and depending upon the same cause — inflammation and ob- 
struction of the great vein that returns the blood from the limb towards the heart. 
I believe that the inflammation extends itself, in such cases, from some of the 
smaller veins of the mesentery, and is excited in them by the intestinal ulceration. 
Fomentation of the affected limb comprises all the remedial treatment which this 
accident requires or admits of. 

The management of the patient during convalescence is scarcely of less im- 
portance than during the progress of the fever. The chief danger is, that his 
desire to be allowed to get up, and his wish to eat animal food, should be too 
soon indulged. The latter of these errors is more frequently the cause of a relapse 
than any other circumstance; and relapses are often more perilous and difficult to 
remedy than the original malady. You must be prepared, therefore, to withstand 
the solicitations of the patient and of his friends, who think that if strength be 
wanting, strong drinks, and plenty of meat, are the things to impart it. Until the 
tongue is quite clean and moist, and of its natural colour, and the pulse has lost 
all its hardness, and the skin its excess of heat, the patient must be kept to broth, 
jellies, puddings, and preparations of the well-known farinaceous articles of food. 
Then he may begin with some boiled white fish, and so gradually eat his way, 
through chicken, and a mutton-chop, to his ordinary diet again. 

Such, I say, is the general plan of treatment which some observation of this 
disorder has persuaded me is the best. Summarily expressed, it consists in the 
exercise of incessant vigilance, and the adoption of the proper remedy at the 
proper moment. It lies between a timid or sceptical abandonment of all known 
resources, and a meddlesome rashness in applying them. The flame of life may 
be suffered to expire for want of timely succour, by the practitioner who folds his 
arms, and looks on; as it may be rudely extinguished by a restless or routine in- 
terference which has no definite or intelligible purpose. Boerhaave, in the pre- 
face to his Aphorisms, professes that he knows of nothing which can be fitly 
termed a remedy, "quin solo tempestivo usu tale fiat." In fevers the wisdom of 
this maxim is eminently conspicuous. The rational objects of treatment are, to 
mitigate the urgency of symptoms that cannot be wholly subdued ; to redress (so 
far as art may redress) those dangerous complications which are incidental but 
not essential to the disease; and to aid the conservative efforts of nature, when 
these manifestly languish and fail. 

Dr. Williams holds that enemata of warm water and syrup of poppies will do 
all that can be done beneficially. For some time he lost only one patient out of 
sixty-three thus treated. This was a most encouraging result. But then, when 
the fever changed its type, as it did about the period of the arrival of the epidemic 
cholera, he lost one in every four or five; a very large mortality. These facts 
illustrate, in a strong manner, the necessity, which I have so often endeavoured to 
inculcate, of taking into the account, when we would estimate the value of a 
particular remedy or plan, the difference which obtains in different epidemics 
whether bad, good, or no treatment at all be adopted. A far surer method is to 
compare (if you would experiment at all) two or more different modes of practice 
in different cases of the same epidemic. Thus Dr. Latham, finding during one 
season that his wards were full of fever, while yet its type was so mild that 
scarcely any died, thought this a favourable opportunity for trying whether mer- 



BILIOUS REMITTENT FEVER. 



985 



cury had any beneficial operation upon the disease. Accordingly he treated half 
his cases with small doses of the hydrargyrum cum cretd ; and the other half 
with the liquor ammonix acetatis, and so forth, and no mercury ; and he found 
that the patients in the first of these classes were, on the average, convalescent 
sooner than those in the last. Chomel fancies, from some trials, that the chlorate 
of soda is a useful remedy, in addition to the general plan of management; but 
further experience seems wanting to settle this question. 

[Although the present note may be considered somewhat out of place, considering the 
class of diseases with which Dr. Watson has associated Continued Fever, yet as circumstances 
prevented us from introducing an account of Bilious Remittent Fever, after the. author's 
lecture on Intermittents, while that portion of the work was passing through the press, we 
know of no place where it can now be introduced with more propriety than the present ; 
the disease holding a kind "of middle rank, as to external character, between intermittent 
and continued fevers," it matters little in connection with which it is studied. 

Bilious Remittent Fever. — With the exception of the intermittent, the most common 
form of fever prevalent in the middle, southern, and south-western sections of the United 
States is the remittent, or, as it is generally denominated, from the evidences of more or 
less derangement of the hepatic function by which it is attended, the bilious remittent, or, 
simply, bilious fever. It constitutes the summer and autumnal endemic of many of our 
states, and even in those which are exempted from its annual occurrence it occasionally 
prevails, during seasons of unusual heat and dryness, sporadically, or as a severe and 
widely-spread epidemic. It is this form of disease to the attack of which individuals, from 
the cold and temperate sections of our union, are so peculiarly liable on removing to those 
localities where it is endemic, or on visiting them during the summer and autumn. The 
bilious remittent fever is not peculiar to the United States; it prevails extensively in the 
southern portions of France and Italy, and other parts of the south of Europe, in Africa, 
and in the East and West Indies : it is in fact the endemic of the paludal districts of all hot 
climates. A high degree of atmospherical temperature has a very marked influence in the 
production of this form of fever; either by eliminating an aeriform morbific matter, or by pre- 
disposing the system to the action of the morbific causes by which it is constantly surrounded. 
Its prevalence, as well as violence, is almost invariably in direct proportion to the heat of 
the season, while, in many of the more northern states, where the disease is not one of 
ordinary occurrence, during a summer of extreme heat, it will prevail, often to a consider- 
able extent — and, marked occasionally, by symptoms of extreme violence; it being limited, 
however, almost exclusively to those situations, noted in other seasons for their insalubrity, 
or in which the causes of disease are ready to be developed upon the occurrence of any 
unusual degree of atmospherical heat. 

Notwithstanding the bilious remittent fever can scarcely ever be mistaken by the least 
experienced practitioner, it exhibits, nevertheless, considerable diversity in many of its phe- 
nomena indifferent seasons and localities, and often in different individuals. While, in 
many cases, the remissions are well-marked, approaching in some to a complete intermission, 
in others, the remissions are so slight that the fever has almost a continued form. There 
are always, however, certain prominent symptoms, invariably present, an attention to which 
will lead at once to an accurate diagnosis : — These are, gastric irritability, a sense of op- 
pression and distress at the epigastrium, pain of the head, back, and limbs, and the great 
prostration of strength early exhibited by the patient. 

Bilious remittent fever is closely allied in its nature, the localities in which it chiefly 
prevails, and in many of its phenomena, to intermittent fever, of which by many it is con- 
sidered as a mere modification. It is presumed, and with much plausibility, that "a more 
intense operation of the same morbific cause required for the production of intermittent 
fever engenders remittent," and that " the more violent the latter the more remote is its 
character from that of intermittent ; or, in other words, the less perceptible the remissions." 
That a more powerful action of the morbific cause is demanded for the production of re- 
mittent fever, is supposed to be indicated "by the circumstance, that when periodic fevers 
are prevailing in certain countries, the permanent residents are often observed to have the 
disease in the form of ague only, and the mortality among them is small; but strangers 
unhabituated to the climate and its diseases, suffer from remittents, with a proportionably 
greater loss of life. In more sickly seasons remittents will be the prevailing form among 
both classes of persons, but strangers are more violently affected, and the mortality among 
them is greater. Its affinity to intermittent is shown, too, by the tendency which it has to 
pass into that, form, and, inversely, by the proclivity of ague to assume the remittent type." 
( Brown ; Cylcopaedia of Pract. Med.) 

There is a very striking analogy between the milder and more ordinary form of the 
bilious remittent fever, in its course and progress, and the periods of a double tertian ague. 
Although the exacerbations occur daily, yet there is almost always a very manifest aggra- 



986 



BILIOUS REMITTENT FEVER. 



vation of all the symptoms on the odd or alternate days. When the disease assumes, as it 
does occasionally, a quotidian type, the exacerbations generally occur several hours earlier 
than those of the double tertian form — the former happening usually about nine or ten 
o'clock, and the latter not until towards noon, or an hour or two later. 

The milder and more simple form of bilious remittent fever is generally preceded, for 
some days, by listlessness, languor, a bitter taste in the mouth, nausea/aversion from 
food, an indescribable uneasiness and sense of fullness about the epigastrium, sometimes 
costiveness, and, very generally, more or less pain and heaviness over the eyes. The 
attack is usually ushered in by a slight chill, or merely by a sense of coldness, particularly 
about the back, which, after one or more hours, and often sooner, is followed by increased 
heat of the whole surface — the skin becoming, at the same time, dry and constricted, the 
face flushed and turgid, the eyes red and suffused, the respiration hurried and uneven, the 
pulse quick and frequent, but rarely tense ; there is great prostration of strength with con- 
siderable restlessness and watchfulness. The patients complain of pain and a sense of 
fullness, weight, and tension of the head, pain of the back and of the extremities, particu- 
larly of the calves of the legs; — and of a sense of weight or oppression, and often of pain at 
the epigastrium, which part generally, exhibits more or less tenderness upon pressure, even 
when no pain is complained of. The stomach is more or less irritable — some cases being 
attended with distressing nausea, while in others, everything swallowed is instantly rejected. 
Spontaneous vomiting is a not unfrequent symptom — it is often present from the commence- 
ment of the attack, but more generally it does not, commence until the second or third day, 
or even later ; the matter vomited is of a bitter taste and of a yellow, greenish or bright- 
green colour. The tongue is usually moist, red at the sides and edges, and coated on its 
upper surface with a whitish, light-brown, or yellowish fur, which often acquires consider- 
able thickness. There are usually considerable thirst — a costive state of the bowels, and a 
diminished amount and increased coloration of the urine, and, after the disease has con- 
tinued for some days, the skin acquires a yellow tinge, which is sometimes very decided, 
and extends to the adnata of the eyes. The exacerbation lasts from eight to twelve hours, 
when a gradual abatement of all the prominent symptoms takes place, and often a slight 
moisture breaks out upon the surface, and the patient falls into a refreshing sleep; more 
generally, however, the skin continues dry after the heat has declined, and the patient during 
the remission continues restless, uneasy, and disinclined to sleep. The duration of the 
remission varies with the violence of the attack ; gradually, however, the heat of the sur- 
face increases, and an exacerbation of the fever follows, marked by the same degree of in- 
tensity as the former, or even by increased violence. 

All the preceding symptoms, in an aggravated degree, with long-continued exacerbations, 
and less distinct remissions, mark what has been termed the highly inflammatory form of 
the disease. During the exacerbation the skin is intensely hot, the eyes are suffused, of a 
muddy, yellowish hue, and often dull and languid; there are intense pain, and a sense of 
insupportable weight and tension of the head; aversion from light and sound is ordinarily 
present, and, occasionally, delirium ; there are great thirst, and a feeling, often almost insup- 
portable, of oppression at the chest; the respiration being quick and laborious, frequently 
irregular; the pains in the back and extremities are often of great severity; the pulse is 
quick, frequent, and more or less tense; occasionally it exhibits some degree of irregularity; 
the nausea and vomiting are generally peculiarly distressing — the matter discharged being a 
thick ropy fluid of a yellow, darkish-brown or green colour; the bowels are costive, or, if open, 
discharge, with tenesmus and griping, a thin watery fluid: when evacuations are procured 
by appropriate means, they are large in quantity, dark, slimy, tenacious, and offensive. 
There is always an intolerable sense of oppression or constriction at the epigastrium, ac- 
companied by a degree of tenderness which renders the slightest amount of pressure 
insupportable; — or a severe pain and burning, attended, in many cases, with great nausea 
and frequent ineffectual efforts to vomit, are experienced. There is great restlessness, with 
jactitation, and continued watchfulness. In the course of the disease, the skin acquires, 
most generally, a brownish, bronzed, or more frequently, a deep yellow tinge, which is par- 
ticularly marked upon the face and breast. A symptom mentioned by Rush, as generally 
present in cases of bilious remittent; namely, a sereatus, or constant hawking and spitting 
of a small quantity of tough, glairy matter, we have repeatedly noticed. 

The succeeding exacerbations are marked by an increased violence of all the predomi- 
nant symptoms of the disease, and unless the intensity of the fever is relieved by an 
appropriate course of treatment, the powers of life gradually sink; the surface, at length, 
becomes cool and covered, generally or partially, with a cold clammy sweat ; the pulse 
becomes small and weak ; the tongue covered with a dark, thick coating, and, occasionally, 
dry and chapped; the respiration short, quick and difficult; the abdomen, sometimes, 
swollen and tympanitic ; stupor or coma often ensues; not unfrequently repeated, and, at 
length, involuntary discharges take place from the bowels, of a dark, offensive matter, and 
finally, death ensues. 

In the milder forms of the disease, or when it has been from the commencement of the 
attack, subjected to an appropriate treatment, instead of an increased violence in the phe- 



BILIOUS REMITTENT FEVER. 



987 



nomena of each succeeding paroxysm, there is less decided heat of the surface, the pulse 
becomes slower and less frequent, there is less gastric distress, less pain and tenderness 
of the epigastrium ; less pain of the head and back ; the exacerbation is of shorter duration, 
and as it declines, the skin becomes softer and more moist, the tongue less coated, the 
countenance more cheerful, and the patient obtains, often, several hours of quiet and re- 
freshing sleep: — the remissions are more distinct, and of longer continuance ; until finally 
a complete intermission occurs, followed by a state of convalescence — which is usually 
protracted. 

There generally takes place in the milder and uncomplicated forms of bilious remittent, a 
distinct exacerbation, followed by an evident remission, once in every twenty-four hours: 
but in the more violent and decidedly inflammatory form, the remissions, as we have 
already remarked, are so short and slight as almost to pass unnoticed, and hence the in- 
flammatory bilious fever is described by many writers as a continued fever. 

The duration of the disease varies with its degree of violence and its simple or compli- 
cated character — it may terminate in a few days or run on for several weeks — but its 
usual duration is from nine to fifteen days. It is not uncommon, Dr. Dickson, of South 
Carolina, remarks, especially among the most perfectly acclimated adult natives resident 
in malarious localities, and strangers long familiarized to them, to find bilious remittent 
fever of very protracted duration ; "the patient sinking, after the tenth or twelfth day, into 
a low form, resembling the less severe grades of typhus, and hence obtaining among us 
the designation of the typhoid stage of bilious fever. Here the well-marked lines which 
separate the period of exacerbation and remission, are almost effaced; the characteristic 
periodicity almost obliterated; the fever degenerates nearly into the continued type, and the 
patient, in the language of the older practitioners, ' wades through' the attack with no defi- 
nitely regular changes observable from time to time, until by the success or failure of our 
efforts in his behalf, he recovers or is lost. The pulse is small and chorded, the tongue 
throws off its fur, and is smooth, red, and dry, or smeared over, like the teeth and lips, with 
foul sordes; the stomach loses its irritability, and the vomitings cease; the stools are dark 
or even black; meteorism occasionally shows itself; there is muttering delirium or dis- 
position to heavy stupor and coma ; the countenance is dull and inexpressive ; muscular 
languor and great debility ensue, with nervous tremors on motion, and perpetual subsultus 
tendinum." Dr. Dickson has known cases of this kind protracted, in three instances, to 
thirty, thirty-five, and fifty days, though the average, he observes, would scarcely reach 
beyond fifteen or twenty. 

A careful analysis of the phenomena of bilious remittent fever shows, very conclusively, 
that the organs chiefly affected are the liver and stomach, and the results of post-mortem 
examinations confirm the accuracy of this deduction. In many cases, it is true, the symp- 
toms during life, and the lesions detected after death, indicate more or less affection of the 
lungs or brain ; but this latter is to be viewed as an accidental complication and not essen- 
tial to the disease. Basing our conclusions upon the investigations of Dr. Stewardson, 
{American Journ. Med. Scien., April, 1841, and April, 1842,) which are confirmed by the sub- 
sequent observations of Dr. Swett, (ibid, Jan., 1845,) and correspond in many particulars 
with those of Mr. Twining (Diseases of Bengal, chap, v.), a morbid condition of the liver 
would appear to be invariably present in remittent fever — to be indeed diagnostic of the 
disease ; it is nevertheless very certain that few cases of bilious fever, of any intensity, 
occur without being attended, also, by indubitable symptoms of gastro-enteric disease — the 
evidences of which are very generally detected in those who die of the fever. In many cases 
the indications of hepatic disease predominate, while in others those of a gastric affection 
are most prominent; in general, hoM^ever, both are sufficiently well-marked in the same 
case. It has been proposed to distinguish the fever, according as the phenomena of hepatic 
or gastro-enteric disorder predominates, by the terms hepatic and gastric. Hepatic remit- 
tents being characterized by intense febrile heat; violent pain of the head; fullness and 
tension of the right hypochondrium, with pain and pulsation of this part and of the epigas- 
trium; excessive irritability of the stomach; frequent and forcible vomiting, the ejections 
being without any trace of bile ; a clean state of the tongue in the early stages ; a decidedly 
yellow colour of the skin and adnata of the eye ; great torpor of the bowels, until towards 
the decline of the disease, when a copious discharge takes place from the bowels of a dark 
or pitch-like tenacious matter, which may be considered as in some degree critical. 

Gastric remittents are distinguished by a bitter taste in the mouth ; great thirst, with a 
craving for cool and acidulated drinks ; frequent vomiting of a green or dark-brown fluid; 
total loss of appetite, and, generally, disgust for every kind of food; a feeling of great weight 
and anxiety at the praecordia; pain and tenderness, chiefly at the epigastrium; intense 
pain of the loins and knees, and soreness of the calves of the legs; severe and constant 
pain of the forehead; the tongue coated in the centre with a thick layer of yellowish mucus, 
and red at the sides and tip ; the remissions distinctly marked ; bowels costive, or when 
discharges from them take place, these are thin and watery, and often attended with griping 
and tenesmus: in the course of protracted cases the stools not unfrequently consist of a 
reddish fluid resembling the washings of meat. In the progress of the disease, the tongue 



988 



BILIOUS REMITTENT FEVER. 



becomes dry, cracked and covered with a dark-brown or blackish crust; upon the separa- 
tion of which the tongue presents a smooth, shining and red surface. In the advanced 
stage, there is often retention of urine, difficulty of swallowing fluids, meteorism of the 
abdomen, &c. 

Although we frequently meet with cases in which the predominance of hepatic or of 
gastric disorder, but especially of the first is thus strongly marked, nevertheless, in the 
general run of cases there is a complete blending of the two sets of phenomena. 

There is one form of bilious intermittent still to be described, with which " the experience 
of the last ten years" has made the practitioner of the southern and south-western portions 
of the United States, " unhappily, too well acquainted, under the denomination of con- 
gestive fever. In certain localities, indeed, remarks Dr. Dickson, the ancient inflammatory 
features of malarious endemics seem to have disappeared, and to have become supplanted 
by the more hideous and pestilential modification thus entitled." 

The form of the disease to which we allude is marked by a diminished temperature and 
decreased sensibility of the whole surface of the body— the skin being, at the same time, 
soft, contracted, and often clammy, or wet with a copious perspiration; when a partial 
reaction takes place the heat is never considerable, and it is often confined to particular parts 
of the surface. There are considerable and universal lassitude and debility; the head is con- 
fused and affected with vertigo, and sometimes with a deep-seated pain or a sensation of 
oppressive weight or tension; the eyes are heavy, suffused, and dull ; the countenance is 
haggard, and the face pale, and of a dingy, muddy appearance; the pulse is small, frequent 
and indolent, or struggling, compressible and variable; the tone of the voice is often 
changed, the articulation slow and drawling, or imperfect and stammering. The respira- 
tion is anxious and laborious — with frequent sighing. The tongue exhibits, at first, but 
little change, but soon becomes dark-brown or black, especially in those cases in which the 
earlier stages of the disease have been marked by some degree of excitement. The stomach 
is occasionally irritable; the epigastrium and right hypochondrium are tender upon pressure, 
and more or less tumid; the bowels are torpid, and when stools are procured they are dark- 
coloured and offensive, and often attended with tormina and tenesmus. The mind is gene- 
rally dull, indifferent or confused from the commencement of the attack, and, in the. progress 
of the disease, sinks into a state of more or less complete stupor, or of low muttering deli- 
rium. The remissions of the fever in the congestive form are not well-marked, or rather, 
there is an entire absence of the febrile exacerbations and remissions, the phenomena of 
the disease presenting but little other change than a rapid or a gradual augmentation in in- 
tensity. In fatal cases, death which may take place between the fifth and fifteenth days, or 
even later, is often preceded by hiccup, subsultus tendinum, involuntary stools, hemorrhage 
from the stomach or bowels, petechias, &c. 

The congestive form of bilious remittent fever may attack suddenly, when it is apt to 
assume a peculiarly malignant form, and to terminate rapidly in death; in many cases, how- 
ever, it is preceded by the same symptoms as the milder and more open forms of the dis- 
ease. In the more violent attacks of congestive fever, " the system seems," to use the 
words of Dr. Dickson, "to sink at once prostrate before the invasion or exacerbation, which 
can scarcely, at times, be called febrile. Reaction, to use our technical phrase, does not 
take place, or very feebly if at all. The skin is cold, and covered with a clammy sweat, 
as in the collapse of cholera; the pulse is weak and fluttering; the stomach is very irrita- 
ble, with frequent and painful, but usually ineffectual, efforts to vomit; the countenance is 
shrunken and pale or livid; there is often low muttering delirium, with shivering and faint- 
ing. In some cases, no complaint is made, a lethargic insensibility seeming to oppress the 
patient; in others, the most extreme anguish is endured by the miserable sufferer, who in 
his agony, often utters groans or loud cries. The vital powers are speedily and irrecover- 
ably exhausted by the recurrence of a few such exacerbations, although the remissions in 
this class of cases are usually w 7 ell defined, and full of transient relief and hope. The third, 
fourth, or fifth return of the train of symptoms delineated, for the most part, puts an end to 
the distressing scene." 

The phenomena of congestive fever are evidently the result of defective innervation, and 
an impeded action of the heart and lungs; the blood, imperfectly decarbonized, accumu- 
lates in the interior organs, and thus prevents the full and regular exercise of their functions. 
The impression of the morbific causes, by which the disease is produced is, in all proba- 
bility, made primarily upon the nervous centre, and by depressing the energy of its action 
gives rise to all the other phenomena which characterize this form of fever. 

The propriety of denominating these cases of congestive disease bilious remittent fever, 
when they frequently run their course without exhibiting the slightest indication of febrile 
reaction, has been doubted by some. They are, however, produced by the same causes as 
the bilious fever, and, when the congestion is early reduced, the case often assumes all the 
characteristics, and runs the same course as in the ordinary form of bilious fever,showing 
that the phenomena of the latter were merely masked or suspended by the congestive state 
of the principal vital organ. 

The convalescence from an attack of all the forms of bilious remittent fever is always 



BILIOUS REMITTENT FEVER. 989 

protracted, and relapses, from slight irregularities of diet or too early exposure, are not un- 
frequent. After severe attacks the hair often falls entirely off and is only slowly and im- 
perfectly renewed, or the patient remains permanently bald. The functions of the stomach 
and alimentary canal generally, are imperfectly performed for a long period after recovery, 
and require the utmost circumspection on the part of the patient to ensure their complete 
restoration. Jaundice is a very frequent consequence of bilious remittents. This Dr. 
Dickson states "was noticed generally in the summer and autumn of 1824; very few 
patients recovering from the fever in that year without becoming icteric. Nor is it rare to 
meet with hepatic enlargement and induration, attended by a long succession of sufferings 
from visceral obstructions and mechanical impediments to the performance of the abdomi- 
nal functions, and to the transmission of the abdominal circulation. Hence ascites and 
anasarca, and hence diarrhoea and dysenteries called hepatic, and occasionally melsena 
and true intestinal hemorrhage. The spleen suffers from remittents of malarious origin, 
as from their kindred intermittents, though not by any means so uniformly, sometimes 
undergoing a permanent and inconvenient increase of size or hypertrophy." 

With the pathological anatomy of remittent fever we are but imperfectly acquainted; 
very few facts in relation to it have been recorded, and of these few many are loosely and. 
imperfectly detailed, while those upon the accuracy of which reliance can be placed, are 
derived from too limited a series of observations to allow of any positive general conclu- 
sions being based upon them. That, however, the stomach and liver are the organs in 
which indications of disease are the most uniformly detected all the facts in our possession, 
very clearly prove, although the exact nature of the morbid lesion is not very clearly made 
out. " The closest attention to clinical observations," remarks Mr. Twining, {Diseases of 
Bengal, chap, v.), " as well as the result of post-mortem examinations, convince me, that 
remittent fevers in Bengal are invariably connected with local congestions, which often run 
rapidly into inflammations, attended with much interstitial effusion. The seat of these local 
affections is found principally in the stomach, intestines, cellular structure about the duo- 
denum, and at the root of the mesocolon, more especially where it passes across the spine. 
The principal disease is also often found in the spleen, liver, brain or lungs." Dr. Gerhard, 
of Philadelphia, maintains, as the resultof his observations, that the anatomical character of 
the more severe forms of intermittent fever, is to be detected in the spleen, liver and sto- 
mach ; the bilious and remittent fevers being " probably referable to the same class as the 
malignant remittents." These conclusions are confirmed by the observations made by Dr. 
Stewardson, in the Pennsylvania Hospital ; by those of Dr. Swett, made in the New York 
Hospital, and by the results of dissections in single cases as reported by Dr. Howard and 
others. Dr. Boyd describes the indications of disease, after death, in the bilious fever of 
Minorca as occurring in the brain, lungs, liver and stomach; the liver, he states, was in 
most instances enlarged — often inflamed, with its inferior margin livid. — The gall-bladder- 
distended with viscid bile. The stomach and intestines were often inflamed; the villous 
coat being of a dark colour. 

The appearances in the stomach are variously described — but in general, they are stated 
to be injection, with increased redness of the mucous membrane — sometimes thickening 
and occasionally softening of that membrane. — In many instances the same appearances 
are described as being present in the duodenum. — The glands of Brunner, in this intestine, 
were, according to Dr. Stewardson, " developed in a remarkable manner" in the cases ex- 
amined by him; a similar development did not, however, occur in the fatal cases which 
fell under the notice of Dr. Swett. 

In all the dissections made by Drs. Stewardson and Swett, and the one reported by Dr. 
Howard — the liver was found to be flabby, of a bronze colour, the two substances composing 
the organ being blended together in such a manner as to be scarcely distinguishable. The 
spleen was much enlarged and softened. The peculiar condition of the liver just described 
Dr. Stewardson considers to constitute " the essential anatomical character" of remittent 
fever: he thinks it highly probable that the same alteration of the liver will be found to 
exist in intermittents which prove fatal in their early stage — these and intermittents being, 
in his opinion, essentially the same disease. 

Drs. Gerhard, Stewardson, Swett and Howard, never detected in any case, after death 
from remittent fever, the glands of Peyer, and the other intestinal follicles, in a diseased 
condition — and although we believe that these parts will generally be found in a perfectly 
healthy state; nevertheless, it is certain, that cases do occur, particularly of the more pro- 
tracted forms of the disease, in which the evidences of follicular inflammation of some 
portion of the small intestines, terminating occasionally in ulceration, especially of the 
glands of Peyer at the lower end of the ileum, are present after death. Such cases are 
referred to by Dr. Geddings, of Charleston, Drs. Stevens and Vache, of New York, Dr. 
Harrison, of Cincinnati, as quoted by Dr. Dunglison, {Practice of Med., 2d ed., vol. 2., p. 
450.) A diseased condition of the glands of Peyer is stated to have been present, also, 
in all the cases examined by Dr. Richardson in the New York Hospital, in 1840, {Dr. Swett, 
Amer. Journ. Med. Sciences, January, 1845;) and the same lesion was noticed by Dr. 
McWilliam in the African remittent fever. 



990 



BILIOUS REMITTENT FEVER. 



The indications of congestion and of inflammation so frequently met with in the brain 
and lungs, point out, it is true, the tendency there exists in remittent fever to disease of 
those organs, but they are not invariably present, nor are they essential to the disease. 

In cases of congestive intermittents the anatomical lesions are the same as those de- 
scribed above — excepting, that when death takes place previously to the occurrence of 
complete reaction, there is, very generally, extensive hyperemia of the brain, lungs, liver 
and spleen. 

The diagnosis in bilious remittent fever will depend, in a great measure, upon the cha- 
racter which the disease presents in different localities and in different years ; as well as 
upon the constitution and other circumstances connected with the individuals attacked by it. 
In the milder forms of the disease, with distinct exacerbations and remissions, and no 
marked tendency to disease of the more important organs, particularly when they occur in 
persons of temperate habits, and of constitutions neither broken down on the one hand by 
previous disease, fatigue or the depressing passions, &c, nor on the other, marked by undue 
plethora or a tendency to congestive or inflammatory affections of the central organs ; by 
a judicious treatment, early commenced with, a favourable result may very generally be 
obtained. Even the more strongly marked inflammatory form of the fever seldom termi- 
nates fatally when vigorously treated from its onset. The congestive or malignant form of 
the disease is one in which the prognosis is much more unfavourable; in epidemics of 
congestive bilious fever the mortality is often truly appalling. Remittent fever, generally 
speaking, attacks with less severity and is more readily controlled in those acclimatized, as 
it is termed, to the districts of country in which it occurs as an epidemic — that is, persons 
who, having passed through the disease, continue to reside in those districts. A stranger, 
recently arrived, particularly if a high liver, or of intemperate habits — or whose occupation 
subjects him to exposure and fatigue, is not only more liable to be attacked than the former 
class of individuals, but in such a one the disease will usually be marked by greater seve- 4 
rity, and be more liable to terminate fatally. The favourable symptoms, in individual cases 
are, — the mildness and comparative shortness of the exacerbation, the completeness and 
long duration of the remission, particularly when this is accompanied by a free and diffused 
perspiration, and the patient falls into a quiet and refreshing sleep ; the postponement of 
the succeeding exacerbations beyond their anticipated periods; the diminution or removal 
of the tendency to disease of particular organs; the occurrence of more regular and healthy 
discharges from the bowels; the tongue becoming cleaner and the pulse slower and leSsS 
frequent, &c. 

The bilious remittent fever, as we have already remarked, is a disease of hot climates 
and of the season of greatest heat; thus, while it constitutes the summer endemic of the 
southern portion of our Union, it seldom occurs in the middle and northern states excepting 
during those summers that are marked by an unusual elevation of temperature, and here, 
as well as in the places where it prevails endemically, it ceases as the winter approaches. 
Whether the fever can be produced by exposure alone to a high degree of atmospherical 
temperature, is a question that has been frequently raised, and while many maintain the 
affirmative, others as positively assume the negative. It is very certain, however, that the 
Jong-continued action of excessive heat upon the body, by predisposing it to the action of 
other morbific agents, will, in this manner, often bring on an attack of bilious fever, inde- 
pendently of malarious influences. Thus, nothing is more common than for the disease to 
immediately occur in those who, after exposure to the midday sun, or many hours of severe 
labour in intensely hot weather, allow their bodies to become chilled, by sleeping on the 
ground in the open air after night; by neglecting to change their clothing when they be- 
come wet by a shower of rain or other cause ; or, while the perspiration is running in 
streams from every pore, by throwing off a portion of their clothing, and sitting or lying in 
a draught of air, particularly after sundown. But while many of the sporadic cases are 
produced in this manner, and the same species of imprudence is a common exciting cause of 
the fever when it prevails as an endemic or epidemic, a large number of incontestable facts 
would seem to prove that its more common cause is a poison produced by the action of 
high degrees of solar heat upon such portions of the earth's surface as are ordinarily 
covered or soaked with water, when these are accidentally laid bare, or rendered dry by 
long-continued heat and drought. The presence of substances, whether vegetable or ani- 
mal, liable to decomposition, is to be included among the causes capable of generating 
bilious fever in hot climates, and in the more temperate climates during summers of unu- 
sual heat. In our larger cities the disease always prevails most extensively, and in its more 
malignant forms, in the most confined and filthy districts — to which it is often entirely con- 
fined ; or, when it makes its appearance in other parts of them, it can generally be traced to 
the presence of some local cause of infection. In Philadelphia, where bilious remittent 
fever was formerly a common disease of the summer and early autumnal months, it is now 
of rare occurrence, excepting in its mildest form ; and this disappearance of the disease 
from our city is to be ascribed more to the better construction and cleanliness of our docks, 
and the greater attention which is paid to the paving, draining, and sewerage of our streets; 
to the filling up of the numerous ponds which formerly existed in and about the city, and to 



« 

BILIOUS REMITTENT FEVER. 



991 



the preventing any mass of putrefiable materials from being stored in the city proper and 
surrounding districts, than to any very decided diminution in the temperature of our 
summers. 

In the treatment of bilious remittent fever, the first and most important question that 
presents itself is, the propriety of direct depletion by the lancet. This must be determined 
solely by the character of the symptoms and condition of the patient in each case. In the 
more decidedly inflammatory cases, when the exacerbation is well-marked and prolonged — 
when it is attended by a hot skin, flashed and turgid face, severe pain of the head and back, 
great oppression about the prascordia, and a firm or chorded pulse — and when the intermis- 
sions are short and imperfect — more particularly in cases occurring in young, robust, and 
plethoric habits, and who have but lately arrived from a colder climate, there can be no doubt 
of the importance of blood-letting. In such cases a vein in the arm should be opened at the 
early period of the attack, and a sufficient amount of blood drawn off at once to reduce the 
violence of the exacerbation; one sufficient bleeding at the onset of the disease is far more 
efficacious and better adapted to prevent local determination than the repeated detraction of 
small quantities of blood during its course. A repetition of the bleeding will seldom be de- 
manded when the first operation has been carried to a sufficient extent ; should, however, 
the succeeding exacerbation be marked by any degree of violence we should not hesitate 
again to resort to the lancet; but the loss of a less amount of blood will be required to 
reduce the excitement than in the first instance. If direct depletion by the lancet has been 
neglected in the early stage of the disease, it will seldom be admissible subsequently — or, 
should symptoms seem to demand it, it should be employed with the utmost caution, and 
only to a moderate extent. 

That numerous cases of bilious fever occur in which venesection is altogether unneces- 
sary is unquestionably true; in those, however, that are marked in their early stage by a 
high degree of arterial excitement, and a tendency to local hyperamia or inflammation, the 
remedy cannot be dispensed with without danger to the patient. When timely employed, we 
have repeatedly been surprised at the very great and prompt relief produced by it — the vio- 
lence of the exacerbations becoming reduced, the intermissions more complete, the skin 
cooler and more relaxed — the pain of the head relieved — the bowels readily acted upon; 
and a state of calmness, often of refreshing sleep, mil often succeed to the previous rest- 
lessness and distress. 

Local blood-letting is a remedy more generally demanded in bilious remittent fever than 
bleeding from the arm. — In all cases attended with intense pain of the head, throbbing of 
the temples or delirium — or with pain or decided tenderness of the epigastrium and right 
hypochondrium, or with pain and a sense of tightness, or oppression about the thorax — in 
conjunction with general bleeding, or where this has not been judged necessary, the appli- 
cation of leeches or cups in the neighbourhood of the local suffering, in numbers propor- 
tionate to its intensity and to the age and condition of the patient, will invariably be followed 
by decided and, generally, permanent relief. The very great suffering which many patients 
experience from pain in the back and loins, we have, in repeated instances, known to be 
completely relieved by cups applied along the spine. 

In regard to the propriety of cathartics in the treatment of bilious remittent fever, there is 
a much greater unanimity of opinion than in relation to blood-letting. There are few, if any 
cases, in which their operation will not be found beneficial, by removing from the intestines 
the vitiated secretions with which they are often filled — procuring regular stools, and by 
assisting to reduce the congestion of the portal system, and thus restoring the healthy func- 
tions of the liver and digestive organs generally. 

It is not, however, every purgative from which good effects are to be anticipated in bili- 
ous fever. — Under the free employment of certain cathartics the patient will often be found 
gradually to become more and more debilitated, and finally to sink into a state of stupor, 
with suffused eyes, weak, fluttering pulse, and other symptoms of extreme exhaustion; in 
such cases it will be found that the discharges from the bowels consist of a thin, serous 
fluid; whereas, under the employment of such purgatives as produce consistent, viscid and 
dark-coloured stools, the indications of improvement in the symptoms of the disease are often 
prompt and striking. Calomel is probably one of our best cathartics in this disease. It may 
be given either alone, in a full dose, and followed by occasional doses of castor oil — senna 
tea — calcined magnesia — or laxative enemata; or the calomel may be combined with rhu- 
barb, or jalap; or what is frequently a more effectual plan, a full dose of the calomel ad- 
ministered at first, and then, every three or four hours, according to the effects produced, 
moderate doses of the blue mass and rhubarb, with the addition of a small portion of 
ipecacuanha. By these means we shall generally succeed in freeing the bowels of the 
dark-coloured, viscid matter with which they are often loaded, and procuring more regular 
and healthy stools — after which, an occasional dose of the milder laxatives will alone be 
required. 

In all cases of bilious remittent fever attended with a hot and dry skin, the application 
of cold to the surface, either by sponging it with cold water or cold water and vinegar, or by 
the application of cold water in the form of affusion, will have the effect, while it reduces the 



992 



BILIOUS REMITTENT FEVER. 



morbidly increased temperature, of relaxing the skin, and promoting perspiration, and in this 
manner of shortening the exacerbations and inducing a complete intermission; even the ex- 
posure of the body to a current of cool air — by throwing off the clothing and opening the doors 
and windows of the patient's chamber, will in most cases be productive of the most beneficial 
effects. The mere immersion of the hands and arms in cold water, by carrying off a portion 
of the morbid heat and allaying thirst and restlessness, will be found grateful to the patient 
who not unfrequently will fall immediately afterwards into a refreshing sleep — whenever, 
however, the exacerbation is attended by intense heat of the surface and other symptoms of 
violent excitement,it is from the application of cold water to the surface by affusion or spong- 
ing that the most prompt and permanent advantage is to be obtained. Dr. Dickson ranks 
it among the most efficient of our febrifuge measures — far above the lancet both in the ex 
tent of its adaptation, and in its degree of specific utility. All that we can hope or anticipate 
from blood-letting may be obtained, in the majority of cases, from the use of the cold bath, 
while the latter possesses this striking and obvious advantage, that we can repeat it as often 
as the symptoms are renewed thatrequire its employment. The local determination which it 
controls most promptly, he very correctly remarks, is that to the brain, shown by headache, 
flushed face, red eye, delirium, &c, with a full, hard, bounding pulse. In such cases the 
patient being seated in a convenient receptacle, a large stream of cold water should be 
poured over his head and naked body from some elevation, and continued until he becomes 
pale, or his pulse loses it fullness, or his skin becomes corrugated and he begins to shiver; 
he should then be dried and placed in bed, with just so much covering as he feels to be 
comfortable, the chamber being, at the same time, fully and freely ventilated; or without 
removing the patient from the bed, he may be supported in a leaning posture over its edge 
and the cold water poured from a pitcher over the vertex. 

The application of cold water* to the surface is proper only when the temperature of the 
latter is considerably and permanently increased over the whole body, and at the same time 
the surface is perfectly dry — when the skin is cool or covered wilh moisture, the use of the 
cold water is inadmissible; itis also of doubtful propriety when there exists a decided tend- 
ency to hyperaemia or inflammation of the lungs, or in cases attended with diarrhoea. Its 
repetition is forbidden when it has occasioned a protracted chill or rigor; or the patient 
continues to feel cold or uncomfortable after its use. 

The testimony of Dr. Dickson in relation to the curative powers of cold water applied to 
the surface in the bilious remittent fevers of the south is strong and pointed, and is fully 
borne out by the experience of physicians of other portions of the United States and of 
Europe, who have extensively employed it in the disease under consideration. Equally 
important with the external employment of cold water is its use internally; — allowing the 
patient to drink freely of cold, or even iced water, or iced lemonade is not only highly 
grateful to him, but it tends to diminish the morbid excitement, relax g the skin, and pro- 
mote a free and uniform diaphoresis. 

Diaphoretics, particularly a combination of tartar emetic, nitre, and calomel, have been 
recommended and highly extolled by many practitioners, in the inflammatory forms of 
bilious fever. We have occasionally employed the combination just mentioned, but have 
never seen any decidedly beneficial effects produced by it, while the emetic tartar, in how- 
ever minute doses administered, we have found, very generally, to augment the irritability 
of the stomach, and increase in this manner the distress of the patient. The neutral mix- 
ture, spirits of mindererus with the sweet spirits of nitre, or a weak solution of nitre in 
water, we have occasionally employed, but we must frankly confess, that we are not aware 
of any benefit resulting in a single case from the administration of either. 

Upon the propriety of blisters in bilious remittent fever, there exists not a little dispute, 
their use being entirely condemned by some practitioners, while others rank them among 
our most valuable remedies. In the more inflammatory forms of the disease, until the 
violence of the exacerbation has been reduced, by the remedies already detailed, from the 
application of blisters more injury than good will unquestionably result, but, as soon as the 
exacerbations have become less intense, and the remissions more marked, in all cases 
where considerable gastric distress remains, or any considerable affection of the head or 
lungs, from blisters over the epigastrium and right hypochondrium, to the nape of the neck, 
along the spine, or to the chest very considerable and prompt relief will always be obtained. 

In many cases of bilious fever there is so great a degree of irritability of the stomach, 
that not only is everything taken into it rejected as soon as it is swallowed, but the patient 
is tormented with almost constant vomiting or frequent ineffectual efforts to vomit. This 
distressing symptom will, very often, be completely removed by the abstraction of blood 
from the arm, whenever this is admissible, or by cups or leeches over the epigastrium, or 
by a large blister applied to the latter part. Relief will also be obtained from small po tions 
of ice held in the mouth — from the effervescing draught, the artificial mineral water of the 
shops, taken perfectly cold, or from iced lemonade or toast water. Minute doses of calomel, say 
a third to half of a grain, suspended in some simple mucilage, and repeated at short intervals, 
will, very generally, promptly relieve the gastric irritability and suspend the vomiting. In 
cases where every other remedy has failed in relieving the irritable state of the stomach, 



BILIOUS REMITTENT FEVER. 



993 



we have repeatedly seen it promptly removed by a grain of the acetate of lead, given every 
hour or two, dissolved in a small quantity of water. 

By a few practitioners a mercurial course is recommended in all the more violent forms 
of bilious remittent fever. Calomel is directed to be given first, in large doses as a purga- 
tive, and subsequently, in small doses continued until its specific effects are obtained — our 
own experience is not, however, in favour of this practice. In the inflammatory form of 
the disease a mercurial impression is calculated rather to protract than to diminish the 
suffering and danger of the patients, while the milder forms of the fever may be readily 
controlled without it. Cases, however, occasionally occur in which an alterative course 
of mercury will be found, we are convinced, highly advantageous. We have repeatedly 
observed, that after the violence of the exacerbations have been reduced, the patients will 
continue to be affected by a low form of fever, marked by a dry skin, a small irritated pulse, 
a dry dark-brown tongue, frequent watery discharges from -the bowels, restless nights, and 
a total want of appetite, and have found this condition of things to be speedily removed by 
a cautious mercurial course, carried to the extent of producing a slight tenderness of the 
gums. In these cases small doses of calomel, or what is preferable, the blue mass, combined 
with a portion of opium and ipecacuanha, may be given every three hours until the de- 
sired effect results. A form of the disease somewhat similar to the one just referred to is 
described by Eberle as occurring, "when, either from the imprudent employment of irri- 
tating purges, or from other causes, the mucous membrane of the intestinal canal is brought 
into a state of high irritation or subacute inflammation. The disease then generally loses its 
remittent form, and often assumes a low typhoid character, with almost constant delirium, a 
tender and tympanitic state of the abdomen ; a dry, dark-brown, or black crust on the tongue, 
with clean red edges; watery and reddish stools; great prostration; and a very dry and hot 
skin. Cases of this kind frequently run on for several weeks; and the convalescence is 
always very gradual and tedious." The treatment directed by Dr. Eberle is leeches to the 
abdomen, followed by a large emollient poultice; small doses of calomel and opium — one- 
sixth of a grain of the former to a quarter of a grain of the latter — every two or three hours. 
The bowels to be kept open by laxative enemata, and the patient directed to partake freely 
of some bland mucilaginous fluid — such as barley water, very thin oatmeal gruel, or a 
solution of gum acacia in water; no other article of food being allowed. " In such cases," 
he remarks, "I have thought that considerable benefit was derived from epispastics on the 
legs just above the ankles; this measure is particularly useful when the extremities are 
cool, while the skin of the body is hot — a circumstance which is not uncommon in instances 
of this kind. An emulsion of balsam copaiba may also be frequently employed with un- 
equivocal advantage. I have so often seen the most decided benefit derived from this 
article, in cases attended with great irritation or subacute inflammation of the bowels, that 
I should consider myself neglecting an important curative means, were I to omit prescribing 
it in diseases of this character." — "Although very considerable prostration often occurs in 
such cases, stimulants or tonics are by no means admissible." 

Throughout the entire course of bilious remittent fever, little desire for food will be ex- 
pressed by the patient, nor should any be allowed until after the disease is fully subdued; 
and then only barley or rice water, thin gruel or panada, in very moderate quantities. 
To allay the thirst, which is always present and frequently very urgent, the cold drinks, 
already pointed out, will be the most suitable. Perfectly cold toast water, slightly acidulated 
with lemon or orange juice, tamarinds, or currant or plum jelly, forms generally a very 
palatable beverage, of which the patient may partake at short intervals. Small quantities 
of cold acidulated fluids, slowly swallowed, it is to be recollected, are far more efficacious) 
in allaying thirst than large draughts hastily swallowed. Frequently sponging the patient's 
mouth with cold water, cleaning his tongue with a slice of orange or allowing him to suck 
the juice of the latter, will aid very materially in abating his sense of thirst, and is always 
refreshing to him. 

The chamber of the patient should be kept perfectly clean and cool, and while a free 
ventilation is kept up, it should be guarded from any glare of light. His body should be 
slightly covered with bed-clothes, which, together with his linen, should be frequently 
changed. At all times the patient should be kept perfectly quiet, and the most perfect 
calmness and quietness should be maintained within and around his apartment. 

In our enumeration of the symptoms of bilious fever, it was stated that great restlessness 
and wakefulness were very commonly present. So long as the period of increased excite- 
ment lasts, or there is any tendency to disease of the brain, the only means by which the 
restlessness of the patient is to be subdued and sleep procured are the general remedies that 
have been already enumerated; but after the morbid excitement, and whatever cerebral 
affection that may exist have been reduced, a state of restlessness and an inability to sleep 
often still continue from mere nervous irritability, when the exhibition of an opiate in the 
form of Dover's powder, about bed-time, will very generally be found advantageous: by 
some practitioners the extract of hyoscyamus combined with ipecacuanha is preferred to any 
preparation of opium, while others again, recommend the tincture of opium combined with 
63 



994 



BILIOUS REMITTENT FEVER. 



a vegetable acid, as Tinct. opii gss. Acid, citric, gr. v to viij, Aq. pura ^ij., m. ; of which a 
tablespoonful or half an ounce is a dose, to be repeated, if necessary, after a short interval* 

We have now presented a general outline of the treatment of bilious remittent fever in 
its mild and inflammatory forms. It is hardly necessary for us to repeat, that the extent to 
which each remedy is to be carried, and the propriety of its repetition, and continuance as 
well as the period and particular circumstances of the disease to which it is adapted, 
must be determined by the application of the general principles of pathology and thera- 
peutics to each case we are called upon to treat; and although this will demand a degree of 
judgment in the practitioner, which he can only acquire by habits of close attention and 
nice discrimination, and a somewhat extended field for observation, it is the only course 
from which success can be anticipated in the treatment of a disease, which, like the one 
under consideration, varies so much in its character in different seasons and localities, and 
even in different indviduals attacked at the same place and during the same period. 

When the disease, notwithstanding our best directed efforts, runs on to that stage when 
its symptoms resemble those of the last stage of typhus fever, nothing is left us but to en- 
deavour to sustain the patient's strength, and remove or relieve any urgent cause of dis- 
tress or danger. He should be allowed such nourishing food as is easy of digestion, 
as beef tea, sago, arrow root and the like, with wine — whey, wine, pure or diluted, porter, 
milk — punch or brandy, in quantities adapted to the emergency of the symptoms and the 
effects produced. Sinapisms or blisters may at the same time be applied to the inside of the 
thighs or calves of the legs, and to the epigastrium. If diarrhoea be present, this we should 
attempt to abate or suspend by opiate and astringent injections. The singultus which is 
often present to a very distressing degree, may be frequently allayed by the camphor julep, 
and the meteorism of the abdomen may often be considerably relieved by the spirits of 
turpentine — thirty drops of which may be given every two or three hours — this latter is said 
indeed to be among the safest and most useful remedies at this stage of the disease — it will 
often be found to produce a beneficial impression upon the diseased mucous membrane of 
the alimentary canal, to suspend the frequent griping stools, and to correct the morbid 
character of the discharges. In the sinking stage of bilious remittent fever, the effects of 
ammonia, with a strong decoction of serpentaria or valerian, or combined with the aromatic 
confection, have been represented as peculiarly beneficial ; but, unfortunately, when the 
disease has arrived at this stage, every remedy will too often be found unavailing and our 
best directed efforts to save the life of the patient ineffectual. 

A question has been agitated both as to the propriety of and proper period for the ad- 
ministration of cinchona or quinia in remittent fever. Without attempting to detail the 
various and opposite opinions that have been advanced upon this subject, we shall merely 
remark, that in the simple and inflammatory forms of bilious remittent fever, it would be 
reasonably inferred from the character of the disease that the bark or quinia is not a remedy 
adapted to control the symptoms of its earlier stages, and the correctness of this inference 
has been very fully established by the result of experience. So soon, however, as a com- 
plete intermission has been obtained, and no indications of visceral hyperaemia or inflam- 
mation are present, a cautious administration of the cold infusion of the cinchona, combined 
with serpentaria or some agreeable aromatic, will be found, in general, to cut short the 
remaining symptoms of the disease and accelerate the period of convalescence. The qui- 
nine may be given in solution with the addition of a few drops of the elixir of vitriol, and to 
the extent of from three to five grains, repeated at such intervals as the circumstances 
of the case may demand. The more violent the form of disease has been, the more im- 
portant is the administration of the quinine so soon as a complete remission has been ob- 
tained, and the larger should be the dose of the remedy. 

During the period of convalescence the patient should be guarded from the effects of 
any sudden transitions of temperature, and from incurring the least degree of fatigue by 
sitting up too soon or for too long a period, and while his mind should be occupied and 
amused, at proper times of the day, by the conversation of his friends, or some light occu- 
pation, fatigue from this source must also be avoided. His bowels are to be kept regularly 
open, which may generally be done by allowing him to partake, in moderation, of any of 
the perfectly ripe subacid fruits of the season ; if they, however, should become closed, some 
mild laxative should be occasionally administered. In regard to diet much caution is to be 
observed. The patient should be confined at first to moderate quantities of the more agree- 
able farinaceous articles — and if his strength has been greatly prostrated, a glass or two of 
sound wine will not be improper. — As his digestive powers improve he may be allowed 
plain beef or chicken broth, oysters slightly cooked, parboiled eggs, and finally, the lighter 
and more readily digested meats, plainly but nicely cooked. The appetite often remains 
for a long time, weak and capricious — and frequently, some agreeable bitter infusion as 
Colombo, quassia or the wild cherry tree bark will be proper to augment the tone of the 
stomach. In all cases the food of the patient should be presented to him in small quantities 
and served with great neatness — large masses of food, slovenly prepared and served, will 
in general disgust, and thus destroy what little appetite may exist. In regard to exercise, 
and exposure to the open air, the convalescent should undertake only so soon as he has 



BILIOUS REMITTENT FEVER. 



995 



acquired some degree of strength, when a trip to some agreeably situated watering place 
will often restore him to perfect health, more quickly than can be effected during his continu- 
ance at home — where his mind is too early directed with anxious care to the concerns of his 
family and of his profession. 

In the congestive form of bilious fever, the indications of cure are, to rouse the nervous 
energies of the system, to relieve as quickly as possible the central organs from their state 
of hyperemia, and to restore to the capillaries of the surface their healthy action. Among 
the most important of the remedies calculated to effect these objects, is the external appli- 
cation of heat to the surface of the body in the form of the warm or hot bath, the vapour 
bath, or in a dry form by bags of heated bran, salt or sand, bottles of hot water, &c. We 
shall often succeed in rousing the patient by immersing the whole of his body, as early as 
possible after he is attacked, in water, of a temperature proportioned to the urgency of his 
Symptoms ; that is, of a greater or less degree of heat, within proper limits, according as 
the temperature of the skin, the state of the pulse, and the general strength is more or less 
depressed, and the greater or less degree of torpor of the nervous system ; at the same 
time applying brisk friction with a soft brush or a flannel cloth, to the whole surface, and 
particularly to the epigastric and abdominal regions. On coming out of the bath the 
patient is to be rubbed dry with heated flannels, put into a well-aired bed between blankets, 
and supplied with some mild diaphoretic drink, as the infusion of serpentaria, of tepid 
warmth. A full dose of the Dover's powder, or a combination of opium, camphor and 
ipecacuanha, one grain each, with ten of nitre, given at this period, will often be found 
par ticularly beneficial. 

Next in efficacy to the warm bath, we may rank external stimulants — sinapisms should, 
therefore, be early applied to the extremities and over the epigastrium, while frictions, with 
some stimulating liniment, are made along the spine. By some practitioners internal 
stimulants have been strongly recommended, as a means of rousing the central organs from 
their state of torpor, and bringing on a general and moderate reaction — it is probable that in 
certain cases, where the state of congestion is very considerable, and it is not promptly and 
permanently relieved by the remedies already recited, some mild stimulant, as the ammo- 
nia, or turpentine, or wine whey, may prove advantageous if cautiously administered and 
its effects carefully watched; as a general rule, however, the free use of stimulants, par- 
ticularly of the more active class, is calculated to produce injury rather than good. 

An active cathartic, as the combination of calomel or blue mass with aloes and extract 
of colocynth, followed in a few hours by the compound infusion of senna, will very gene- 
rally cause a copious discharge from the bowels, of a dark-coloured, tenacious matter, and 
by thus assisting to unload the portal system, will often produce a marked improvement in 
the general symptoms of the disease. In the treatment of congestive bilious fever, the 
abstraction of blood from the arm, in the first period of the attack, or, subsequent to the 
use of the warm bath and frictions to the surface, has been recommended by many practi- 
tioners as an important remedy — one indeed from which more prompt and certain relief is to 
be obtained than from any other that we can employ. The evidence in its favour is certainly 
very strong; and we believe that there are many cases in which prompt reaction may be 
produced, and the danger of permanent local disease prevented by its employment. The 
greatest judgment and caution, however, are demanded in the use of the lancet in all cases 
of congestive disease; the effect produced upon the pulse must be carefully watched, and 
the flow of blood instantly stopped if any disposition to sinking is detected. To determine 
beforehand the amount of blood that it will be proper to take away is impossible — the effects 
produced — the relief obtained are the only guide. Even, however, when during the flow of 
blood the pulse becomes more free and developed, but a moderate quantity should be taken 
away at once — should we have to repeat the operation after a short interval. Occasionally 
but a drop or two of blood will escape from the vein when it is first opened, but, after a 
short time, the circulation becoming more free, the blood flows in a full stream, with deci- 
ded relief to the patient. It is only, however, in the early stage of the highly congestive 
forms of bilious fever that venesection is admissible, and even in these the flow of blood 
should be instantly arrested if the pulse is found to sink, or even to remain oppressed and 
undeveloped after a small quantity has been lost. 

When prominent symptoms of hyperaemia of the brain, lungs, or other important viscera 
present themselves, the application of cups to the head, chest or in the neighbourhood of 
the affected organ will often be found decidedly advantageous. 

As soon as reaction takes place, the use of quinia should be commenced with, in large 
doses, repeated at short intervals. — Of the curative powers of the quinia in this form of fever 
we have the fullest and most unquestionable testimony. — Many of the physicians of the 
southern and western portions of the United States place their chief reliance, in congestive 
remittent fever, upon the sulphate of quinia prescribed in enormous doses — twenty — thirty 
and even fifty grains repeated at short intervals until a solution of the disease is obtained ; 
but although we are convinced of the propriety of large and frequent doses, those alluded to 
are certainly excessive and uncalled for. 



996 



SMALL-POX. 



The period of convalescence from the congestive form of bilious fever will require the 
same management as that from the more open and inflammatory forms. 

In the highly malignant remittent, occasionally met with, in which the vital forces, 
crushed at once by the overwhelming intensity of the morbid cause, fail apparently to ex- 
hibit any resistance or reaction; they must be sustained, to use the words of Dr. Dickson, 
{Essays on Pathol, and Therapeut., vol. i. p. 3L9,) by every means within our power, while 
we have immediate recourse to the most impressive revulsives. The hot bath, sinapisms, 
vesicatories, must be quickly and assiduously applied, while we stimulate, by the freest use 
of internal remedies — carefully selecting such as are best adapted to the circumstances 
presented. If, as is often the case, the patient suffers severely from pain in the chest or 
abdomen, large doses of opium or morphine must be administered, while we keep up his 
sinking strength by brandy, ammonia or ether. In the superintendence of such cases we 
should rather incur the risk of over-stimulating transiently, than fall below the requisite 
point of excitement in our use of stimulants. Dr. Dickson is fully persuaded, that he has 
seen more than one patient die from the timidity of his physician in this respect; who 
keeping at acautious distance behind the disease, would not venture on the exhibition of any 
excitant adapted to the feeble excitability, until the vital energies upon which alone stimu- 
lants can act, had become worn out and exhausted. If the stomach will bear it, it will be 
proper to administer, also, some of the preparations of cinchona. The sulphate of quinia in 
full doses will be often retained and do good. "Alternate, combine.^nd recombine your 
stimulants, the effects of which may perhaps be aided by warm and nutritious fluids, wine 
whey, arrow root with wine, wine alone or spiced, brandy with milk or in mucilage. These 
energetic measures will usually be found effective within a very short period — improving the 
pulse, and arousing the general powers of the system. Yet you must not permit yourselves 
to be disheartened into inaction by their apparent inefficacy or slowness of impression. 
Persevere, not only while there is a reasonable hope, but even after all hope seems extin- 
guished ; and you will feel yourselves amply repaid by the gratification, which will not 
perhaps be denied you, of saving more than one fellow-creature from the destruction which 
seems inevitably to await him." — C] 

I pass, without pausing, from the consideration of continued fever, to that of 
small-pox or variola: a disease, fortunately, less common in this country than it 
used to be, yet still sufficiently frequent and formidable to require that we should 
acquaint ourselves with the phenomena it is accustomed to present; and very 
prevalent here, as it happens, at present (1838). I have already mentioned, by 
anticipation, several points in its history. 

This frightful disease sets in with smart febrile symptoms : rigors, followed by 
heat and dryness of skin, a hard and frequent pulse, pain in the epigastrium, with 
nausea and vomiting, and headache. Sometimes wild delirium, sometimes con- 
vulsions, mark its outset. Then, to use the words of Cullen's definition, " tertio 
die incipit, et quinto finitur, eruptio papularum phlegmonodearum, quae spatio 
octo dierum, in suppurationem et in crustas demum abeunt, saepe cicatrices de- 
pressas, sive foveolas, in cute relinquentes." 

When small-pox is fully formed, itcannot be mistaken for any other complaint: 
but it is of some importance to recognize it at its very commencement, for the 
force of the impending disorder may sometimes be lessened by judicious measures 
adopted at that early stage. The symptoms, however, that mark the outset of all 
febrile diseases are necessarily very much the same. If the pyrexia set in when 
small-pox is prevalent in the neighbourhood, if the person in whom it occurs be 
an " unprotected" person (i. e., one who has neither been inoculated nor vacci- 
nated previously), and especially if he be known to have deen exposed, within 
from nine or ten days to a fortnight, to the contagion of variola, we may well 
suspect that the disease will turn out to be small-pox, and act upon that suspicion. 

Nevertheless there are some symptoms which, being common in the commence- 
ment of variola, and not common at the beginning of continued fever, or of the 
other exanthemata, may assist the early diagnosis. Vomiting is one of these; 
pain of the back another. When these symptoms are violent, they usually usher 
in a severe form of the disease. The same may be inferred from a continuance of 
the nausea and vomiting, after the coming out of the eruption; which is very 
unusual. Heberden noticed that acute pain in the loins was almost always fol- 
lowed by a severe disorder; that pain higher up, between the shoulder, was of 



SMALL-POX. 



997 



better augury ; and that it was to be reckoned in all cases a good sign, if there 
was no pain of the back at all. Early delirium, stupor, or convulsions, announce 
severity in the subsequent course of the malady. Yet not always, especially in 
children. Within the last month I was asked to see a child which had been sud- 
denly attacked with convulsions, followed by coma. In due time the eruption 
of variola appeared, and the disease ran a mild course, with little aid from medi- 
cine, although the child was previously unprotected. 

The peculiar eruption almost always begins to show itself on the third day of 
the fever. The earlier it comes, the severer generally does the disorder prove. 
In judging of the date of the eruption, you must bear in mind that parents and 
servants are apt to state its accession to have been later than it was in reality: for 
the spots are at first so minute that they often escape observation. They also 
frequently begin to come out in the night; and the morning of the second day of 
the eruption is called the first day. 

The eruption comes out first on the face, then on the neck and wrists and on 
the trunk of the body, and lastly on the lower extremities. Such is the rule ; so 
that (as is specified in the definition) it does not cease to come out till the fifth 
day : and it keeps a-head, in that order, throughout the disease. There are, 
indeed, some exceptions to this rule. Occasionally the spots appear first upon 
the extremities, but this is very rare. In some instances straggling papulae con- 
tinue to spring up after the main crop is fairly completed ; but these stragglers 
seldom arrive at the same size with the others. 

The pimples, or papulae, ripen gradually into pustules , the suppuration being 
complete by their eighth day; and on that day the pustules generally begin to 
break, and crusts or scabs to form. In four or five days more the scabs are falling 
off. There are some variations in all this also. In children, the crusts are some- 
times visible on the seventh day: and in adults, when the disease is severe, they 
sometimes do not begin to form till the ninth day. In all cases some of the pus- 
tules are liable to be prematurely broken, by accident, or by the patient's scratch- 
ing; and these will crust over earlier than they otherwise would have done. So 
that in fixing the period of incrustation, you are to regard those pustules only of 
which the natural progress has not been interfered with. 

All that I have hitherto been saying, applies, with more or less exactness, to 
the disease in all its varieties. But its severity differs exceedingly, as I have 
already hinted, in different cases. Its severity, in truth, is almost always in direct 
relation to the quantity of the eruption. The number of pustules indicates, in 
the first place, the quantity of the variolous poison which has been reproduced in 
the blood. In the second place, it is also a direct measure of the extent to which 
the skin suffers inflammation. Sometimes there are not more than half a dozen 
pustules; sometimes there are many thousands. If all these were collected into 
one, it would be an enormous phlegmon. For both these reasons the system 
suffers commotion, distress, and peril, in proportion to the quantity of the eruption. 

When the pustules are very many, they run together; when they are few, they 
are separate from each other. And this affords a broad line of distinction, which 
can neither be overlooked nor mistaken, into the variola discreta, and the variola 
confliiens. In the one, the pustules are distinct, and of a regularly circumscribed 
circular form. In the other they coalesce, and their common outline becomes 
irregular. Now the discrete form of the disease is scarcely ever dangerous ; the 
confluent form is never free from danger. The distinction therefore is of the 
greatest importance and interest. For its full estimation, each form must be con- 
sidered separately. 

In the discrete variety, in which the disorder may be presumed to run its most 
natural course, the eruption is at first, according to the phraseology of Willan, 
papular. The pimples gradually increase in magnitude, but it is not till the third 
day of their appearance that they begin to contain a little fluid. on their summits. 

For two days after this they increase in breadth only, and a depression is ob- 
servable in the centre of many of them. The cuticle is bound down there some- 



998 



SMALL-POX. 



how, for a time, to the cutis vera. It is the eighth day of the disease, or the fifth 
day of the eruption, before the pustules become perfectly turgid and hemispheroidal. 
During the time in which they are thus filling up, the face swells ; often to so 
great a degree that the eyelids are closed, and the natural aspect is completely 
changed or concealed. The skin between the pustules on the face assumes a 
damask red colour. About the eighth day of the eruption a dark spot makes its 
appearance on the top of each turgid pustule, and at that spot the cuticle breaks, 
a portion of the matter oozes out, and the pustule dries into a scab. When this 
crust at length falls off, it leaves behind it either a purplish red stain, which is still 
very characteristic of the disease, and which very slowly fades ; or a depressed 
scar, which is indelible. In the latter case the patient, or more properly his skin, 
is said to be pitted w'nh the small-pox, or pock-marked. The swelling of the 
face begins gradually to diminish after the eruption has become thoroughly pustular. 

This is the course which the eruption pursues on the face, where the pustules, 
even in the discrete form of the disease, are usually thicker set than on any other 
part of the surface. And it pursues the same course, only two or three days later, 
upon the extremities, where it also begins later. The feet and hands swell just 
as the face swelled, but they begin to tumefy as the features begin to subside. 
Some of the pustules, especially on the extremities, do not burst at all, but 
shrivel up. 

In this, the distinct variety of the disorder, the fever generally ceases entirely 
upon the coming out of the eruption: the headache, the pain of the back, the 
vomiting, the restlessness, abate and disappear, the pulse resumes its natural force 
and frequency, and the skin its natural temperature. About the seventh or eighth 
day of the eruption there is commonly for a day or two a recurrence of fever. 
This is called the fever of maturation. 

You are to observe that we judge of the eruption as it appears on the face. 
The disease is of the confluent kind, when the pustules are confluent there, 
whether they be so or not upon the trunk and extremities. Sometimes they are 
neither strictly confluent nor strictly separate, but stand just thick enough to touch 
each other, without absolutely coalescing ; every pustule preserving its circular 
outline. In that case the disease is said to be of the cohering form. When the 
pustules are confluent over the whole body, their number is often prodigiously 
great, and their progress is less regular than in the discrete and milder variety of 
the complaint. 

In the first place the eruptive fever itself is usually more violent and tumultuous 
in the confluent disease : the disturbance of the sensorial functions is more common 
and more decided, the sickness more distressing, the pain of the back and loins 
more severe. The eruption comes out earlier, and more confusedly; the pimples 
being at first very minute, and crowded together in patches, and not seldom accom- 
panied by a rash like that of scarlet fever, or erysipelas : whereby the diagnosis, 
in so far as it depends upon the appearance of the skin, is rendered for a while 
uncertain. I have at present in the Middlesex Hospital a patient in whom the 
papulae of small-pox were, at the outset, so intermingled with the appearances 
and sensations of urticaria, that I doubted, for twenty-four hours, what the true 
character of the eruption might be. It is sometimes like that of measles; but the 
similarity and the uncertainty are soon at an end, for the pimples soon begin to 
exhibit a fluid on their summits. They do not, however, as they advance, and 
pass into pustules, fill up so completely as in the distinct form ; they are flatter, 
less plump, more irregularly depressed, and even of a different colour; being at 
first whitish and then of a brown tint, and seldom of the yellow purulent hue 
which is seen in the variola discreta. Sometimes they are even bluish, or purple. 
In the confluent form there is commonly some abatement of the febrile distress 
upon the coming out of the eruption, but the remission is much less marked than 
in the discrete. About the fifth or sixth day fresh rigors are apt to occur, marking 
the fever of maturation. Most of these points of distinction between the two 
varieties of the disease are, well marked in Cullen's definitions, The distinct 



SMALL-POX. 



999 



form he defines thus: "Variola (discreta) pustulis paucis, discretis, circumscrip- 
tione circularibus, turgidis ; febre, eruptione facta, protinus cessante." And of 
the confluent kind his definition is " Variola (confluens) pustulis numerosis, con- 
fluentibus, circumscriptione irregularibus, flaccidis, parum elevatis ; febre post 
eruptionem perstante." 

But the most important difference between the two forms is in what is called 
the secondary fever, which sets in about the eleventh day of the disease, or the 
eighth of the eruption, just when the maturation of the pustules is complete, and 
they begin to desiccate. This secondary fever is slightly marked in the distinct 
small-pox, and very intense and perilous in most instances of the confluent. It 
is at this period of'the disorder, that death, in the fatal cases, oftenest occurs. Of 
168 such cases, recorded by Dr. Gregory, the deaths happened in twenty-seven 
(nearly one-sixth of the whole) upon the eighth day of the eruption. That, therefore, 
is the most perilous day, as the second is the most perilous week. Thirty-two 
died in the first week, ninety-nine in the second, twenty-one in the third. The 
early occurrence of death denotes a peculiar malignancy in the disease. The 
nervous system appears to be overwhelmed by the force of the poison. During the 
second week the disorder proves fatal chiefly in the way of apncea ; from some 
affection of the respiratory passages. After that period the characters of asthenia 
commonly predominate. The patient sinks under some casual complication, or 
the powers of life are gradually worn out by so much irritation of the surface, and 
so large an amount of suppuration. 

So much for the ordinary course of small-pox, and of the symptoms that are 
essential to that disease. There are, however, other concomitant circumstances, 
with which you ought to be acquainted: and these I will endeavour to specify at 
our next assembling. 



LECTURE L XXX VII. 

Small-pox, continued. Inoculation. Vaccination. Their comparative advan- 
tages. Treatment of Small-pox. 

In the last lecture I brought before yon, in a rapid sketch, the ordinary course, 
and the essential symptoms of small-pox; both in its distinct and in its confluent 
form. I have yet to mention some other circumstances that are very frequently 
to be noticed in connection with that disease. 

Both kinds are accompanied by sore throat; the tonsils and fauces are tumid 
and red : and with this sore throat there is associated, about the period when the 
face swells, sometimes in the discrete variety, and almost always in the confluent, 
more or less salivation, which lasts for several days. At first the discharge is 
thin and plentiful; but, towards the period of maturation, it often becomes viscid 
and ropy, and is with difficulty got rid of by the patient. This salivation is of 
some importance as a prognostic symptom. If it cease abruptly, and especially 
if at the same time the swelling of the face suddenly and prematurely subside, the 
peril is great. Besides this, Sydenham regarded the ptyalism as a diagnostic 
circumstance; as a mark which identified with true small-pox a fever called by 
him the variolous fever, the variolse sine variolis of De Haen and others. " The 
resemblance (says he) which this fever bore, in its symptoms, to small-pox, 
induced me to give it the title of variolous fever, which seemed indeed so much 
the more appropriate, as the fever raged at the same time with small-pox, and got 
well under the same treatment. The two diseases belonged evidently to one 
family, and there was no difference between them, saving that in small-pox the 
morbific matter was directed towards the skin, in the shape of an eruption ; while 
in the variolous fever this matter was expelled from the system by the salivary 



1000 



SMALL-POX. 



glands." Notwithstanding this statement, it is difficult to believe that any such 
disorder as variola? sine variolis ever proceeds from the contagion of small-pox. 

This affection of the salivary glands does not so often occur in children ; but 
diarrhoea appears sometimes to take its place. 

The soreness of the fauces often depends, in great measure, upon pustules there 
situate. You may see that the tongue, the roof of the mouth, the inside of the 
cheeks, the uvula, and the velum palati, are thickly studded with them. It is 
affirmed by some writers that the pustules of small-pox occur in various internal 
parts of the body, and especially upon the mucous membrane of the intestinal 
canal. I believe this to be a mistake. The enlarged solitary follicles often put 
on very much the appearance of pustules. Cotunnius, who has written a good 
book, De sedibus variolar um, asserts that pustules appear only upon the skin, and 
upon those parts of the mucous membranes which are freely exposed to the air. 
In one solitary instance he met with them in the trachea so low as its third ring. 
He fancied that previous desiccation of the part was necessary to their formation. 
He says that none appear on the cornea, while it is kept moist. He denies that 
they are seen in the interior of the body, or upon the foetus in utero: but in this 
last point he is certainly wrong: and this is a strong objection to his theory. 
The most striking facts which he alleges in support of his opinion of the neces- 
sary presence of air — besides the fact of the eruption being more copious on parts 
usually exposed to the atmosphere, as the face and hands — are, that pustules do 
not form on the inner surface of the eyelids, except in cases of ectr opium ; that 
they appear on hemorrhoidal tumours only when these project beyond the margin 
of the anus ; and that that portion alone of the glans penis is ever affected by them 
which is uncovered by the prepuce. 

Dr. Gregory, however, states that true variolous pustules do not form upon the 
conjunctival membrane: and that the blindness of one or both eyes which is so 
common a result of small-pox, especially in children, is produced by an intense 
kind of ophthalmia, which sets in at the period of the secondary fever, and rapidly 
involves and spoils the transparent tissues of the organ. 

During the period of maturation, a peculiar greasy, disagreeable odour, quite 
sui generis, proceeds from the body of the patient. If taken into the sick cham- 
ber blindfolded, one might name the disease at once by this smell. About the 
same time also many patients are tormented by itching of the surface ; so that 
they are provoked to scratch off the heads of the pustules : and by so doing they 
often ensure the formation of pits. In many cases of confluent small-pox this 
itching appears to constitute the chief part of the patient's suffering. 

There are various troublesome complications to which, in severe cases of the 
confluent form, the patients are liable during the secondary fever; erysipelatous 
inflammation involving the subcutaneous areolar tissue in various parts of the 
body, and leading to the formation of abscesses ; glandular swellings in the groins 
and axillae, going on sometimes to suppuration ; sloughing sores on the hips and 
sacrum; phlebitis; and in two or three instances I have seen the large joints, 
after death, full of matter. One of the most serious symptoms, at this period of 
the disease, is dyspnoea. The air-passages, and especially the larynx, become 
clogged by viscid mucus, the arterialization of the blood is interfered with, and 
the patient is in danger of suffocation. Occasionally life is suddenly extinguished 
by oedema of the glottis, supervening upon that affection of the fauces which I 
mentioned just now. 

In one most fearful phase of this always formidable disorder, symptoms indica- 
tive of what is called the putrid diathesis manifest themselves — petechias, vibices, 
hemorrhages from various parts of the body. The pustules, instead of being 
plump and yellow, are flat, red, purple, or, blue ; that is, they contain blood, or a 
sanious ichor, in the place of pus, constituting the variolse nigrse of Sydenham, 
the bloody small-pox of Mead. I believe that these appearances augur in all cases 
a fatal result. Hemorrhage from the uterus is not uncommon; and in pregnant 
women abortion, and then, most commonly, death. Heberden says that he exa- 



SMALL-POX. 



1001 



mined, in many instances, the fetuses so parted with, but never could perceive 
upon them any traces of small-pox. His experience, therefore, agreed with that 
of Cotunnius; and we may conclude that infection of the foetus in utero is very 
rare. Yet, unquestionably, it sometimes happens; and the circumstances under 
which it has been noticed are various and interesting. In one instance, related 
by Mr. Flinders, the disorder was eight or ten days later in the foetus than in the 
mother. A woman, near her full time, took small-pox. The pustules were 
mature about the 10th or 11th of June. On the 18ih she gave birth to a full- 
grown boy, upon whose face and body there were many pustules, discrete, and 
nearly ripe. The child died the same night. It is a very curious fact that the 
foetus has caught the disorder, doubtless through the medium of the mother, al- 
though she, having had it previously, was unaffected by the contagion. Dr. 
Mead relates that "a certain woman, who had formerly had the- small-pox, and 
was now near her reckoning, attended her husband in this distemper. She went 
her full time, and was delivered of a dead child. It may be needless to add, that 
she did not catch it on this occasion ; but the dead body of the infant was a horrid 
sight, being covered all over with pustules." In the first volume of the Medico- 
Ciiirurgiccd Transactions, Dr. Jenner gives an account of an infant which, upon 
the fifth day of its age, became indisposed, and on the seventh exhibited the erup- 
tion of small-pox; so that the contagion must have been communicated to it while 
yet in the womb. A few days before her confinement the mother of this child 
had seen, in the street, a person covered with small-pox pustules, the smell and 
sight of whose body had sensibly affected her. I see no reason, therefore, for 
doubting that the unborn being may pass safely through the disease while in the 
womb, and derive from that attack the customary immunity for the future. My 
namesake, Sir William Watson, describes in the Philosophical Transactions, an 
instance in which the scars left by the pustules were visible upon an infant at its 
birth. The child was afterwards inoculated without taking the disease. Its mo- 
ther, who had formerly had it, nursed, when far advanced in pregnancy, a servant 
ill of small-pox. Dr. Pearson met with a similar example. Mary Spooner was 
inoculated by him in her sixth month of uterogestation, and had the disease 
severely. Her child was twice inoculated with small-pox matter, but without 
effect. 

Like all these contagious exanthemata, small-pox has its periods of dormancy 
and of activity. Every now and then, at irregular intervals — and, as it would 
seem to our ignorance of the cause, capriciously — it over spreads a district or 
country as an epidemic. At this moment (1838) it is more prevalent in London, 
and in many parts of England, than it has been known to be for many years past. 
When epidemic, it is also, in general, more than ordinarily severe; although dif- 
ferent epidemics vary much in that respect. 

There is no contagion so strong and sure as that of small-pox : none that ope- 
rates at so great a distance. Dr. Hay garth states, "that during his long attention 
to this subject, not a single instance had occurred to prove that persons liable to 
the small-pox could associate in the same chamber with a patient in the distem- 
per, without receiving the infection." It is readily communicable in every way; 
by inoculation, by breathing a contaminated atmosphere, by the contact or vicinity 
of fomites. Nay, it may be caught from the dead body. Mr. Csesar Hawkins 
has recorded an interesting example of this. The body of a man who died of 
small-pox, was brought into his dissecting room in Windmill Street; and four 
students took the disease from that source. Of these, one only had touched the 
body. 

There is one appearance which I think curious, although, perhaps, it has not 
any great practical interest; and which I omitted to notice in the last lecture, 
when describing the course of the eruption. Without going minutely into the 
anatomy of the pustules, you may distinctly see, if you closely examine them 
when they are about five or six days old — you may see, at least, in many of them 
— two colours, viz., a central whitish disc of lymph, set in, or surrounded by, a 



1002 



SMALL-POX. 



circle of yellower puriform matter. In truth, there is, in the centre a vesicle, 
which is distinct from the pus. You may puncture the vesicle, and empty it of 
its contents, without letting out any of the pus ; or you may puncture the part 
containing the pus, and let that out, without evacuating the contents of the vesi- 
cle. The vesicles have even, by careful dissection, been taken out entire ; and 
they are said to consist of several little cells. It is most probable that the lymph 
contained in this separate vesicle is the purest part of the variolous poison. 

Before I say anything of the measures to be adopted during the progress of 
small-pox, I have to bring under your notice two expedients of still greater interest 
and importance; the one of them contemplating a mitigation of the disorder, the 
other its total prevention. You anticipate that I am about to speak of inoculated 
small-pox in the first instance, and of the vaccine disease in the second. 

I have many times stated, and all the world knows, that small-pox may be im- 
parted to a healthy person by inserting beneath his cuticle a minute quantity of 
the matter taken from a variolous pustule. This, perhaps, is not very surprising; 
but it is surprising that the disease, so received, should be much milder than if it 
had been contracted in what is called " the natural way," by breathing an atmo- 
sphere charged with the contagious poison. Why it should be so it is difficult to 
conjecture. The fact is sometimes expressed by saying that the disease is milder 
when the virus is admitted through the cutaneous, than when through the mucous 
tissues. But I am not at all sure that the hypothesis involved in this proposition 
is true. No attempts have been made, that I know of, to introduce the poison 
artificially through a wound in any mucous surface. I should rather guess that 
the small quantity of the poison conveyed by inoculation into the blood may make 
the difference. But whatever the explanation, the fact is unquestionable, and ob- 
viously of the highest importance. By what accident it was first learned (for it 
evidently could not have been reasoned out) we do not know. The Chinese 
claim to have been in the habit, for many centuries, of sowing the disorder, by putting 
some of the crusts into the nostrils. But this is a different thing from inoculation, 
the surface being entire, and the effluvia from the crusts being drawn into the 
lungs by the act of inspiration. It is said that a true engrafting of the virus has 
been in use by the Brahmins in India, time out of mind. It certainly was prac- 
tised in Turkey at the very beginning of the last century, and perhaps somewhat 
earlier. In 1713, Dr. Emanuel Timoni, an Oxford graduate, who had settled at 
Constantinople, wrote to Dr. Woodward, in London, giving him an account of 
the new process, and testifying to its success. This account was communicated 
to the Royal Society, and published in its Transactions the following year. In 
1715, Mr. Kennedy, an English surgeon who had traveled in Turkey, gave 
similar information to the English public in his Essay on External Remedies, 
And in the Philosophical Transactions for 1716 you may see a notice of the same 
process, as described by M. Pylarini, the Venetian consul at Smyrna. But these 
statements were neglected, or had no practical result. We owe the actual intro- 
duction of the practice of inoculation into Great Britain to the good sense and 
courage of an English lady, whose lively epistles have taken their permanent place 
in our country's literature. Lady Mary Wortley Montagu, the wife of our ambas- 
sador at the Ottoman Court, writes thus, from Adrianople, in the year 1718: 
6t The small-pox, so fatal and so general amongst us, is here entirely harmless by 
the invention of engrafting, which is the term they give it. Every year thou- 
sands undergo the operation ; and the French ambassador says, pleasantly, that 
they take the small-pox here by way of diversion, as they take the waters in other 
countries. There is no example of any one who has died in it; and you may 
believe I am well satisfied of the safety of this experiment, since I intend to try it 
on my dear little son. I am patriot enough to take pains to bring this useful 
invention into fashion in England." In fact, she recommended it by her own 
example. The first person inoculated with small-pox in England was her daugh- 
ter. Then a child of a physician, Dr. Keith, who had visited Miss Wortley; 
afterwards some condemned felons, who were pardoned on condition of their sub- 



VACCINATION. 



1003 



mining to the experiment; and at length some of the royal family. But the 
practice was not thoroughly established, nor properly appreciated, by the English 
public, until the middle of that century. 

Its efficacy in mitigating the severity and danger of the disease, in saving life 
and preventing deformity, was signally great. The mortality in the natural small- 
pox was estimated at one in five. But Baron Dimsdale, a great inoculator, de- 
clared that not one in fifteen hundred died of the engrafted disease. Two brothers, 
named Sutton, who had introduced, or rather revived, a very improved method of 
treating the disorder, professed to have inoculated 20,000 persons without fairly 
losing one. But these, doubtless, were exaggerated statements. Among 5964 
individuals, inoculated at the Small-pox Hospital in 1797, 1798, and 1799, there 
were nine deaths ; i. e., one in six hundred and sixty-two. We may take Dr. 
Gregory's estimate of one death in five hundred cases, as being probably within 
the mark. 

In the inoculated disease the period of incubation is comparatively short; the 
pustules are seldom numerous, and still more seldom confluent ; and the secondary 
fever is generally slight or awanting. 

I may mention here, also, that the eruption is not unfrequently preceded by a 
rash, something like that of scarlet fever, and called by Willan the roseola vario- 
losa. It fades in the course of a day or two, and then the small-pox pustules are 
seen emerging just in the same state that they would have been in, at the same 
period, if no such rash had appeared. The efflorescence happens oftener in the 
inoculated than in the casual disease. In the former it is looked upon as rather a 
favourable sign; in the latter, especially if the rash be of a dark red colour, it is 
considered unfavourable, and as the herald of a severe confluent disorder. 

A far superior expedient has since been discovered, in the practice of vaccina- 
tion, which has rendered the inoculation of small-pox not merely unnecessary, 
but, in most cases, perfectly unjustifiable. Yet circumstances do sometimes arise, 
even now, in which it may be allowable and right to engraft the matter of small- 
pox ; as when an unprotected person is unavoidably exposed, or has recently been 
exposed, to the contagion of that disease, and there is no vaccine matter at hand. 
The advantage of inoculating in such a case is, that the inoculated or milder form 
gets the start of the natural and severer; the fever commencing sooner than it 
would otherwise do. To show you the value of the practice in such cases, and 
the degree of protection which it affords to individuals whom we cannot vaccinate, 
I may mention a fact which Professor Gregory, of Edinburgh, was in the habit 
of relating, and which was told him by a naval surgeon. The small-pox was in- 
troduced among the crew of a man-of-war, in a tropical climate, where no vaccine 
matter was to be procured. The men were almost all unprotected. Sixteen of 
them took the disease in the natural way ; and of these, nine, or more than one- 
half, died. Of 363 who were inoculated, under the disadvantages of a hot climate, 
and no preparation, not one perished. 

That a disorder communicated to the human animal from one of the brutes 
should protect the former against the contagion of small-pox, is one of the most 
interesting facts in the whole history of medicine. How glimpses of a truth so 
remarkable were first revealed to the casual observation of certain peasants, and 
how the result of this chance observation was gradually " matured into a rational 
and scientific form by a mind deeply imbued with the best principles of sound 
philosophy," I have not leisure to tell you in detail. And it is the less necessary 
that I should do so, as you may find the whole subject thoroughly narrated and 
discussed by Dr. Baron, in his interesting biography of Edward Jenner. 

Dr. Jenner found among the great dairy farms in Gloucestershire a popular 
belief that no person who had had the coiv-pox (an eruptive vesicular complaint 
communicated from the udder of the cow to the hands of the milkers) could " take 
the small-pox." Satisfied, by inoculating with small pox matterseveral individuals 
who had had the vaccine eruption, that this was not an unfounded notion, he at 
length conceived the great and happy idea of propagating the cow : pox from one 



1004 



SMALL-POX. 



human being to another, and so preventing, in all cases, the perilous distemper of 
small-pox, which he hoped might thus be finally expelled from the earth. 

By degrees, Dr. Jenner ascertained that some persons, who had had sore hands 
from milking, were not thereby rendered proof against the contagion of small-pox ; 
but this difficulty was soon cleared up by the discovery that the teats of cows were 
liable to different kinds of eruption, and he learned, by close observation, which 
of these was the peculiar eruption that produced in the human frame the protect- 
ing disorder. 

Dr. Jenner set himself to trace, if possible, the origin of the disease of the cow. 
First, he found that it was peculiar to certain dairies; then, that in those dairies 
men were employed in milking. Following up this clue, he further made out 
that those men had also the charge of the farm-horses. Next, he learned that the 
teats of the cows generally began to exhibit the specific eruption at that time of the 
year when a complaint called "the grease" chiefly prevailed among the horses. 
Hence he concluded, that the malady was conveyed to the cows by the hands of 
the men who had been dressing the heels of horses affected with the grease. 
Subsequent inquiries have, however, shown that this conclusion was not strictly 
correct. 

Another difficulty which lay in Dr. Jenner's way, and which his patience and 
sagacity surmounted, was this. He found that some who were casually infected 
from the true complaint in the cow were not protected. This depended, as he 
afterwards ascertained, upon the period of the disease in the cow, at which the 
virus was communicated to the milker. The thick matter proceeding from the 
vesicle late in its progress produced indeed a severer local sore than the thinner 
matter of its earlier state, but it did not confer the desired protection. The same 
thing is observed in respect to small-pox. If the matter used for inoculating be 
taken from a fully matured pustule, it does not so surely excite the disease as 
when taken from a more crude one. 

The next important step in this most interesting investigation was to determine 
whether the vaccine disease could be transmitted, by engrafting, from one human 
being to another, and whether, if so transmitted, it retained its protecting power. 
The 14th of May, 1796, was the birth-day of vaccination. On that day, " matter 
was taken from the hand of Sarah Nelmes, who had been infected by her master's 
cows, and inserted by two superficial incisions into the arms of James Phipps, a 
healthy boy of about eight years old. He went through the disease apparently 
in a regular and satisfactory manner; but the most agitating part of the trial still 
remained to be performed. It was needful to ascertain whether he was secure 
from the contagion of small-pox. This point, so full of anxiety to Dr. Jenner, 
was fairly put to issue on the 1st of the following July. Variolous matter, im- 
mediately taken from a pustule, was carefully inserted by several incisions — but 
no disease followed." 

It is scarcely necessary for me to notice the objections which were made to the 
practice of vaccination. Some of them were merely foolish — as, that it was un- 
natural and impious to engraft the diseases of a brute upon a Christian. Others 
were untrue — as, that it introduced into the system new disorders, distinct from 
the cow-pox. It triumphed over all these cavils; and in six years from its first 
promulgation the discovery was known in every region of the world. 

It was soon found, however, that some, who had apparently had the cow-pox 
by inoculation, were nevertheless not incapable of taking the small-pox; and that 
these failures were, many of them at least, attributable to the mistakes that were 
made in the time or manner of performing the operation. It became necessary, 
therefore, to ascertain precisely the conditions requisite for the production of the 
genuine disease. And these conditions have been successfully investigated by Dr. 
Jenner and by subsequent surveyors. 

You will learn to recognize the true vaccine vesicle only by repeatedly examin- 
ing it for yourselves. Yet a brief description of its characters and progressive 
changes may be useful to you. 



VACCINATION. 



1005 



On the second or third day after the insertion of the vaccine matter into the 
arm, the punctures look red and inflamed, and on the fourth or fifth day the vesicle 
becomes perceptible; a pearl-coloured elevation of the cuticle enclosing a minute 
quantity of a thin transparent liquid. • It gradually increases in magnitude till the 
eighth day, when it should measure from a quarter to half an inch across. Like 
the pustule of small-pox, it is more prominent at its circumference than at its 
centre, and it consists of small cells, from ten to fourteen in number. By punc- 
turing carefully one of these cells, a drop of the virus may be let out, the other 
cells remaining full. Up to the seventh, or eighth, or even to the beginning of 
the ninth day, the inflammation around ihe vesicle should extend to only a very 
small distance from it. After this, it spreads, and what is called the areola is 
formed; a circular red border which continues to increase during the ninth and 
tenth days, and begins to fade on the eleventh, passing through shades of blue as 
it declines, and leaving a degree of hardness behind for two or three days more. 
By this time, a brown or mahogany-coloured crust has formed over the vesicle, 
of a nearly circular shape; this becomes gradually harder and darker, and finally 
detaches itself about the twentieth day. The cicatrix which it leaves should be 
somewhat less than half an inch broad, circular, slightly depressed, marked by 
radiating lines, and dotted with little pits which seem to correspond to the cells 
of the vesicle. • 

About the eighth day there is usually some slight febrile excitement manifested, 
which soon subsides. This is analogous to the secondary fever of small-pox: 
and it appears to furnish the condition of the desired protection. 

Of course it is of much moment to determine whether the cow-pox has run its 
proper course or not; and it is not always easy to say how far the progress of the 
vesicle may deviate from that which has just been described, without failing of 
its protecting influence. A very ingenious test of this, free from all ambiguity 
has been devised by Mr. Bryce. His plan is this. He vaccinates the other 
arm, or some other part of the body, four or five days after the first vaccination. 
If the constitution has been properly affected by the first operation, the inflamma- 
tion of the second vesicle will proceed so much more rapidly than usual, that it 
will be at its height, and will decline and disappear as early as that of the first : 
only the vesicle and its areola will be smaller. In fact, from the time of the forma- 
tion of the areola, the second vesicle is an exact miniature of the first. If the 
system has not been duly influenced by the first vesicle, the second will run its 
own course, increasing up to its eighth day, and so on. Should this be the case, 
the second vesicle should be tested by a third. 

We find the germ of this criterion in the early history of vaccination. Dr. 
Jenner vaccinated the children of his friend Mr. Hicks, the first gentleman who 
Consented to adopt the practice. This Mr. Hicks became afterwards an expert 
vaccinator himself, and it was his custom, in a doubtful case, to perform a second 
vaccination in a few days after the first: and he remarked that the second vesicle 
made " immense strides to overtake the first." 

After some time it became apparent that Dr. Jenner's estimate of the protecting 
power of the vaccine disease had been set too high. He had hoped and believed, 
as others also had, that the cow-pox would in all cases prove a perfect and per- 
manent protection against the small-pox ; but those hopes have been disappointed. 
Doubtless complete protection is the rule; but — how thoroughly and regularly 
soever the vaccine malady may have proceeded — it is most certain that very many 
exceptions to this rule have taken place, and are daily taking place around us. 

And this fact, which has become too glaring to be denied or explained away, 
has depreciated the value of the process of vaccination, in the public esteem, far 
more than, if rightly considered, it should have done. For it is a remarkable and 
most important truth that the disease which, in some duly vaccinated persons, 
follows exposure to the contagion of small-pox, is much milder and shorter even 
than the inoculated, and d fortiori, than the natural small-pox. The disorder thus 



1006 SMALL-POX. 

occurring is, therefore, denominated the varioloid disease, or (more conveniently, 
in my opinion), the modified small-pox. 

The constitutional symptoms of this modified disease are, in general, at the 
outset, and for several days, much the same with those of the regular small-pox. 
The eruptive fever is of equal length and intensity. There are frequently much 
headache, and sickness, and sometimes even delirium. The eruption begins about 
the third day ; it is often copious, and sometimes confluent; and in the confluent 
cases the eruptive fever does not entirely subside as soon as the crop of pimples 
has come out. 

It is in its subsequent progress that the complaint is modified : in respect both 
to the appearances presented by the skin, and to the constitutional symptoms. 
Three distinct kinds of eruption have been observed — 

1. The eruption sometimes approaches in its character and course very nearly 
to that of the ordinary small-pox. The pustules fill up, have the central depres- 
sion, and ultimately crust over, and the face swells. But this course is performed 
ia a shorter time than that of the ordinary disease, and the pustules are usually 
smaller. This is the severest and the least common form of the modified small- 
pox. 

2. Sometimes the papulae show a little fluid on their tops only, but never fairly 
suppurate, nor break; but the vesicles dry up, and hard prominences, with livid 
bases and horny summits, remain. 

3. There are other cases in which a great part of the eruption consists of red 
pimples, which soon become livid, but contain from first to last, no fluid whatever. 

In the majority of instances of modified small-pox, all these forms of eruption 
co-exist. Some of the papulae go on to suppuration, others become crowned with 
a horny summit, and others never exhibit any fluid at all. 

But the most important characteristic of the modified disease, is the total absence 
of secondary fever. The constitutional disturbance which, for the first week, 
may have been as severe as in the ordinary small-pox, generally subsides entirely 
when the eruption has reached its acme. The patient is convalescent just when, 
in the unchecked and regular form of the malady, his danger is beginning to be 
most urgent. 

These two circumstances, then — the short duration of the eruption, and espe- 
cially the absence of secondary fever — furnish the broad distinctions between the 
regular and the modified small-pox : and almost always, when vaccination has 
been thoroughly effected, and small-pox occurs afterwards, it occurs in this modi- 
fied form ; and the modified form of small-pox is seldom fatal, though some 
instances of death resulting from it have certainly happened. 

Several questions of the greatest practical moment and interest here present 
themselves : but it is impossible that I should discuss them. I will state some of 
them, however, that you may bear them in mind in your future opportunities of 
observation; especially as they are yet, for the most part, undecided questions ; 
and questions which can be answered only after repeated and careful observation. 

The first is, whether the protecting influence of cow-pox upon the human frame 
diminishes by lapse of time, and at length wears out. There seems reason for 
suspecting that such may, sometimes at least, be the case. Certainly in many, 
but not in all, of those who have gone through the vaccine disease, revaccination 
at a distant period reproduces, in a greater or less degree, its primary effects. A 
friend of mine, who was vaccinated in 1799, has a son nine or ten years old, who 
was vaccinated at the age of three weeks. Both of them have lately been revac- 
cinated. The boy was somewhat affected by the renewal of the operation; the 
father not at all. It yet remains to be determined whether all those who are suscep- 
tible of some impression from a second vaccination, are liable to be affected by 
the contagion of small-pox: and whether a repetition of the operation of engraft- 
ing the cow-pox renews, or adds to, their security against small-pox. At any 
rate, the practice of revaccination is a safe and advisable precaution. Dr. Gre- 
gory says of it, " we have sufficient facts before us to state with confidence that 



SMALL-POX. 



1007 



it need never be recommended prior to the tenth year of life ; and that the age 
best fitted for it is from the period of puberty to that of confirmed manhood. 

But, secondly, is there any ground for supposing that the wished-for protection 
ever fads to be conferred, because the operation is performed too early ? It has 
been suspected that it is less likely to produce the requisite, or an enduring, effect 
upon the constitution when it is done while the child is at the breast. But most 
children are vaccinated within that period. We know that this is a time when 
they are but little susceptible of contagious disorders in general. If this suspicion 
be well-founded, Dr. Gregory's first proposition requires correction. 

A third question is, how far the frequent failure, in late years, of complete pro- 
tection can be ascribed to the circumstance that the vaccine virus has been repeat- 
edly transmitted from one human being to another, and its supply thus kept up, 
without any fresh recurrence to the cow, the original source of the disorder. Dr. 
Jenner was, himself, not without apprehension that this might prove a cause of 
failure. But the analogy of other animal poisons supplies no warrant for such a 
belief. For one year 1 had a seat, as the Senior Censor of the College of Physi- 
cians, at the National Vaccine Board, and I then had opportunities of satisfying 
myself that lymph which had been transmitted without interruption from person 
to person ever since the time of Jenner, continued to generate as perfect a cow-pox 
vesicle as at first. If, as Dr. Heim asserts, there are no less than five kinds of 
spurious cow-pox, all communicable by inoculation from the teats of the animal to 
the human body, I cannot help thinking that recourse should not be had rashly or 
needlessly to lymph recently obtained from the cow. 

In the fourth place there are yet moot points, respecting the number of vesicles, 
and the degree of constitutional disturbance, which are requisite to ensure, and to 
prolong, the protective power of vaccination. The constitutional effect will bear 
some proportion to the number of vesicles; and of these, it would seem, there 
should be several ; and one or two of them, at least, should be suffered to pursue 
their entire course untouched. 

With regard to a fifth question, the most important of all, we may speak very 
decidedly; and it is a question concerning which it is of the utmost consequence 
that medical men should form, and disseminate among the public, correct opinions: 
I allude to the comparative merits and advantages of inoculation with small-pox, 
and vaccination. 

The advantages of the practice of inoculation to the individual, supposing him 
doomed to have small-pox, were great and obvious ; to the community at large 
they were very doubtful. It gave the undoomed individual, for certain, an ugly 
disease, which was comparatively free from danger, in exchange for the chances, 
on the one hand, of contracting a very hazardous form, and on the other, of escap- 
ing altogether from any form, of variola. We need not inquire which is the most 
eligible branch of this alternative ; we know which was by most men actually 
chosen. But the practice of inoculation, by carrying the virus and the disease 
into every village throughout the length and breadth of the land, filled the country 
with contagion; ensured the disease to all who were subjected to the operation; 
and diminished to all who were not, the chances of escaping it. No doubt the dis- 
temper was produced artificially in many more persons than would have caught it 
naturally, had inoculation never been thought of. So that while the relative mor- 
tality, the per centage of deaths from small-pox, was lessened by this practice, the 
absolute mortality was fearfully increased. Such at least is the judgment expressed 
by most who have thought and written on the subject. Dr. Heberden compared 
the number of deaths ascribed in the London bills of mortality to small-pox during 
the first thirty years of the last century, with the number during the same period 
of years at the close of the century, and he found that they had increased from 7*4 
per cent, to 9-5 per cent. To be sure, some allowance must be made for the in- 
crease in the whole population of London during that interval ; but on the other 
hand we must take into account the deaths (not noted in those bills) which followed 
the inoculation of small-pox in secluded villages, where but for that practice, the 



1008 



SMALL-POX. 



poison might seldom have been found. It is right, I say, that this matter should 
be steadily contemplated, in all its lights, and with all its shadows, in order that 
the inestimable blessing conferred upon mankind by the researches of Dr. Jenner 
may be fairly set forth, and adequately appreciated. The vaccine virus produces 
a slight disorder, which is attended with no risk, and which (unluckily I may say) 
is not communicable except by direct engrafting. It not only does not dissemi- 
nate a dangerous and deadly poison, but if rightly used, it affords, the means of 
eradicating from a well-regulated community, or at. least of confining within nar- 
rower limits, the most loathsome pestilence which the world has known.. Where 
vaccination is, the contagion of small-pox need never come. In Denmark, as I 
told you, variola had at one time disappeared before the defensive influence of 
compelled vaccination. Chance, and a careless security, engendered by the ab- 
sence of the pest, have led to its re-introduction there. It is much to be regretted 
that the boasted liberty of this country renders it almost impossible to enforce by 
law a practice which would be so conducive to the public weal. Some good 
might be done by enacting that no person should be eligible to even any parochial 
office of trust or profit who could not produce a certificate that he had been duly 
vaccinated. And the benefits which this safeguard confers on the individual are 
scarcely inferior to those which it is calculated to bestow upon society. It unfor- 
tunately does not give complete protection against small-pox to all, but it gives 
complete protection to many. And you must recollect that small-pox itself is not 
a universal and absolute assurance against its own return. But the cow-pox 
relieves all from the necessity, imposed by inoculation, of coming within the 
sphere of the variolous contagion. It renders many, I repeat, impregnable to that 
poison, if they do chance to be within its range; and its advantage to the com- 
parative few who suffer the double misfortune of being exposed to the contagion 
of small-pox, and of being affected by it, is this, that it gives safety, though not 
exemption ; that it takes away the sting and peril of the variolous disease, by 
curtailing it of the secondary fever. At the very worst, it leaves the individual 
liable, by a twofold ill luck, to contract a form of small-pox less dangerous than that 
which he would voluntarily accept by submitting to the operation of inoculation.* 

It is difficult to adduce exact numerical comparisons in illustration of this rea- 
soning; but I may quote two short series of facts as samples. 

During an epidemic in Scotland, Dr. John Thomson saw from June, 1818, to 
December, J 819, 556 cases. Of these 205 had previously had neither small-pox 
nor cow-pox, and 50 of them died ; nearly 1 in 4. Forty-one took the small-pox 
for the second time, and Dr. Thomson knew of 30 other such cases, making 71 
in all, whereof 3 died ; or 1 in 23. Three hundred and ten had been previously 
vaccinated, and among these there was but one death. 

The population of Marseilles at the time of an epidemic there, in 1828, was 
estimated at 40,000 ; that is to say, of 30,000 vaccinated, 2000 variolated, and 
8000 unprotected. Among the 30,000 vaccinated, about 2000 were attacked with 
small-pox, and 20 perished; 1, namely, in 100. Of the 8000 unprotected, 4000 
were attacked ; and 1000, or 1 in every 4, died. And out of the 2000 variolated, 
20 took the disease a second time, and 4 died ; or 1 in 5. 

There yet remains a highly interesting, but a less practical question. Dr. Jen- 
ner, as I stated before, believed that he had traced the cow-pox to its origin in the 
heels of the horse afflicted with the grease. It has since been made out that the 
disease which, in the horse, corresponds with and produces the specific malady 
of the cow, is a vesicular eruption, having no necessary connection with the 
grease, but extending sometimes all over the animal's body. Now the question 
is, whether these two distempers, occurring in the cow and in the horse, are 
identical in their essence and nature with the small-pox of man. If so (as Dr. 
Jenner believed, and Dr. Baron strongly maintains), a part of the mystery atlend- 

* The accuracy of* this latter statement is contravened by statistical results, derived from 
recent epidemics of small-pox in this country. But neither the tendency, nor the force of 
the main argument, is much affected by this admission. 



SMALL-POX. 



1009 



ing the whole subject vanishes. The protection furnished by the cow-pox resolves 
itself into the more familiar law, that certain diseases engendered by animal poi- 
sons, happen to the same individual hut once, and shield the body against, their 
own recurrence. In conformity with this theory, Dr. Baron names the disorders 
respectively, variolae, variolas vaccinas, and variolar equinae. 

The notion, you see, is this, that the vaccine disease is in truth small-pox, ren- 
dered mild by passing through the system of the cow. The great object of inocu- 
lating the small-pox is to produce a benignant form of that disease, by diminishing 
the number of pustules. The cow-pox diminishes the number to one ; and while 
it reduces the severity of the disorder to a minimum, it absolutely takes away its 
power of propagating itself, except by a direct engrafting of the visible virus. 
The disease is not sufficiently intense to taint the air with poisonous effluvia. At 
the same time it affords (but less surely and less permanently) the customary 
protection. Such is the theory, which is intelligible and plausible, and supported 
by strong facts and persuasive reasoning; for all which I must needs refer you to 
Dr. Baron's book. 

To avoid breaking the thread which connects the different parts of the main 
subject, I have postponed to the last what I have to say respecting the treatment 
of small-pox. 

This, for a long time, was conducted upon an erroneous principle, and emi- 
nently disastrous. The older physicians attempted to force out, through the skin, 
the morbid matter existing in the blood. The eruption they considered to be the 
natural and only cure: and adopting the vulgar maxim, that "it was better out 
than in," they did all they could to promote a copious eruption, by a hot regimen, 
by covering the patient with bed-clothes, by keeping the doors and windows jea- 
lously closed, and excluding every breath of fresh air, and sometimes by adminis- 
tering wine and cordials. The celebrated John of Gaddesden, the author of that 
curious book, the Rosa Jlnglica, improved even upon this. He surrounded the 
half-suffocated patient with red curtains, red walls, red furniture of all kinds: 
everything he saw was to be red ; for in that colour there was, he pretended, a 
peculiar virtue. This John of Gaddesden, by the way, was a very sad knave, 
and the first Englishman, I believe, who had the luck to be made court physician. 
He had one medicine so good as to be fit for the rich only; and he recommended 
a double dose for the wealthy. ** Duplum sit, si pro divite." He flourished in the 
fourteenth century. 

Sydenham was the first, in this country, to employ the opposite or cool regi- 
men in small-pox; and although his prejudiced cotemporaries refused to follow 
his example, and adopt his practice, he confidently predicted its final triumph — 
"obtinebit demum me vita functo." 

But it was subsequently to the introduction of the method of inoculation that 
the cooling treatment was fairly established, by the Suttons — two brothers, one 
of whom, Robert, lived at Bury St. Edmunds; the other, Daniel, at Ingatestone, 
in Essex. These men, wiser in their generation than the regular physicians, had 
the good sense to pursue the same plan of general management whieh had been 
so prosperous in the East, whence the practice of engrafting was originally im- 
ported. Daniel, in particular, became famous for his successful inoculations : and 
the great secret of his success seems to have consisted in his making one punc- 
ture only; exposing his patients much and often to a cool atmosphere; supplying 
them freely wilh refrigerant drinks ; and restricting them to a spare diet. Under 
this course, Cullen, who adopted it from the Suttons, declares that ninety-nine 
times in the hundred, inoculation imparts a distinct small-pox, and very generally 
of the mildest form. 

Now the same principle applies to the casual disease when we have reason to 
suspect that it is impending, or to have the opportunity of treating it at its com- 
mencement. The object is to prevent, if possible, a copious eruption; upon 
which, as we have seen, the severity and peril of 'the disorder entirely depend. 
It has been thought that venesection, by its antiphlogistic power, and, perhaps, 



1010 



SMALL-POX. 



by letting out, with the blood, some portion of the regenerated virus, might lessen 
the number of the forthcoming pustules. But you cannot ensure this effect by 
blood-letting: and you must bear in mind that, should the eruption prove conflu- 
ent, suppuration, to a large amount, is inevitable, and — like that of an extensive 
burn — will require, in order to go on favourably, a certain degree of constitutional 
vigour. 

You may abate the force of the eruptive fever, and keep down, it is believed, 
the number of pustules, by saline purgatives, so exhibited as to produce two or 
three loose stools every day, and by free ventilation of the surface of the body. 
The skin may even be sponged with tepid water, if the temperature be very high. 

When the eruption is all come out, if the pimples on the face be very few and 
distinct, the danger is over, and there is no more to be done. At this period Cul- 
len dissuades the further use of purgatives, as being sometimes hurtful. 

But if the pimples -on the face be many, and confluent, the patient will still 
require a great deal of attention. Our business is to look out for, and to meet, 
untoward symptoms. 

About the eighth or ninth day, wakefulness, and restlessness, and sometimes 
tremors, are apt to come on ; and the proper remedies for this set of symptoms, 
in small-pox as well as in continued fever, are opiates. In variola, when given 
in full doses at bed-time, their good effects are often very conspicuous the next 
day. 

If the maturation of the pustules should proceed tardily, if they should not fill 
up properly, nor their contents become purulent, then strong broths may be of 
use, or even wine. But the effects of these must be carefully watched, and their 
mount adjusted to the necessities of the case. 

When the pustules are livid, and intermixed with petechia, and typhoid symp- 
toms occur, the disorder generally proves fatal. In such cases it is customary to 
prescribe bark and acids, in addition to the wine and opiates. 

The proper plan of managing the patient during the continuance of the second- 
ary fever, is to keep his bowels moderately open by gentle laxatives, or by ene- 
mata ; and to give opiates once or twice a day. These are the more necessary 
on account of the irritation of the skin. The cooling regimen must now be given 
up ; and the strength must be supported by a nourishing diet. Wine and cordials 
are indicated if the pulse be feeble ; but the swelling of the hands and wrists often 
makes it difficult to feel the pulse. 

Various external applications have been tried, with the view of relieving the 
intolerable itching ; which often induces the patients to scratch and tear their faces, 
and to ensure the formation of scars. Cold cream is used for this purpose : or a 
solution of common salt, applied lukewarm ; or a liniment composed of equal 
parts of olive oil and lime-water. This may be smeared, from time to lime, over 
the itching surface, by means of a soft camel's hair pencil. 

The dyspnoea which sometimes comes on late in the disease, is a very ugly 
symptom. I know of nothing that can be done for it beyond blistering the throat 
and chest."* 

* [The following presents a very fair exposition of the views of a large portion of the 
physicians of the Continent of Europe in relation to the protective powers of vaccination. 
It is the substance of a report made to the Academy of Sciences, of France, on the 25th of 
February, 1845, by the Committee on Vaccination, to which were referred the various essays 
sent in by the competitors for the prize proposed by the Academy for the most satisfactory 
solution of the following questions: — 

1. Is the preservative power of vaccination absolute, or merely temporary? If it is tem- 
porary only, determine, by accurate experiments and authentic facts, what is the period for 
which the vaccine matter exerts its protective influence against small-pox ? 2. Has vaccine 
matter taken directly from the cow, a more certain and durable protective power than vac- 
cine matter transmitted a greater or lesser number of times through the human subject'? 
3. If the protective power of vaccine matter becomes enfeebled, should it be renewed, 
and if so, how? 4. Is it necessary to vaccinate the same individual several times, and 



SMALL-POX. 



1011 



if so, after how many years should the vaccination be repeated] The portion of the 
report of which the following is an abstract, relates to the first two questions only. 

The protecting power of vaccination being definitely established, the question arises — Is 
it possible, after forty-five years' experience, to determine the limits of that power? The 
answer to this question is extremely difficult, as it embraces inquiries not in France alone, 
but throughout the whole world: in fact, a general investigation of every case in which 
vaccination had been performed could alone supply the fundamental elements of the pro- 
blem to be answered. The competitors for the prize have particularly examined how vac- 
cinated persons are circumstanced during the prevalence of epidemic small-pox ; in other 
words what is the proportion of vaccinated persons in the entire number of those attacked 
with small-pox. The protective power of vaccination is, by this mode of investigation, 
reduced to a numerical question. An attentive examination of what occurred during 
thirty epidemics of small-pox in France, shows two important facts. — First, that somewhat 
more than one-third of the entire number of persons attacked with the small-pox had been 
vaccinated; secondly, that the mortality among the vaccinated persons was very small. 
According to the author of one of the memoirs, more than one-third of those attacked in 
the epidemics which occurred at Montbeillard had been vaccinated, but there was no 
corresponding increase in the amount of mortality amongst the vaccinated patients ; and 
the same result was observed in the epidemic of 1828, at Marseilles. The same results 
follow, also, from an examination of the epidemics that have occurred in England, Sweden, 
Denmark, Italy, Malta, Geneva, &c. 

The fact, then, being established, that vaccinated persons can become affected with small- 
pox, and the proportion so attacked during epidemics being nearly determined, a most im- 
portant problem remained to be solved — viz., what was the condition of the vaccinated 
persons affected as regarded the mere fact of their vaccination 1 The authors of all the 
memoirs agree in stating that vaccinated persons were not affected indiscriminately or by 
chance, as it were; on the contrary, the small-pox seems to make a kind of selection from 
amongst them. With some exceptions, the small-pox attacks those who have been vac- 
cinated since a long period, and spares those who are recently so. An examination of the 
tables published in various parts of Europe, proves positively, that children are seldom 
attacked with small-pox before the ninth year aftei- vaccination, and also, the converse 
fact, namely, that it attacks in preference persons who had been vaccinated fifteen, 
twenty, thirty, or even thirty-five years previously. A general fact, which may be antici- 
pated from the history of eruptive complaints is, that after the age of thirty-five years, the 
aptitude of vaccinated persons to contract small-pox becomes so slight that it may be con- 
sidered as having vanished. 

An investigation of the facts relative to the occurrence of small-pox in vaccinated persons 
leads to the three following conclusions: — First. The protective power of vaccination is 
absolute and general for the first five or six years, and even to the eleventh or twelfth year, 
to judge from the experiments on revaccination. Second. After the foregoing period, a part, 
but a part only, of those vaccinated again become liable, especially under the influence of 
an epidemic, to contract small-pox. Third. The greater number of those vaccinated pro- 
bably remain completely protected from small-pox during their entire life. 

Has the cow-pox, taken directly from the cow, a more certain and permanent protective 
power than vaccine matter that has been transmitted more or less frequently through the 
human constitution] The experiments contained in several of the memoirs confirm the 
observations made by the Committee on Vaccination, at Paris. The greater intensity of 
the new vaccine matter, as compared with that long in use, is a fact definitely established 
by experience in England, Germany, Italy, and France. But is this greater intensity 
coupled with a greater preservative power] or, as the report puts the question — Is there any 
relation between the lesser or greater intensity of the local phenomena and the protective 
power of the variolous matter 1 The experiments made on this point show that the protective 
power of vaccine matter is not proportionate to the intensity of the local symptoms, but that 
vaccination with matter taken from the cow is more certain than with oid vaccine matter. 
Admitting that the protective power of vaccine matter diminishes with time, should it be 
removed, and if so, how ] 

As to the means of renewal, the first mode employed was the transmission of the vaccine 
matter from man to the cow — an experiment frequently performed as a matter of curiosity, 
but only recently sought to be rendered a means of restoring to the vaccine matter its lost 
energy. The authors of several of the memoirs maintain that the cow, when thus vac- 
cinated, restores the vaccine matter unaltered, and therefore unregenerated ; but the com- 
mission of the Academy thinks this conclusion too absolute: in fact, it has been established 
by the experiments of the author of one of these memoirs, that vaccine matter taken from 
man is regenerated during its transmission through the cow. The same fact results from 
thousands of experiments made in Bavaria under the direction of the government. Vaccine 
matter thus regenerated, failed in less than one case in a hundred, while the failures of the 
old vaccine matter were nearly three per cent. Would it not be better to transmit the vac 



1012 



SMALL-POX. 



cine matter through several cows in succession than through one only? The mode, how- 
ever, which should be preferred to all others — the only one on which we can entirely rely 
— is, as recommended by Jenner, to obtain vaccine matter from its original source. Several 
circumstances seem to show that the cow-pox is perhaps of less frequent occurrence than 
is commonly supposed, and the commission suggests, that those who happen to meet with 
it, should not content themselves, as has been done hitherto, with transmitting it to man, but 
transmit it to other cows, and thus regenerate the infection. 

Is it necessary to vaccinate the same person several times] and if so, after the lapse of 
how many years should the revaccination be performed] On this head the report first 
refers to the fact that the revaccinations, performed for a considerable period after the dis- 
covery of vaccination, did not succeed, except in some rare cases, because they were per- 
formed too soon after the primary vaccination. But when, at a later period, experience 
showed that the protective power of vaccination diminished with time, the practice of 
revaccination was resumed, and then succeeded beyond expectation. In some parts of 
Germany especially, revaccination has been practised universally in the army, and even 
in civil life. Physicians, also, who had had small-pox, in some instances revaccinated 
themselves with success, of which Dr. Heim is a remarkable example. He attended on his 
brother for three weeks while he laboured under confluent small-pox, and three weeks after 
having gone through this decisive trial, he vaccinated himself, and had pustules almost of 
the ordinary size. M. Moreau, the celebrated accoucheur, who had small-pox in early life, 
revaccinated himself three times with success. 

A document published by the Government of Wurtemberg, which showed that of 1677 
persons affected with small-pox, between the years 1831 and 1836, 1055 had been vaccinated, 
contributed greatly to extend the practice of revaccination in Germany, and in the nonh of 
Europe. In France, the statistics of epidemic small-pox show that the number of vaccinated 
persons attacked with small-pox constitute more than a third of the whole number of pa- 
tients affected. It is impossible, therefore, to doubt the propriety of practising revaccination. 
It is during epidemic small-pox, especially, that the utility of revaccination becomes obvious. 
Not only have individuals been thus protected, but the spread of the epidemic has been 
arrested. In Prussia revaccination has been practised in the army since 1833, and the 
small-pox has been almost entirely extirpated. In Wurtemberg but one case of variola oc- 
curred in five years, among 14,384 revaccinated soldiers, and three only among 29,864 
revaccinated civilians. Epidemic small-pox has not appeared in France since 1830, the 
period when revaccination was commenced; The authors of the memoir agree that dur- 
ing epidemics it is prudent to revaccinate after about the eighth or ninth year. 

The answers given by the competitors for the prize to the questions proposed by the 
Academy, may be thus summed up : — 

1st. The preservative power of vaccination is absolute for the majority, and temporary 
for a small number; and even in the latter, it is absolute until adolescence. 

2d. Small-pox rarely attacks those who have been vaccinated in infancy before the age 
often or twelve; from which age, however, until thirty or thirty-five, they are particularly 
liable to small-pox. 

3d. In addition to its protective power, vaccination so modifies the animal economy that it 
attenuates the symptoms of small-pox, abridges its duration, and considerably diminishes 
its danger. 

4th. Vaccine matter taken directly from the cow causes local symptoms of greater inten- 
sity ; its effects are also more certain than those of old vaccine matter, but after being 
transmitted for a few weeks through the human subject, the local intensity disappears. 

5th. The preservative power of vaccine matter does not seem to be intimately connected 
with the intensity of the symptoms of vaccination, nevertheless it is prudent to regenerate 
vaccine matter as frequently as possible, to preserve its protective power. 

6th. The only mode of regenerating vaccine matter deserving of confidence is to procure 
it from the cow. 

7th. Revaccination is the only known method of distinguishing those vaccinated persons 
that remain protected from those that do not. 

8th. The success of revaccination is not a certain proof that the person in whom it suc- 
ceeds was liable to contract small-pox; it merely establishes a tolerably strong presump- 
tion that they were more or less liable to be so. 

9th. In ordinary periods, revaccination should be practised after fourteen years, but sooner, 
as already remarked, during an epidemic. 

See also, on this subject, Condie on Diseases of Children, p. 458, et seq. — C] 



CHICKEN-POX. 



1013 



LECTURE LXXXVIII. 

Chicken-Pox. Measles. Scarlet Fever. 

I must not omit a short notice of the disorder called chicken-pox ; for although 
a very unimportant complaint, it has given rise to many disputes. Other names 
which it has borne are varicella, crystal/i, variolas pusillx. 

Connected with the small-pox, and arising from the same contagion, there are 
several forms of eruptive disease. I mentioned the chief of them in the last lec- 
ture, as varieties of modified small-pox. Now these mild and irregular forms of 
variola, both parents and medical men, wishing, I suppose, to believe nothing in 
disparagement of the protecting power of vaccination, are very apt to consider, 
and to call, chicken-pox : and this error having been discovered, some persons 
have rushed to, or rather revived, the opposite opinion — equally erroneous in my 
judgment — that there is no such substantial disorder as chicken-pox ; but that all 
the eruptions which have passed under that name have really been forms of modi- 
fied small-pox. Dr. John Thomson, of Edinburgh, is one of the stoutest main- 
tained of this doctrine. No doubt an eruption of short duration, and vesicular 
through the greater part of its progress, is often caused, especially in persons who 
have been vaccinated, by the contagion of small-pox: but a similar eruption pro- 
ceeds also from another distinct contagion, that, namely, of chicken-pox. 

The best description of the true chicken-pox that I am acquainted with has been 
given by Dr. Gregory. The disorder is almost peculiar to infants, and children 
of tender years. Willan has, however, described one unambiguous example of it, 
in a gentleman thirty years old : and another genuine instance was seen by Dr. 
Gregory, at the Small-pox Hospital, in the person of an adult female. The erup- 
tion is preceded by little or no premonitory fever, commencing usually on the 
shoulders, neck, and breast, affecting almost always the scalp, but sparing very 
much the face — which, in small-pox, never escapes. 

The eruption is composed, from the very first, of perfectly transparent vesicles, 
surrounded by a very slight degree of superficial redness. They are usually 
numerous, but distinct. Dr. Gregory says that when the eruption is very copious, 
the body has the appearance of having been exposed to a momentary shower of 
boiling water, each drop of which had occasioned a minute blister. Crops of 
vesicles appear in succession for two or three days; and while new ones are form- 
ing, the first are beginning to shrivel. The vesicles that remain after the second 
or third day become slightly opaque, and like pearls. When irritated by friction, 
they sometimes take on so much inflammation as to be converted into pustules. 
The scabs are small and gummy, dry quickly, and crumble off, instead of being 
detached in one mass. In a few instances, shallow cicatrices are left by the vesi- 
cles. During the short progress of this eruptive disease there is no constitutional 
disturbance of any consequence. 

It has been ascertained of this genuine chicken-pox, or varicella lymphatica, 
that it occurs once only to the same person ; that it spreads by contagion ; that 
nevertheless, it is not communicable by inoculation— whereas the matter of modi- 
fied small-pox, when engrafted, produces genuine variola; that it occurs equally 
among those who have, and those who have not, been vaccinated ; that its course 
is not affected by antecedent vaccination ; and that the vaccine vesicle and disease 
proceed with perfect regularity after the occurrence of chicken-pox. Now this 
never happens after small-pox. 

It appears, from Mohl's work Be Varioloidibus et Varicellis, that from the year 
1809 to 1823, chicken-pox was annually observed at Copenhagen without con- 
comitant small-pox ; and that both diseases have since prevailed at intervals epi- 



1014 



MEASLES. 



demically, but always under circumstances which satisfied the physicians of the 
town that their sources were distinct. 

It must, therefore, I think, be admitted, that there is a separate disease, called 
chicken-pox^which springs from a specific poison ; produces a vesicular eruption ; 
runs a definite course ; has no tendency, when undisturbed, to suppuration; occurs 
but once ; and affords no protection against small-pox, while, on the other hand, 
small-pox affords no protection against it. 

The main point of practical importance is, however, this ; that if we meet with 
any eruption which is at all equivocal, we should use the same precautionary 
measures for preventing the extension of the disease as if we were sure that it was 
modified small-pox. But this salutary rule is often, I say, neglected or infringed, 
to the danger and detriment of those unprotected persons who happen to be in the 
vicinity of the sick child. 

The treatment required in chicken-pox is abundantly simple; it is the same, in 
fact, which has been already recommended for the mildest cases of the discrete 
small-pox. 

Another of these blood diseases is the measles ; called, also, by nosologists, 
rubeola, and morbilli. 

Like different human faces, all the complaints belonging to this group have the 
same set of features, and therefore a mutual resemblance, while the separate linea- 
ments differ so much in their character and relative circumstances, as to give to 
each disease its distinctive aspect. There are also minor shades of difference 
between individual cases of the same specific malady. 

Measles, accordingly, has its introductory fever, its period of eruption, its pecu- 
liar kind of eruption, its course by stages. It is communicable from person to 
person, and it generally occurs but once to the same person. On some of these 
points I spoke before. 

The introductory fever is sometimes severe, and nearer in its type to synocha 
than to typhus. Like all fevers, it begins with lassitude, and shivering, which is 
soon followed by heat of skin, acceleration of the pulse, anorexia, and thirst. But 
the peculiarity in the fever which precedes the eruption of measles is, that it is 
very constantly attended with an inflammatory condition of the mucous mem- 
branes; especially of those which are proper to the air-passages. The eyes 
become vascular and watery, the eyelids heavy, turgid, and red. The membrane 
which lines the nasal cavities, the fauces, the larynx, trachea, and bronchial tubes, 
is affected. Hence we have, generally, as fymptoms, much sneezing, as well as 
lachrymation, a copious defluxion from the nostrils, soreness of the throat, and 
an obvious redness of the fauces, and most commonly a dry, hoarse, peculiar 
cough. In short, the symptoms which usher in an attack of measles are the 
symptoms of coryza and catarrh. In some instances there is diarrhoea also, indi- 
cating a simultaneous affection of the mucous membrane of the intestines; and not 
unfrequently vomiting: but the vomiting, as in small-pox, ceases upon the coming 
out of the eruption. 

The regular period for the appearance of the eruption is the fourth day of the 
disease; seldom earlier, frequently later: sometimes as late as the eighth or tenth 
day from the commencement of the catarrh. The eruption itself is a rash, con- 
sisting, at first, of minute papulae, which, as they multiply, coalesce into blotches 
that have, more or less, a horse-shoe or crescentic shape, and leave the interme- 
diate portions of skin of their natural colour. It is two or three days in coming 
out, beginning on the face, neck, and arms, then reaching the trunk of the body, 
and so traveling down to the lower extremities. In this course it resembles the 
eruption of small-pox. It fades in the same order, standing out three days at 
least on the face before it begins to decline ; so that its whole duration comprises 
a space of six or seven days. It becomes browner as it fades. You may feel 
that it is slightly elevated above the general surface of the skin, especially upon 
the face, which is somewhat bloated and swollen. The parts which the rash has 



MEASLES. 



1015 



recently occupied are left covered with a dry, smali scurf. The cuticle does not 
peel off in large flakes, as I shall have to tell you that it oftentimes does in scarlet 
fever, but a great part of it crumbles away in a fine branny powder. Occasionally, 
yet very seldom I believe, the rash is intermixed with a few small and short-lived 
vesicles. 

This termination of papulae is -very unlike what happens in variola: and con- 
nected with the eruption there are two other important particulars in which the 
measles differs essentially from the small-pox. In the first place, the fever does 
not cease, nor even abate, upon the emergence of the eruption ; but sometimes 
increases in intensity. And in the second place, the disorder is not more severe, 
nor more dangerous, because the eruption is plentiful, or early. So far from it, 
indeed, that in some of the worst and most perilous eases the eruption is apt to 
be partial, and to appear late and irregularly. 

The eruption is the distinguishing feature of measles, but the catarrhal affection 
is, in every way, the most important. Indeed the rash may, and sometimes does, 
happen without the fever and the catarrh ; and nosologists recognize a variety of 
the disorder under the title of rubeola sine catarrho. But it is observed of this 
variety, that it confers no protection whatever against the recurrence of the mala- 
dy : in truth, it is most commonly succeeded in a few days by an attack of measles 
in its regular and complete form. 

I need not stop to repeat what I told you in a former lecture about the other 
general features of this eruptive complaint. The period of incubation is from ten 
days to a fortnight. The contagion is active enough, though certainly it is less 
strong and diffusive than that of small-pox. When once introduced into a family 
or school, the disease rapidly spreads to those individuals who have not already 
had it. It is capable, though with much less readiness and certainty than small- 
pox, of being propagated by inoculation ; but as the disorder is not rendered 
milder by being so introduced into the system, this process has no utility or inte- 
rest, and is never resorted to. Occasionally rubeola visits the same individual 
twice; but this is the exception to the general rule. Perhaps, in some reputed 
instances of its recurrence, the first accession may have been without fever and 
catarrh, and therefore an ineffectual safeguard for the future. I myself know, 
however, two large families in which most of the children have suffered a repeti- 
tion of the genuine unmitigated disease. 

The measles resembles the other diseases of the group in this also, that at times 
it pervades a community as an epidemic; at times occurs here and there only, 
sporadically. The general character of the symptoms varies considerably in dif- 
ferent epidemics. Morton and Sydenham, and after them Sir William Watson, 
have described visitations of what they call putrid measles. Sir William Watson 
was physician to the Foundling Hospital, and^£ witnessed two epidemics of this 
putrid kind among the children in that institution. He states that the eruption 
appeared unusually early, so early as the second day of the disease ; and that, 
besides cough and dyspnoea, the complaint was marked by extreme debility, and 
attended with dysenteric diarrhoea. More seemed to die of the intestinal affection 
than of the pectoral. He lost, in one of these epidemics, nineteen out of one 
hundred and eighty-three patients. The malignant character of the disorder was 
manifested by the frequent occurrence of gangrene, both externally and internally. 
In this more typhoid variety of measles, the rash is often irregularly and imper- 
fectly developed, and of a livid colour. 

Sydenham found that measles of an unusually bad kind prevailed in London in 
the years 1670 and 1674; the very same years in which small-pox was also 
remarkably malignant and fatal. This illustrates what I have stated before ; viz., 
that the typhoid tendencies of these and other febrile disorders depend less upon 
any peculiar virulence in their exciting causes, than upon some ehange previously 
effected in the human body by the silent and gradual influence of certain predis- 
posing causes. 

The diagnosis of measles is seldom difficult. In the outset of the fever you 



1016 



MEASLES. 



may guess what is coming by the coryza, catarrh, and hoarse cough ; especially 
if the disease be about. On the very first day of the eruption, the small, red, 
and hitherto separate spots are very like the incipient pimples of small-pox. Do 
not, therefore, at this period, express too confidently your opinion respecting the 
nature of the complaint. Parents and nurses might be uncharitable enough to 
attribute your mistake to inexperience or ignorance. The progress of the disease 
will soon remove all doubt. The eruption of small-pox presently exhibits some 
fluid, while that of measles has none — unless, indeed (what is uncommon), a few 
miliary vesicles mix themselves with it. But these make no advance in twenty- 
four hours. Ordinarily the isolated pimples visible upon the first day soon aug- 
ment in number, and collect themselves into semicircular groups; and if any 
question at all arises, it is whether the disease be measles or scarlet fever. I shall 
presently describe the latter disorder; and then I will point out the marks of dis- 
tinction between the two. 

The prognosis in measles is governed chiefly by the mildness or the severity of 
the pectoral symptoms. The most common cause of death, in the fatal cases, is 
inflammation of some one or more of the textures that compose the lungs. And 
even when this immediate danger has passed by, the disease too often leaves 
chronic pulmonary mischief behind it. In scrofulous children, and young 1 persons, 
it frequently awakens the slumbering germs of consumption. And when that 
specific effect is not produced, it is apt, in adults, to inflict upon the constitution 
a blow which is never thoroughly recovered from ; the patient becoming, from 
that time forwards, delicate and valetudinary. The prognosis is always unfavour- 
able when the eruption does not stand out well, is of a livid colour, and accom- 
panied with typhoid symptoms, or with a disposition to gangrene. 

We augur favourably of the case when the thoracic symptoms are not severe ; 
when the fever moderates upon the coming out of the rash; and when the rash is 
steadily persistent, and there is no excessive prostration of the strength. 

Being contagious, and occurring for the most part but once, measles is princi- 
pally seen in children; although no period of life is exempt from its attacks. In 
many children the disorder is so slight as to require little more than judicious 
domestic attentions. The free application of cold air to the surface, which is so 
beneficial in small-pox, would in measles be unsafe, on account of the pectoral 
symptoms. For this reason the patient should be kept in bed ; with no more 
clothes, however, or warmth of the apartment, than he is accustomed to in health. 
The antiphlogistic regimen must be adopted ; and if the bowels are not quite open 
naturally, gentle laxatives should be given. It may be well, also, to prescribe 
some diaphoretic medicine ; a draught, for example, containing two or three 
drachms of the liquor ammonias acetatis, with half a drachm of the spiritus setheris 
nitrici, and an ounce of camphor^ulep, to be taken three or four times in the 
twenty-four hours. 

The most important part, however, of the treatment relates to the remedies to 
be employed for the pulmonary symptoms, which in the outset depend, almost 
always, upon bronchitis. But the inflammation is apt, in severe cases, to spread 
insidiously from the mucous to the other tissues — the bronchitis becomes pneu- 
monia — and we find, after death, some portions of the lungs hepatized; usually 
small portions. For the most part, however, it is extensive inflammation of the 
bronchial mucous membrane that we have to dread. And really I cannot give you 
any better or fuller directions in respect to the management of these inflammatory 
affections, than I endeavoured to lay down when I was speaking of bronchitis 
and pneumonia, as they occur idiopathically. You will judge of the extent and 
severity of the inflammation, partly by the common symptoms, partly by the help 
of your ear ; and you must apportion your remedies to that intensity, so judged of. 
You will take blood from the arm, or from the chest, apply a blister, and give 
tartar emetic. And it is of importance that whatever kind or amount of depletion 
is adopted, should be resorted to early. 

When the rash is about to decline, a spontaneous diarrhoea often sets in, and 



SCARLET FEVER. 



1017 



appears to have a beneficial effect in abating the febrile symptoms. If this natural 
curative process should fail to occur, it may be imitated by the exhibition of gentle 
aperients. 

In weakly children blisters are apt to cause troublesome sores; and in some 
epidemics of measles, the sores thus produced show a disposition to become gan- 
grenous. When any such tendency is noticed, blisters had better be avoided 
altogether. At other times, the inconvenience to be apprehended from a blister 
may be prevented by one of two plans; either by interposing a piece of silver 
paper between the blistering plaster and the skin; or by suffering the blister to 
remain upon the part three or four hours only, then taking it off, and applying a 
poultice. The cuticle will rise under the poultice, and the sore will not, in general, 
be a troublesome one. 

If the eruption disappear prematurely, it may sometimes be restored by putting 
the patient into a warm bath. And if he be at the same time in a low state, 
especially if typhoid symptoms threaten or show themselves, you must treat the 
case upon that indication, just as you would in continued fever; giving wine and 
support, with great caution and watching of their effects. 

It is of considerable importance to protect the patient from danger after the 
disease has subsided; by warm clothing, by preventing him from going out of 
doors too early, or being in any way exposed to cold. Pueumonic inflammation, 
and dysenteric purging, are frequent consequences of the want of prudence in this 
respect. 

I proceed, in the next place, to the consideration of scarlet fever. 

This also is a contagious febrile disease, attended almost always, during a part 
of its course, by a rash, and by sore throat. It seldom comes on a second time. 

There are some distinct varieties of this disorder, concerning which it is neces- 
sary that I should say a few words. . 

The two striking and important features of the disease are the affection of the 
throat, and the affection of the skin. They may both be well marked ; or only 
one of them may be well marked: and this circumstance has led nosologists to 
divide one and the same complaint into two independent maladies ; to which 
Cullen and others have assigned the respective names of cynanche maligna, and 
scarlatina. When, in an earlier part of the course, I was treating of the diseases 
of the throat, I purposely omitted the cynanche maligna ; because that is only 
another name for a particular form of scarlet fever. If you look to Cujlen's de- 
finitions of these complaints, you will see how very much alike they are. They 
both specify inflammation of the fauces, a cutaneous rash, and fever. But in the 
definition of scarlatina, the rash is dwelt upon and described, and the fever is 
called synocha; while in that of cynanche maligna, the ulceration of the throat is 
more insisted on, and the fever is said to be typhoid. The truth is, that these 
two kinds of disorder both spring from the same contagious poison. The ma- 
lignant sore threat may be caught from a patient who has mild scarlet fever; and 
mild scarlet fever may, in like manner, be contracted from one who is labouring 
under the malignant sore throat. The two forms graduate insensibly, in different 
cases, towards each other; and it would be impossible, even if it were desirable, 
to draw any strict line of separation between them.. 

For convenience, however, of description, and for the better direction of the 
treatment, authors generally make three varieties of scarlatina. Scarlatina sim- 
plex, in which there is a florid rash, and little or no affection of the throat; scar- 
latina anginosa, in which both the skin and the throat are decidedly implicated; 
and scarlatina maligna, in which the stress of the disease falls upon the throat. 
The epithet maligna marks truly the fearful character of this form of the malady. 

I need scarcely remind you of a sort of mystification which prevails among 
the public about this complaint, and which many practitioners, for no good reason 
that I can see, seem disposed to encourage. Mistaking the Latin and scientific 
name of the disorder for a mere diminutive, you will hear mammas say, " Oh, 



1018 



SCARLET FEVER. 



my children have not got the scarlet fever, but only the scarlatina." I always 
disabuse them of this absurd error, when the opportunity of doing so occurs. It 
can produce nothing but confusion, and a disregard of requisite precautions. 

Like measles, and for the same reasons, scarlet fever, though persons of all 
ages are susceptible of it, is eminently a disease of children ; but it is much more 
to be dreaded than the measles. 

It is somewhat strange that scarlet fever was not recognized, in this country at 
least, as a distinct disease, till about two centuries ago. In all probability it had 
long existed, and had been always confounded with measles. Morton speaks of 
it under the name of morbilli confluentes ; and Hoffman calls it, by a similar 
mistake, rubeola rossalia. The febris scarlatina described by Sydenham must 
have been of a very mild kind ; for he does not mention any ulceration of the 
throat. Dr. Fothergill, in 1748, was the first to describe, as a new and separate 
disorder, that perilous form of the complaint which Cullen designates cynanche 
maligna ; and it was long called the Fothergill sore-throat. The identity of this 
affection with genuine scarlet fever has been slowly established by subsequent ob- 
servers. The characteristic differences between scarlet fever and measles were 
first fully specified by Dr. Withering. 

The disease begins, as the exanthemata in general begin, and as continued 
fever which I have grouped with them is apt to begin, with shivering, lassitude, 
and rapidly augmenting debility; headache, frequently severe, sometimes with 
delirium, occasionally with nausea and vomiting. Then, generally, on the second 
day (and Cullen is wrong when he says it is generally on the fourth), the eruption 
begins to come out. In some of the worst forms of the disease, it may, indeed, 
be deferred till the fourth day. 

Although scarlet fever and measles were so long confounded together, the dif- 
ferences between them are well pronounced, and, when once pointed out, are 
easily enough recognized. 

Rubeola is distinguishable, then, from scarlatina — 

1. By the presence, at the outset, of catarrhal symptoms — by the sneezing, 
the cough, the defluxion from the eyes and nose, which precede the rash There 
is, doubtless, in many cases of scarlatina, a running from the eyes and nose, but 
not till late in the disease; at any rate not prior to the eruption. 

2. By the absence of severe inflammation and ulceration of the throat ; symptoms 
which always accompany severe cases, at least, of scarlet fever. 

3. By .the characters of the eruption itself. The rash in measles is more ele- 
vated above the surface than in scarlatina, and of a darker colour. In measles it 
is said to present somewhat the tint of a raspberry, and in scarlet fever to be that 
of a boiled lobster. In measles the papulae are collected into semilunar clusters, 
leaving interstices between them of healthy skin. The redness of scarlatina 
commences in minute points, whicli speedily become so numerous and crowded, 
that the surface appears to be universally red. They begin on the face, neck, 
and breast, and extend to the extremities, pervading at last every^art of the skin. 
The scarlet colour is deeper, in general, about the groins, and in the flexures of 
the joints, than elsewhere. Lastly, the rash of measles, in its most regular form, 
appears on the fourth day of the disease ; that of scarlet fever on the second. 

On the arms and legs the eruption of scarlatina occasionally differs somewhat 
from that which is visible on the trunk; is more spotty, more papular, and the 
papulae are somewhat prominent, while over the body there is a general diffused 
blush. 

In some cases of scarlet fever (probably in some epidemics, for I observed the 
phenomena I am about to mention in four or five cases in succession which were 
brought into the Middlesex Hospital within the space of a month or six weeks), 
some parts of the red surface are closely studded with little transparent vesicles, 
containing a thin colourless liquid, and resembling what I described to you before 
as sudamina. In all the instances in which I have seen them, these minute vesi- 
cles have been most thickly set on the thorax, and on the front and sides of the 



SCARLET FEVER. 



1019 



neck. The liquid is soon re-absorbed, and the cuticle under which it had been 
enclosed shrivels up, turns white, and comes off in a thick white scurf: so that 
the part from which it separates looks at first sight as if it had been powdered. 
I have recently seen two cases of this vesicular form of scarlatina in private prac- 
tice. I show you Rayer's delineation of the vesicles. 

The eruption, in the most regular and favourable cases, stands out for three or 
four days, and then begins to fade and decline, becoming by degrees indistinct, 
and disappearing altogether, in the majority of instances, before the end of the 
seventh day. About this time desquamation of the cuticle begins to take place, 
in smaller scurf or scales from the face and body, in large flakes frequently from 
the extremities. The scarf-skin of the hands and of the feet sometimes separates 
almost entire. A glove or a slipper of cuticle comes away at once. You may 
see such things in most museums. 

In that variety of the disorder which we call scarlatina maligna, the rash is 
apt to come out late, and imperfectly, and sometimes not at all; and instead of 
being bright and florid, to present a bluish or livid tint. Sometimes it suddenly 
recedes; and then, perhaps, appears again: and occasionally it is diversified by 
purple spots. 

Willan and Bateman have given the name of roseola to an eruption which is 
also attended with inflammation of the throat, and between which and scarlatina 
it is certainly difficult, if not impossible, at first to discriminate. The roseola, 
however, is not contagious, and has more of a chronic character than scarlatina. 
It comes and goes, and has no settled or definite course. Dr. A. T. Thomson 
lays down this distinction between them ; but I do not know that we can trust to 
it: — "In scarlatina (he says) the rash first attacks the face, and then extends to 
the trunk of the body, passing off by the extremities ; whereas in roseola the ex- 
tremities are first affected." 

The appearances of the tongue in scarlet fever are also peculiar and character- 
istic. In the scarlatina simplex, and anginosa, it is often covered, at the outset* 
with a thick, white, cream-like fur, through which are seen projecting the red 
and exaggerated papillae ; the edges of the tongue being likewise of a bright red 
colour. The red points gradually multiply, and the white fur clears away, and 
at length the whole surface of the tongue becomes preternaturally red, and clean, 
and raw-looking: and after becoming thus clean, as well as red and rough, and 
like a strawberry, it will sometimes, when the disease goes on unpromisingly, get 
dry, and hard, and brown — as you know it is apt to be in certain forms and stages 
of continued fever. 

The first thing of which the feverish patient usually complains is sore throat, 
with some stiffness of the neck: and if you inspect the fauces, you will see, 
without in general so much swelling of the tonsils as occurs in common quinsy, 
a diffused redness, sometimes of a dark claret colour, including a large part of the 
palate. In a shqrt time you may perceive that the tonsils and vellum are covered 
irregularly with whitish exudations, or gray aphthous crusts : or, perhaps, you 
see a sloughy kind of ulceration left by trfe separation of these crusts. 

The progress of the distemper, and its degree of severity and of danger, differ 
very greatly in different cases. Sometimes the deviation from the feelings and 
condition of health is so very slight as scarcely to deserve the name of a disease ; 
sometimes the disorder defies all treatment, and the deadliest forms of plague are 
not more fatal. 

In these malignant and terrible cases, the eruption, if it appear at all, is livid 
and partial, and fades early, and is attended with a feeble pulse, a cold skin, and 
typhoid depression. Sometimes the patient sinks at once, and irretrievably, under 
the virulence of the poison, and life is extinguished in a few hours. A gentleman 
called one day at my house, and not finding me there, followed me between twelve 
and one o'clock to the hospital. He wished me to visit his wife, four or five miles 
out of town, who had been taken ill that morning. He feared that she was about 
to have scarlet fever, but he was not much alarmed for her safety ; for when he 



1020 



SCARLET FEVER. 



found that I could not be at his house before six, he said that that hour would not 
suit the general practitioner in attendance upon her, and he begged me to fix some 
time for seeing her the next day. I did so; but the same afternoon rapid sinking 
came on, and the patient was dead very soon after the hour at which I had first 
proposed to visit her. 

In other cases of scarlatina maligna, the typhoid symptoms rapidly deepen ; and 
death, in children, is apt to occur on the fifth day of the complaint ; and not 
uncommonly as soon as the third. The pulse becomes frequent and feeble; the 
tongue dry, brown, and tremulous; the debility extreme; the throat is ulcerated 
and gangrenous; and the respiration is impeded by viscid mucus which collects 
about the fauces. Over this variety of the disease, medicine has comparatively 
little control. 

The chance of recovery is much greater in the scarlatina anginosa, when the 
eruption is florid, and stands well out. But even in this form of the disorder there 
are many sources of danger, and various ways in which it may prove fatal. 

In the first place many of the patients die, apparently from inflammation or 
effusion within the head. They have violent headache, with furious delirium, 
which is followed by coma, and death. 

And secondly, the state of the throat is full of peril. As the disease proceeds, 
although the rash may be steadily persistent, the throat becomes foul and sloughy, 
an acrid discharge from the nostrils, which are so stuffed and swollen internally that 
the patient can scarcely breathe through them, runs over and frets the upper lip; 
the parotid and sub-maxillary glands swell, sometimes enormously; and fever is 
lighted up afresh. In this way many cases prove fatal in the second week of the 
disorder. The cervical swelling causes constriction of the fauces and stiffness of 
the neck ; and sometimes, doubtless by interfering with the free return of the blood 
from the head through the jugular veins, they produce a tendency to coma. With 
these symptoms there are often also purging, and an excoriated anus. 

The acrid matters furnished by the ulcerating and gangrenous throat irritate the 
nasal membrane in the one direction, and that of the alimentary canal in the other. 
We thus account for the running from the nose, the soreness of the alae nasi and 
upper lip, and the smarting diarrhoea: and the swelling of the parotids and neigh- 
bouring glands is evidently caused by absorption of the irritating and poisonous 
matter from the ulcerated throat. There is just the same relation and dependency 
between these different local alterations, as between the enlarged mesenteric glands, 
and ulceration of the follicles of Peyer in continued fever ; between a bubo in the 
groin, and a chancre on the glans penis. It is the condition of the throat that 
gives rise, in these cases, to the most formidable symptoms. The system is rein- 
oculated from that source. Whenever I see the glands much enlarged at the 
angle of the jaw, and beneath the jaw, in a child labouring under scarlet fever, I 
augur ill of the case. Sometimes the mischief extends into the larynx, and so 
destroys the patient. But this is probably a very rare event. There is, however, 
still another, and a very common consequence of the throat affection — I mean 
inflammation of the Eustachian tube, reaching sometimes the tympanum itself, and 
causing permanent deafness, either by closing up the tube, or by the destruction 
of the membrana tympani, and of the little bones belonging to it. In one case, 
which was under my own care, I observed that, for a short time before death, 
every time the child swallowed, a part of the fluid food ran out immediately at one 
of its ears. I had no opportunity of examining the state of the part after death, but 
the disorganization arising from the sloughing ulceration of the throat must have 
been frightful. 

Scarlet fever sometimes befalls parturient women ; and then it almost always 
proves fatal. I have seen three instanced only of recovery from this perilous 
complication. 

Scarlatina simplex is scarcely, I repeat, a disease. Sydenham has said of it 
that it is " fatal only through the officiousness of the doctor." 

Even when the patient has escaped from the complaint itself, he is often ex- 



SCARLET FEVER. 



1021 



posed to great hazard and distress from its consequences. Children who have suf- 
fered a severe attack of scarlet fever are liable to fall into a state of permanent bad 
health, and to become a prey to some of the many chronic forms of scrofula: boils, 
strumous ulcers, diseases of the scalp, sores behind the ears, scrofulous swellings 
of the cervical glands and of the upper lip, chronic inflammation of the eyes and 
eyelids. The same afflicting results are very common after small-pox also, and 
measles. 

I have several times, when the rash of scarlet fever was disappearing, known 
pain and swelling of the larger joints to supervene, simulating very closely the 
local phenomena of subacute rheumatism : and I have noticed that the painful joints 
were eased and benefited by friction; a circumstance which may help to distin- 
guish this articular affection from true rheumatism. Another distinctive circum- 
stance seemed to be that, although all these patients were children, the heart in 
no instance became implicated, in connection with the tumid joints. Upon this 
point, however, my own experience may have been fallacious. Dr. Scott Alison 
has recently invited attention to the subject, in an interesting essay " On Pericar- 
ditis, a complication and sequela of Scarlatina." Accepting his facts, I should 
ascribe the articular affection, and the cardiac affection, whether they occurred 
together or separately, to one and the same cause ; namely, to the retention in the 
blood of a poisonous excrement, by the default of the principal emunctories, and 
especially of the kidney. 

But certainly the most common, and a very serious sequel of scarlatina, is ana- 
sarca, serous infiltration of the subcutaneous areolar tissue, accompanied often 
with dropsy of the larger serous cavities. So common is this that Cullen has 
even introduced the circumstance as a part of his definition of scarlet fever. He 
found the dropsy a very manageable complaint; but it really is, in many — nay, 
in most cases, if we look to its probable ultimate consequences — a most formidable 
one. This affection belongs to the class of febrile dropsies. It appears to have 
no relation, or, if any, an inverse relation, to the violence and danger of the pre- 
ceding exanthem. It is much more common after a mild than after a severe dis- 
ease. This, in all probability, is owing to the circumstance that less care and 
caution are observed in the milder cases during the dangerous period of desqua- 
mation and convalescence ; a period more dangerous, in that variety of scarlatina, 
than any other. In the graver cases the convalescence is slower, and more doubt- 
ful; and accidental or careless exposure to cold is more guarded against, or takes 
place later : whereas, in the slighter kinds of the disorder, the patients are apt to 
go out while the new cuticle is still forming. If you carefully trace the histories 
of dropsy succeeding to scarlet fever, you will almost always find that the fever 
had been trifling; and that the patient, considering himself well or nearly so, had 
heedlessly encountered a cold or damp atmosphere so soon as he felt himself 
strong enough to leave the sick chamber. Plenciz, who has written well on this 
subject, and who was quite aware of its importance, remarks that those patients 
who have had much desquamation of the cuticle are the most liable to the dropsy ; 
that it is more frequent in winter than in summer; and in such as are early exposed 
to the open air after having passed through the fever, than in those who remain 
longer at home. When the desquamation is over, and the new surface has 
become in some degree hardened, the peril is past. According to the observations 
of Dr. Wells, the dropsical symptoms commonly show themselves on the twenty- 
second or twenty-third day after the commencement of the preceding fever. They 
have been known to begin as early as the sixteenth, and as late as the twenty- fifth 
day. When no dropsy took place before the end of the fourth week, Dr. Wells 
always ventured to state that it was no longer to be dreaded. 

This anasarca is seldom observed except in children and young persons. The 
age of the oldest patient that Dr. Wells had known to be so affected was seven- 
teen. Of ten instances of the disease seen by Dr. Blackall, six occurred in chil- 
dren not exceeding the age of ten, and two others in persons who were respectively 
ten and sixteen years old. 



1022 



SCARLET FEVER. 



We cannot infer, from this, that the susceptibility of this dropsical condition 
lessens as years increase. The great prevalence of this variety of dropsy in early 
life has no direct relation to age as a predisposing cause. The fact is explained 
by the accidental peculiarities of the antecedent disease. Tue contagion of scarlet 
fever is active and widely diffused. Few children escape its agency. Few are 
capable of taking the disorder a second time. It follows that scarlet fever is rare 
in adult life: and as dropsy succeeds that disease in a very limited number of 
instances only, dropsy arising in connection with scarlet fever must, at the adult 
age, be still more uncommon. 

Yet it is not unknown. One of Dr. Blackall's ten patients was thirty, another 
forty-two years old. Both of these were women. 

In this, as in other species of febrile dropsy, the urine is very constantly 
troubled, bloody*, albuminous; and it is an interesting fact, that the chronic form 
of renal dropsy, manifesting itself at some distance of time, has been distinctly 
traced back to its source in the acute anasarca immediately consequent upon scarlet 
fever. The sequence has occurred, in all probability, much oftener than it has 
been noticed. There is scarcely room for doubting that the series of organic 
changes in the kidney, described by Dr. Bright, do frequently date their origin 
from an attack of febrile anasarca: and in proportion as facts, accurately observed, 
accumulate on this subject, the chain of connection becomes more clearly visible 
between acute febrile dropsy, dropsy succeeding scarlet fever, and chronic renal 
dropsy. It is evident, indeed, that the two first of these three are, in their charac- 
ters and exciting causes, identical, the only difference between them consisting 
in the remarkable predisposition towards the second, impressed upon the body by 
the preceding exanthem. Both of them again are, in many instances, initiative 
of the third. 

It is natural therefore to expect that in the variety of febrile dropsy now under 
consideration, as well as in those which I formerly described, inflammation, and 
especially inflammation of the serous membranes, should be common, and evi- 
denced by its unequivocal effects. And it is so. But the dropsy, I am per- 
suaded, has no essential connection with common inflammation of any part, 
unless the state of the kidney be of that kind. I have examined the body very 
carefully in fatal cases, and found the serous cavities full of clear liquid without a 
trace of redness or of any of the unmistakeable products, or events, of inflamma- 
tory action. 

The earliest threatenings of this formidable complaint demand attention. It is 
usually preceded for a day or two, or longer, by languor and peevishness ; fre- 
quently by nausea and vomiting, and a costive state of the bowels. The pulse, 
in the outset, has been found slow, and beating with irregular intervals ; but it 
afterwards becomes frequent. The urine, at first, is scanty as well as altered in 
appearance. The face becomes pale, and chuffy. Sometimes, as the disease 
proceeds, violent headache, dilatation of the pupils, convulsions, or palsy, denote 
effusion within the head. Much more frequently the pleurae are the seat of the 
internal dropsical accumulation, and dyspnoea is a prominent symptom. Ascites, 
to any considerable amount, is rare. 

The contagion of scarlet fever is active, but uncertain. It is not so strong, nor 
so uniform in its operation, as that of small-pox ; but it seems to be peculiarly 
subtle and tenacious. Fomites infected with the variolous poison soon lose their 
power to excite the disease if they are freely exposed to fresh air. But the con- 
tagion of scarlet fever lurks about an apartment, or clings to furniture and clothes, 
for a very long time, even after some care has been taken to purify them. Of this 
I have known several remarkable examples. You will be asked at what period 
the danger of imparting the disease on the one hand, or of catching it on the other, 
is over; and I would recommend you to answer that you do not know. I am 
sure I do not: and therefore I always decline the responsibility of giving an ora- 
cular opinion on the matter. 

I may arrange what I have to say of the treatment of scarlet fever, according 



SCARLET FEVER. 



1023 



to the three varieties of it already mentioned, the scarlatina simplex — anginosa — 
and maligna. 

The first of these requires nothing more than confinement to the house ; and 
the observance of the antiphlogistic regimen in regard to diet ; and regulation of 
the bowels. 

With respect to the management of the severer forms of scarlet fever, great dif- 
ferences of opinion have prevailed. I should recommend you to look into Dr. 
Williams's book on Morbid Poisons, for some interesting and satisfactory infor- 
mation on this head. Satisfactory tcr me at least it is, because the result of it goes 
to justify that kind of practice which I have always considered to be the safest and 
the best in this disorder. 

In the scarlatina anginosa, the treatment I employ is very much the same as 
that which I consider proper for many cases of continued fever. If the heat of the 
surface be very great and distressing, I should certainly and recommend the cold 
affusion, but cold or tepid sponging will be very refreshing and beneficial. If 
delirium should come on, I would shave the scalp, and apply cold to it, and 
take away some blood by leeches : and the leeches I would apply to the throat 
rather than to the temples ; for the tonsils, in this form of the disorder, are more 
swelled and inflamed, and probably a part of the head affection may arise from 
disturbance of the balance of the cerebral circulation, produced by the tumefaction 
around the great veins that return the blood from the head. By leeching the 
throat you relieve that part, and at the same time the head also. If the fever were 
extreme and the delirium violent, I would take blood cautiously from the arm, 
while the patient was sitting up, and carefully watch the effect. 

When none of these untoward head symptoms declare themselves, all that we 
have to do is to keep the bowels open by moderate laxatives. The patient may 
take saline draughts, which are grateful and cooling. The citrate of ammonia 
thus administered is what I frequently prescribe : and if the pulse be without 
hardness, and feeble, I order an excess of the carbonate of ammonia, so that four 
or five grains of it in each dose may remain unsaturated by the lemon-juice. 

With respect, then, to this form of the complaint, the principles of treatment 
are, not to interfere unnecessarily ; to take blood when certain symptoms require 
it, but to take no more than seems likely to be sufficient for the purpose in view ; 
to bear in mind that the system is labouring under a morbid poison, which we 
cannot eliminate from the blood, but the dangerous effects of which we are to watch 
and obviate. 

In that worst form of scarlet fever, the scarlatina maligna, all our care will too 
often be in vain. There appear to me two main sources of danger. The one 
arises from the primary impression of the contagious poison upon the body, and 
particularly upon the nervous system, which is overwhelmed by its influence. 
The patients sink often at a very early period, with but little affection either of 
the throat or of the skin. If we can save such patients at all, it must be by the 
liberal administration of wine and bark, to sustain the flagging powers until the 
deadly agency of the poison in some measure passes by. But another source of 
danger arises from the gangrenous ulceration which is apt to ensue in the fauces, 
when the patient is not killed by the first violence of the contagion. The system 
is re-inoculated, I believe, with the poisonous secretion from the throat. Now 
under these circumstances also, quina, or wine, and upon the whole I should give 
the preference to wine, are to be diligently, though watchfully given. And some- 
thing may be done, by way of gargles, to correct the state of the throat, and to 
prevent the distressing and perilous consequences which would otherwise be 
likely to flow from it. A weak solution of the chloride of soda maybe employed 
for this purpose ; and if the disease occur in a child that is not able to gargle, this 
solution may be injected into the nostrils, and against the fauces, by means of a 
syringe or elastic bottle. The effect of this application is sometimes most en- 
couraging. A quantity of offensive sloughy matter is brought away ; the acid 
discharge is rendered harmless : the running from the nose, and diarrhoea, cease ; 



1024 



SCARLET FEVER. 



and the disease is converted into a form which approximates to the scarlatina 
anginosa. This is a great improvement upon the old plan of ordering capsicum 
gargles. 

Of late I have been in the habit of directing a solution of the chlorate of potass 
in water, (a drachm to a pint,) as a drink for patients in scarlet fever, and in the 
typhoid forms of continued fever. This practice was suggested to me by Dr. 
Hunt, who tells me he has long employed it with advantage. Under the use of 
a pint, or pint and a half, of this solution daily, I have remarked, in many instances, 
a speedy improvement of the tongue, which, from being furred, or brown and dry, 
has become cleaner, and moist. 

From several distinct and highly respectable sources, chlorine itself has been 
strongly pressed upon my notice, as a most valuable remedy in the severest forms 
of scarlet fever. My informants have stated, that whereas they formerly dreaded 
to be summoned to cases of that disease, they now, having had experience of the 
virtues of chlorine, felt no misgivings in undertaking its treatment. Since these 
representations were made to me, I have not had opportunities enough of trying 
this drug to enable me to speak confidently of its sanative power; but I shall cer- 
tainly employ it in future, i presume that its disinfecting properties may, in part, 
account for the good it does. It probably deprives the foul secretions of their 
noxious quality. 

In the fourth volume of the Medical Gazette, Messrs. Taynton and Williams, 
of Bromley, write in high praise of this remedy. I will give you the formula for 
its preparation. 

Two drachms of the chlorate of potass are to be dissolved in two ounces of 
hydrochloric acid, previously diluted with two ounces of distilled water. The 
solution must be put immediately into a stoppered bottle, and kept in a dark place. 

Two drachms of this solution, mixed with a pint of distilled water, constitute 
the chlorine mixture; of which a tablespoonful, or twoj according to the age of 
the patient, may be given for a dose, frequently. 

We must not omit, in this, as well as in the other forms of the complaint, to 
pay attention to the state of the bowels, and by no means to allow them to remain 
costive. 

I have seldom used blisters in this disease ; but an experienced physician has 
lately told me that, when applied early to the neck and throat, they seem to render 
the affection of the fauces mild. 

When the patient is at length convalescent, he will require careful watching till 
that period has gone by at which the dropsical symptoms are apt to appear. It is 
by neglect or imprudence that these symptoms are brought on. The patient should 
be sedulously protected from all exposure to cold, and wet, and fatigue ; indeed he 
ought not to be permitted to go out of the house until the process of desquamation 
is fairly over ; and I would not willingly let a patient go out till some little time 
after this. When dropsical symptoms do occur, if they be very slight, they may 
be removed in general by purgatives, and by digitalis. The bitartrate of potass is 
a good remedy too in such cases, and the use of the warm bath, which may be 
repeated every night. 

But if there be any indication of inflammatory disease within, we must adopt 
more active measures. We have not, now, to contend with the depressing influ- 
ence of the original poison, but we have to dread the consequences of acute in- 
flammation ; or of the sudden effusion of fluid, the mere presence and pressure of 
which may fatally oppress vital organs. We should have for our object to arrest 
the inflammation — or to promote the removal of the effused fluid — by blood-letting, 
and by the exhibition of purgative medicines, and of mercury. The worst case 
of this kind that 1 ever witnessed occurred in a boy of fifteen, the son of a trades- 
man in my neighbourhood. He had had scarlet fever, mildly, and had got well, 
or nearly well, of it, as he believed ; and he went, one evening, into his father's 
stable, and stayed there some time in the cold, during the period of desquamation. 
A day or two afterwards he began to have headache, and in a few hours more was 



SCARLET FEVER. 



1025 



seized with convulsions of one side of the body, coma, and at length hemiplegia; 
and his face and extremities became at the same time anasarcous. A. large quantity 
of blood was taken from his arm, he was cupped on the temples, and took mercury, 
till in a short space of time he was profusely salivated. Under this treatment the 
coma and dropsy rapidly disappeared, and he presently recovered the use of his 
palsied limbs, and got quite well. I make no doubt that some effusion took 
place within the cranium, as well as into the subcutaneous areolar tissue. The 
plan of treatment followed in this case, modified according to particular circum- 
stances, is that which I should again pursue, and therefore what I should recom- 
mend you to pursue, in similar emergencies. 

You are probably aware that belladonna is believed by many to exert a prevent- 
ive and protecting influence upon the body against the contagion of scarlet fever. 
Hahnemann, the author of the Homoeopathic, hypothesis (and thereby of much 
mischief to mankind), was the first to assert this. It is said that belladonna 
administered in small doses causes sometimes a rash resembling that of scarlatina. 
It certainly is apt to produce dryness and redness of the fauces. I know nothing, 
by my own experience, of the alleged conservative power of this vegetable, but 
in the small quantities recommended, there can be no harm in trying it, provided 
that its employment does not lead to a neglect of other precautions. Three grains 
of the extract of belladonna are dissolved in an ounce of distilled water; and three 
drops of the solution are given twice daily to a child under twelve months old, 
and one drop more for every year above that age. It is affirmed that if this remedy 
does not prevent the disease, it will render it mild ; and that if it be taken four or 
five days before exposure to the contagion, the resulting scarlatina never proves 
fatal.* 

* [The question in relation to the prophylactic properties of the belladonna in this disease 
is a highly interesting one. The severe and fatal character of scarlet fever, particularly when 
it occurs as an epidemic, renders every means of prevention, that can be depended upon 
with any degree of certainty, of vast importance. In proof of the power of the belladonna 
to guard those who have been placed under its influence, from an attack of scarlatina, we 
have certainly some very strong and respectable testimony. In a paper published by 
Bayle, in 1830, it is stated that of 2027 individuals to whom the belladonna was adminis- 
tered, 1948 were preserved from scarlet fever, and 79 were attacked. Dusterberg reports, 
that all who were placed under the influence of the belladonna for the space of two weeks, 
were preserved from the scarlet fever. In order to ascertain the real value of the article, he 
purposely omitted to administer it to one child in each family, and this one alone, according 
to his report, was seized with the disease. He adds, however, that occasionally a child 
who had only been taking the remedy during three or four days, was attacked, but the fever 
was in such cases always mild, and often, only manifested its presence by the occurrence 
of desquamation. Zeuch, physician to the Military Hospital for Children, in Tyrol, after 84 
of the children were attacked with scarlet fever, was induced to try the prophylactic powers 
of belladonna on the remaining 61 children: with a single exception, all of these were 
preserved from the fever, although it prevailed all around them. Schenk, Berndt, Kuhler, 
Meglin, De Lens, and many other respectable practitioners, speak in equally high terms of 
the preservative properties of the belladonna. We have ourselves given the belladonna to 
a number of children, on several occasions when the scarlet fever was prevailing epidemi- 
cally, with a view of testing its prophylactic powers ; but although redness and dryness of 
the throat, and a diffuse scarlet effervescence were produced by it, yet in the majority of 
cases, we never found it in any instance to exhibit the slightest influence in shielding those who 
took it from an attack of the disease or in mitigating in.any degree its severity. In one case, 
the efflorescence produced by the belladonna was kept up for forty-eight hours; in a week 
afterwards the child was attacked by the fever in its most violent form, and died on the fourth 
day. Recently, however, Dr. Stievenart, of Valenciennes, has published the results of a 
very extensive trial of the belladonna, as a prophylactic during the prevalence of epidemic 
scarlatina; which results, if they are correctly stated, and all sources of error have been 
carefully guarded against in the performance of the experiments upon which they are 
founded, go very far to prove that the belladonna does actually possess the property of 
shielding the constitution from an attack of scarlet fever. An epidemic of the disease 
ravaged, during the winter of 1840-1, several villages in the neighbourhood of Valen- 
ciennes, when Dr. Stievenart was induced to try the prophylactic properties of belladonna. 
The fatality of the epidemic was such that 30 had already died out of 96 attacked ; conse- 
quently any means of prevention was a subject of vast importance. In a small village, 
65 



1026 



ERYSIPELAS. 



LECTURE LXXXIX. 

Tlie Plague. Erysipelas. Erythema nodosum. Urticaria. Prurigo. Scabies 

Of that group of contagious exanthemata of which I undertook to give you 
some general account, two only remain to be noticed; viz., the plague and erysi- 
pelas. 

Concerning one of these, the plague — as I have never seen, and hope never to 
see it; and as, with Cullen, I " think it unfit for a person who has never seen the 
disease to attempt its particular history" — I shall not presume to offer you any 
observations in detail. It is a very malignant kind of contagious fever; prevailing, 
at certain times and places, epidemically ; attended with a sort of eruption, namely, 
with buboes and carbuncles : and not furnishing, apparently, any sure or permanent 
security against its future recurrence. In Dr. Forbes' Select Medical Bibliography 
you will find a long list of works on the plague. I would second Dr. Cullen's 
recommendation, that you should consult those authors only who have themselves 
had personal experience of the disease. Among the publications that fall within 
this rule may be mentioned Dr. Russell's History of the Plague as he saw it in 
Aleppo ; Sir James M'Grigor's Medical Sketches: Sir Arthur Brooke Faulkner's 
Account of the Plague which occurred at Malta in 1813 ; Desgenettes' Histoire 
Medicale de l'Armee d'Orient ; and Assalini's description of the malady as he 
witnessed it when in attendance upon the French Army in Egypt. 

1 proeeed, therefore, to erysipelas. And I wish, in the first place, to fix and 
define that specific complaint of which alone I propose at present to speak. The 
term erysipelas has been employed by medical men in a very loose and vague 
manner. Any diffused redness and inflammation of the skin is apt to be set down 
as erysipelas ; and hence we have disputes as to the distinction between erysipelas 
and erythema. But it would tend, in my humble judgment, to the formation of 
more settled opinions in respect to erysipelas, if the term were restricted to that 
disease in which the integuments of the/ace and head become diffusely inflamed. 
The phrase erysipelatous inflammation may properly enough be applied to other 

out of 250 individuals. 200 took the belladonna, and were all preserved from the attack of 
scarlet fever. Of the fifty others, 14 were seized with the fever, and four of them died. At 
the village of Curgies, Dr. Stievenart administered the belladonna to the children at the 
public school, and allowed them to continue at their lessons, and have free communication 
with the other children of the village. All to whom the belladonna was administered 
escaped the scarlet fever, while a few who refused to take it were seized with the disease. 

The belladonna was administered in two forms — in solution, or as a powder. Two grains 
of the recent alcoholic extract of belladonna were dissolved in an ounce of any aromatic 
infusion, and of this two drops were given to a child of one year old, daily, for nine or ten 
days : an additional drop being given for every additional year of age. The largest daily dose 
was, however, limited to twelve drops. When the belladonna was used in the form of 
powder, half a grain of the powdered root was mixed with a small quantity of sugar, and 
divided into ten doses. One of these was given — morning and evening — to children of 
from one to two years old ; two powders, at the same periods, to those from three to five ; 
three powders to those from six to nine ; four to those from ten to fifteen, and five to 
adults. These small doses never produced the toxocological effects of belladonna; in fact, 
they scarcely exhibited any marked action. In five or six cases Dr. Stievenart observed a 
rash similar to that of measles; and, in a few other cases, headache, with dilatation of the 
pupils, dryness of the fauces, and a slight soreness of the throat, but which had no resem- 
blance to that of scarlatina anginosa. In all the other cases no sensible or apparent effect 
resulted from the administration of the remedy. Dr. Stievenart generally, continued the 
use of the belladonna for from nine to ten days; in some cases, it was given for fifteen days. 
He thinks this period sufficiently long to put the system under the influence of the preserv- 
ative powers of the remedy; but recommends to resume its use if the epidemic returns or 
breaks out again with renewed violence. — C] 



ERYSIPELAS. 



1027 



cases, similar to this, in so far as the condition of the skin is concerned ; but in 
what I should consider true erysipelas, in the medical sense of the word, there 
are other characters belonging to the disorder quite as important as, and more 
distinctive than, the cutaneous affection. What is usually spoken of as erysipelas 
of the face and head, and what I would call simply erysipelas, falls naturally within 
that group of exanthematous diseases which includes small-pox, measles, scarlet 
fever, the plague, and continued fever. It is an idiopathic inflammatory disorder, 
running a tolerably regular and definite course ; attended by inflammation of the 
integuments of the body, or in other words by an eruption; often prevailing 
epidemically : and capable of being communicated, under circumstances favourable 
to its propagation, from one person to another. Its power to protect the constitu- 
tion from its own recurrence is less certain ; but in truth, so many different affec- 
tions have been lumped together under a common name, that the proper phenomena 
of true erysipelas have not been made sufficiently an object of separate study to 
enable us to speak with any confidence on this point. I recollect, however, a 
certain female who has been three or four times my patient in the hospital with 
erysipelas : and one of the night nurses there, whom I treated for that complaint 
sometime ago, is now lying ill of the same disorder, under the care of one of my 
colleagues. 

Erysipelas, in the sense now explained, called in Scotland the rose, and in this 
country St. Anthony's fire, resembles other disorders of the same group in these 
points also, that the fever precedes the local inflammation, that certain premonitory 
symptoms frequently go before the outbreak of the disease, and that sore throat 
is an early, and almost a constant, accompaniment of the complaint. The patient 
feels ill — shivery, feeble, languid, and often drowsy. The actual attack generally 
sets in with distinct rigors; and the pulse is often very frequent from the first, 
for many hours, perhaps, before the redness commences. Very commonly there 
is also manifest disturbance of the alimentary canal, marked by nausea and vomit- 
ing, and not unfrequently by diarrhosa. Then some part of the face, usually one 
side of the nose, or one cheek, or the rim of one of the ears, begins to feel hot, 
stiff, and tingling: and upon examining it you find it to be of a deep continuous 
red colour, and to be swelled and hard. The redness and swelling gradually, and 
sometimes rapidly, extend themselves: they are defined by a distinct elevated 
margin; which advances, and invades progressively the neighbouring healthy sur- 
face, until the whole of the face, or of the scalp, or of both, is occupied with the 
inflammation. The lips swell enormously, the cheeks enlarge, the eyes are 
sealed up by their osdematous and prominent lids, and all traces of the natural 
countenance are effaced. I know of no disease, except perhaps the confluent 
small-pox, which so completely and speedily deforms and disguises the visage of 
the patient. A stranger seeing a young female in the height of the disorder, and 
revisiting her after her recovery, is astonished at the change. It seems as if, by 
some magic process, such as we read of in our nursery tales, a hideous monster 
has been metamorphosed into a comely damsel. 

The inflammation frequently spreads from the face and forehead, or ears, to the 
hairy scalp; and from the head it travels backwards, in some cases, to the neck 
and the shoulders. Sometimes — and in this it exactly resembles a scald — the 
inflamed surface becomes covered with irregular bullae, or blisters ; but often there 
is no vesication. This circumstance, therefore, which has been mentioned by 
some as furnishing a point of distinction between erythema and erysipelas, fails 
of that purpose. 

In many cases the inflammation is quite superficial : in others it dips, as it were, 
through the skin, and affects the subcutaneous areolar tissue; and then, and there, 
suppuration, and even sloughing of that tissue, are apt to take place. We find 
this to be the case often in the loose tissue of the eyelids ; and it is more common 
on the scalp perhaps than on the face. 

After the redness has lasted three or four days, it fades, the swollen surface 
subsides, and desquamation ensues; and as the inflammation creeps, perhaps, 



1028 



ERYSIPELAS. 



gradually from one part of the surface to another, you may find the face becoming 
pale, and covered with patches of dead cuticle, while the scalp, or the upper part 
of the neck, is becoming red. Sometimes those parts of the inflamed surface on 
which blisters had formed are covered with crusts, rather than with merely dead 
and dry cuticle. In almost all these cases of erysipelas of the head and face there 
will be found to be redness and soreness of the throat also ; although this is not 
always inquired into, or complained of. 

There is considerable variety in the intensity and complication of the symp- 
toms. Sometimes the sufferer lies patiently still, yet apparently conscious and 
rational, till the tumefaction diminishes, and he is again able to open his eyes. 
Generally there is some wandering of the mind, especially at night ; and in bad 
cases there is much delirium, and at length complete coma, and the patient dies 
at the end of a few days. In some of these cases the inflammation has extended 
to the encephalon ; in others it is probable that the functions of the brain are dis- 
turbed through the febrile derangement of the circulation. When death takes 
place, and the head is examined, serous fluid is usually discovered beneath the 
arachnoid, and in the cerebral ventricles ; and the veins of the pia mater are turgid. 
I have stated before that I doubt whether such appearances are always to be attri- 
buted to inflammation. Sometimes there are no morbid appearances at all within 
the skull. 

It is said that the erysipelas does, now and then, suddenly desert the surface ; 
and that inflammation of some internal part, and particularly of the brain, is apt 
to follow such rapid subsidence of the external malady. I presume that this me- 
tastasis is rare. I do not recollect to have seen it. But the extension of the 
inflammation, the supervention of delirium and coma, while the external inflam- 
mation continues, are of common occurrence. 

This, then, is one way in which erysipelas is accustomed to prdve fatal; by 
effusion within the head, and coma. 

And there is another mode in which death is not unfrequently brought about, 
and which has not been so much attended to ; I mean by the affection of the 
throat. The patient dies sometimes almost suddenly ; unexpectedly; you cannot 
account for the unlooked-for dissolution. But if the throat be examined you may 
(sometimes at least) there discover the solution of the mystery. The sub-mucous 
tissue of the glottis and epiglottis is filled with serum, the chink of the larynx has 
been nearly or completely closed, and the patient has died of apncea. This is 
just analogous to what takes place externally : the enormous swelling of the eye- 
lids, and lips, and face, is owing, in a great degree, to serous fluid poured out 
into the sub- cutaneous areolar membrane. , 

Another way in which erysipelas may kill, is by gradual asthenia. Without 
any stupor or much wandering, without any marked affection of the breath, the 
pulse becomes weaker and weaker, the surface cold, and the heart at length ceases 
to pulsate. This mode of dying is less common in this disorder than the other 
two. 

The causes of e^sipelas are various, and often obscure. I have stated that it 
is communicable, by contagion, from person to person : yet this contagious pro- 
perty is so feebly marked, that it is denied by many. It is more active at certain 
times, at certain seasons, at certain places, than at others ; which is the same 
thing as to say that there are predisposing causes of the disease ; that there are 
influences which augment the susceptibility of the body to the agency of the 
poison. 

I believe that on the continent they do not allow erysipelas to be contagious at 
all : but very satisfactory evidence of the fact has been collected by several of our 
own practitioners. In the second volume of the Transactions of a Society for 
the Improvement of Medical and Chirurgical Knowledge, Dr. Wells has brought 
together several examples in which the complaint appeared to be unequivocally 
propagated by contagion. " I visited (says he), on the 8th of August, 1796, in 
Vine street, Clerkenwell, an elderly man, named Skelton, who had been attacked 



ERYSIPELAS. 



1029 



several days before with erysipelas of the face. In about a week afterwards he 
died. On the 19th of the following month, I saw a Mrs. Dyke, of about seventy 
years of age, the landlady of the house in which Skelton had been a lodger, and 
found her labouring under an erysipelas of her face. I inquired whether any other 
person in her house had been ill of the same disease since the death of Skelton, 
and was told that his wife had been seized with it a few days after his decease, 
and had died in about a week. During my attendance upon Mrs. Dyke, an old 
woman, her nurse, was attacked with the same disorder, and was sent to her 
parish- workhouse, where she died. Mrs. Dyke has since informed me that a 
young man, the nephew of Skelton, was taken with the disease of which his uncle 
had died, shortly after visiting him, and survived the attack only a few days. 
That she herself had been several times with Skelton and his wife during their 
sickness, and after their death had removed some furniture from the room they 
had occupied to her own apartment." Dr. Wells relates other histories of the 
same kind, all occurring when there was no particular epidemic of erysipelas 
prevailing to account for them. Professor Arnott has given some other examples, 
still more striking, of the propagation of erysipelas from one person to another, 
not only under the same roof, and in the same locality, but also when the parties 
lived at a distance from each other, and the intercourse between them had been 
casual and temporary. These cases are stated, I think, in the fifty-seventh volume 
of the London Medical and Physical Journal. The following incident has been 
told me upon good authority. A man living somewhere in Westminster fell ill 
of idiopathic erysipelas. In that state, for some reason or other, he was removed 
thence ; and his brother, who was a servant in or near Portland Place, received 
him clandestinely into his master's house, and allowed him (for two nights, I 
believe) to share his bed. That brother was soon attacked with erysipelas; and 
in the course of his illness was visited by his master. The master also was 
attacked ; and it is worthy of remark, that in both master and servant, the disease 
showed itself just seven days after they had respectively come near another who 
was affected with it. Dr. Elliotson gives an account of having suffered the dis- 
ease in his own person. It came on in him five days after the breath from one of 
his patients, over whom he was stooping to examine the skin, and who had ery- 
sipelas badly, and died of it, had come upon his face. " I turned away (he says) 
disgusted, and said, I hope I have not caught if. ; but five days afterwards, having 
forgotten the circumstance, I was seized with it." More than once I have had 
occasion to remark that successive tenants of the same bed in a hospital have been 
seized with erysipelas after admission. . 

But allowing, as I think we cannot but allow, that contagion is one of the ex- 
citing causes of erysipelas, there are others which more frequently excite it. At 
least there are many instances of the disorder in which we can trace no exposure 
to contagion, and in which we can perceive some other probable reason for its 
occurrence. Sometimes, no doubt, it comes on without any obvious cause. The 
application of cold often gives rise to it. Irregularity of diet is said to do the 
same. Violent mental emotions are also accused of being occasionally its cause: 
it is said to have been brought on both by anger, which is an exciting, and by 
fear, which is a depressing, passion. It is incidental to what I have called puru- 
lent infection of the blood. Many cases, not to be distinguished in their appear- 
ances and effects from idiopathic erysipelas, result from local injury. I have 
already told you that there is no inconsistency or absurdity in supposing that a 
disorder which originates in some common cause, may be capable of spreading in 
the way of contagion. And the testimony of Mr. Lawrence (who is not prone 
to admit of contagion on light grounds) goes to the effect that such is the case 
with the disease in question. He mentions an instance in which erysipelas of 
the head and face, which commenced after the insertion of a seton in the neck, 
appeared to him to have affected two individuals by contagion. 

I say that erysipelas further resembles the disorders of the group in which I 
have placed it, that it sometimes prevails epidemically: and on those occasions, 



1030 



ERYSIPELAS. 



like the rest of the group, its occurrence is promoted by all circumstances that 
tend to debilitate the body: by intemperance; by previous disease; by low spirits 
and anxiety; by insufficient nourishment; and by foul air. It used to be much 
more common formerly in hospitals than it is at present; when less attention was 
paid to cleanliness and ventilation. 

Erysipelas is another of the diseases concerning the treatment of which there 
has been, and there is, a most embarrassing difference of opinion. Some, pre- 
scribing according to a name, tell you that it is inflammation, and therefore that 
the remedies of inflammation, and especially blood-letting, are to be vigorously 
employed. Others declare that the safety of the patient lies in the early and 
liberal administration of wine and bark. You will not think me a trimmer, I hope, 
or one who is content with indecisive practice, when I state that neither of these 
plans, in my judgment, is universally either proper or safe ; yet that each of them 
is the best, under certain circumstances. 

I think, the more you see of this disease the more convinced you will be that 
it is not to be cut short by any particular mode of treatment ; that it will run a 
certain course ; and that it will generally terminate sooner or later, by resolution, 
whether remedies be employed or not. It does not follow from this that reme- 
dies are of no use: but it does follow that we are to exhibit them, not with the 
view of curing the disorder, but with the view of conducting it safely to its ter- 
mination. 

If you look at the history of erysipelas, and of the notions which have prevailed 
respecting it, you will find that the opinions in favour of giving support, and of 
abstaining, as much as possible, from the abstraction of blood, greatly preponder- 
ate. In the outset of the complaint, if the pulse be hard as well as frequent, and 
there be much headache, and active delirium, you must take blood either from the 
arm, or from the neck by cupping, or by leeches from behind the ears. But (I 
speak of the disease as it occurs in London) the time for this kind of practice 
soon passes by: and when you do bleed from the arm, you must (in this town) 
bleed with caution, and in the upright posture; that the desired effect may be 
produced by the abstraction of the smallest quantity of blood. 

In all cases it will be right to purge the patient briskly at the commencement. 
A full dose of neutral salts, or of rhubarb and magnesia, will answer better, I think, 
in these cases, than calomel and senna. If you see the patient very early, and if 
there be any nausea or oppression of the stomach, it will be proper to administer 
an emetic. 

In most instances you will soon perceive evidence of great debility: a feeble as 
well as a frequent pulse; tremors; a dry and brown tongue often. And these 
symptoms increase, if you then persist in drawing blood. The carbonate of am- 
monia does great good sometimes in such a condition: and this I am very much 
in the habit of giving. The bad cases of erysipelas are apt to baffle us all. I am 
not aware that I lose more of them than my neighbours. Speaking generally, a 
large majority of my patients get well ; but I do not bleed one patient in a hundred, 
from the arm. 

I am bound, however, to set before you the kind of evidence which exists in 
favour of the bark ; or rather of the sulphate of quina, which is what I mean when 
I speak of the bark. 

Dr. Fordyce, Dr. Wells, Dr. Heberden — all men of great sagacity and experience 
— recommend the treatment by bark. Dr. Jackson, an American physician, advo- 
cates, I see, the same plan. He says that after a purge, and, if necessary, an 
emetic, the sulphate of quina should be given in as large doses as the patient will 
bear ; that from twelve to twenty-five grains in the twenty-four hours will generally 
suffice; and that we may know when the dose is sufficient by a buzzing which 
comes on in the ears. Dr. Elliotson also — whom I here quote the more willingly 
because I think he is rather of an antiphlogistic turn than otherwise, in general — 
says, that he has never seen quina do harm, even in active tonic erysipelas; and 
that in doubtful cases, when you hesitate whether to bleed and put the antiphlo- 



ERYSIPELAS. 



1031 



gistic plan in force, or to stimulate and support, the quina is always a safe and 
eligible medicine. Dr. Williams, of St. Thomas's Hospital, thinks better still of 
wine, which he gives in all cases from the very beginning. 

I have hitherto limited my observations to erysipelas of the face and head as it 
occurs in London: and I have done so because I really believe that in the purer 
air of the country, and in young, strong, vigorous country persons, bleeding may 
be proper and requisite. You will find country practitioners pretty well agreed 
on this point. 

But taking the disease as I see it here, I should say that many cases do well 
with but little care or interference from medicine; that many also, hut a fewer 
number than the former, prove fatal under whatever plan of treatment may be 
adopted; and that many patients are to be saved, by judicious management, who 
would otherwise die. 

The first requisite for rescuing these perilous, yet recoverable cases, is that 
they should be perpetually watched and tended. The indications of treatment 
may alter from one hour to another, and it is only by great vigilance on the part 
of the medical attendant, and on the part of an intelligent and obedient nurse, that 
medicine obtains its full chance of bringing the patient through. 

After clearing out the alimentary canal, then, I would not be active in either 
way, unless I saw some plain indication for activity. If the pulse became weaker, 
and I did not feel sure about the propriety of stimulating, I would give five or six 
grains of the carbonate of ammonia every four hours, and beef-tea. If the dis- 
ease went on smoothly under that treatment, well and good. If the powers still 
continued to sink, I should have recourse to wine, or to both bark and wine ; but 
of the two, I am more friendly to wine ; and as the patients like it better, you may 
be more sure of their taking it. If, on the other hand, there were much headache, 
and the pulse were hard, and the febrile distress great, I should apply a few 
leeches, and prescribe the tartarized antimony in a saline draught. The bowels 
should not be allowed to become confined; but the mild aperients are better than 
the drastic in these cases. 

Various external medicaments have been used and recommended for the in- 
flamed part. Putting leeches, upon it; puncturing it with needles, or lancets; 
covering, or surrounding it with blister, or with the lunar caustic, in substance or 
in strong solution ; dusting the surface over with magnesia, or flour; smearing it 
with various unguents, and particularly with mercurial ointment; keeping it wet 
with some cold lotion ; or fomenting it with hot flannels. 

Now of all these local appliances, that which, according to my own observa- 
tion, is the most useful, and which affords the greatest comfort to the patient, is 
the last that I mentioned ; fomentation by flannels wrung out of a hot decoction 
of poppy-heads. But in order to give this, also, fair play, it should be continual; 
not used for half an hour, and then intermitted ; but it should be one person's 
business to apply the fomentation assiduously, as long as it is soothing and 
grateful to the patient. In a few cases, and but a few, the warm applications 
have been disliked, and cold lotions preferred : and when such is the case, there 
is no risk incurred by using 1 them, so far as I know ; no hazard, I mean, such as 
you may read of, of the inflammation being repelled from the surface, and driven 
in upon some vital organ. The local treatment most in favour with our apothe- 
cary at the hospital is that of covering the inflamed face and head with flour, by 
means of a dredging box. The patients declare that the flour cools, soothes, and 
comforts them. Now this is a more convenient, and, in some respects, a more 
eligible, application than that of hot flannels. It is less likely to fail of its purpose 
through the negligence of the nurse.* 

So much for erysipelas, as it usually comes under the notice and the manage- 

* [Keeping the inflamed surface constantly covered with perfectly fresh hog's lard, has 
a very soothing effect, and tends to reduce the violence of the inflammation. We have 
occasionally employed an ointment formed of acetate of lead fifteen grains, rubbed up with 
one ounce of hog's lard, and have been pleased with its effects. — C] 



1032 



ERYTHEMA. 



mem of the physician. You are aware that an affection of the skin very similar 
to that which I have been describing, and called also by the same name of erysi- 
pelas, is very common in other parts of the body ; on the extremities especially, 
and occasionally on the trunk: and it will travel sometimes from an extremity till 
it reaches the head. These varieties of cutaneous inflammation are, in most in- 
stances, the indirect consequences of some local injury; of punctured wounds; of 
the stings of insects, or the bites of venomous reptiles : of mere scratches some- 
times. Or the cutaneous inflammation will spread from old sores ; or supervene 
upon dropsical limbs. It is curious that these complaints also are much more apt 
to occur, and even to multiply by a sort of contagion, or in virtue of some epide- 
mic atmospheric influence — at certain times and places than at others. You will 
find there are periods when the surgeons of hospitals dread to perform any ope- 
ration, lest it should be followed by this spreading inflammation of the skin. 
There are many points of great interest connected with these diversified forms of 
what is called erysipelas; they are more liable to be attended with gangrene than 
erysipelas of the face and scalp : on the other hand, they are more liable also to 
be complicated with inflammation of the subcutaneous areolar tissue, and with 
suppuration ; and to require incisions to relieve the great tension of the inflamed 
parts, and to facilitate the escape of the pus, or of sloughy dead portions of areolar 
tissue ; but all these matters belong rather to surgery, and have been discussed, I 
make no doubt, by the Professor of Surgery. 

Very closely connected with erysipelas, and continually confounded with it, is 
erythema. It also consists in superficial redness of some portion of the skin ; but 
is not attended with inflammation of the areolar texture under the skin; nor with 
vesication ; nor, in general, with fever ; nor is it peculiar to the face and head. 

There are numerous varieties of erythema described by writers on cutaneous 
disorders, to whom I must refer you for an account of them. Willan and Bate- 
man ; Wilson; Willis; Rayer; Alibert; and Biett, as his practice and lessons 
are reported by two of his pupils. 

The only variety on which I am disposed to say a word, is one which is at- 
tended with more or less febrile disturbance. I«/nean what is called erythema 
nodosum. 9 

This curious affection occurs much more often in young women than in any- 
other persons ; sometimes in feeble boys. The eruption is commonly preceded 
for a few days by indisposition, and some slight degree of fever. Then red ele- 
vated spots come out, on the fore part of the legs, and occasionally, but very 
rarely, on the arms. The redness appears in oval patches, of which the long 
diameter is parallel to the axis of the limb. They are pretty large patches, an 
inch and half long, and an inch broad perhaps, and they evidently project and 
form bumps upon the anterior surface of the leg. From their look, you would 
suppose abscesses were about to form ; but after lasting a few days, the red colour 
fades, or rather changes to a blue, and the protuberances gradually subside. This 
eruption seems sometimes connected with disturbance of the menstrual functions. 
Rayer has seen it occur in connection with acute rheumatism. So have I. A 
patient of mine in the hospital was attacked with acute rheumatism of the joints 
immediately upon the cessation of erythema nodosum. In another this order was 
reversed. 

Now I am persuaded that, after an aperient, rest, the horizontal posture, and 
quina, constitute the proper treatment of this affection. I had once a housemaid, 
in whom the disorder appeared, and was attended with unusually high fever, and 
much indisposition. I treated her, therefore, antiphlogistically ; i. e., I kept her 
on low diet, and gave purgatives ; but the disease went on. Fresh knots came out 
as the old ones faded. At length, I do not remember why, I prescribed some 
quina for her; and the improvement was immediate, and very striking. She 
relapsed, however, once or twice, upon leaving off the bark; but by persisting 
subsequently in its use for some^ays after she appeared to be well, a permanent 



URTICARIA. 



1033 



cure was effected. Since that time — now ten or twelve years ago — I have seen 
a good many examples of erythema nodosum, and I have treated them all alike; 
viz., first with an aperient, and then with the sulphate of quina: and they have 
all rapidly got well. Probably they would have recovered nearly as soon under 
some other tonic treatment; but I have been so well satisfied with this, since 
I began it, that I have felt no temptation to try any other. 

There is a rash which is well known, and very tormenting, and, therefore, not 
without interest, although it is almost always without danger: I mean urticaria. 
It is arranged by Cullen among the exanthemata ; but it does not properly 
belong to the group to which I would restrict that name, for it is not contagious, 
and it may happen to the same person a hundred times over. The eruption con- 
sists of what, from analogy, are called wheals ; i. e., of little solid eminences, of 
irregular outline, but generally roundish or oblong, and either white, or red, or 
(which is most common) both red and white; the whiteness occupying steadily 
the central and most projecting part of the spot, or becoming manifest there when 
the integuments are put upon the stretch. The rash is accompanied with intense 
heat, a burning and tingling in the affected spots, and great itching and irritation. 

In truth, both the appearances upon the skin, and the sensations that attend 
them, are very much like the appearances and feelings produced by the stinging 
of nettles. Hence its trivial name, nettle-rash ; which is, indeed, the same, in 
meaning, with the scientific appellation, urtica being the Latin for a nettle. 
Similar appearances follow almost immediately upon a smart blow with a cane, 
or with the lash of a whip, on the skin. Red stripes or wheals arise, and within 
the reddened surface one or more elevated spots of a white colour are visible. 

There are two varieties of urticaria: one in which the complaint runs a short 
course, and soon subsides, and may be considered acute; another in which it is 
chronic, and either persistent or intermittent. The acute form is attended with 
feverishness, which sometimes begins two or three days, but commonly not more 
than a few hours, before the eruption ; or the fever and the rash may commence 
together. In most cases, perhaps in all, the disorder is intimately linked with 
some derangement, manifest or latent, of the digestive organs, and it may often 
be traced to the use of particular articles of food. It is very curious that the contact 
of certain substances with the mucous membrane of the alimentary canal should 
affect the external tegument precisely in the same manner as the virus of the net- 
tle, and some other irritants, when these are applied to the skin itself. The 
offending articles of food do not produce the cutaneous affection in all persons, 
nor even necessarily in the same person at all times. But there are some edible 
substances which are much more likely than others to be followed by nettle-rash. 
Certain vegetable matters are very apt to excite the disorder in some persons: 
oatmeal ; almonds, especially the bitter almonds ; any bitter kernels ; particular 
species of strawberries; raw cucumbers; mushrooms. Some of the vegetable 
substances used in medicine are known to have, frequently, the same effect; 
capivi, for example ; the cubebs pepper ; valerian. Urticaria has been brought on 
by drinking porter, or, most probably, by some of the drugs with which our 
porter is sophisticated. These effects are not confined to vegetable substances. 
Shell-fish is a common source of nettle-rash. I have known it to be occasioned by 
prawns; crabs sometimes have the same unpleasant consequence; and still more, 
muscles. An hour or two after some one of these substances has been swallowed, 
and perhaps much sooner, nausea is felt, and oppression about the epigastrium; 
the patient becomes giddy, his face and head sometimes swell, his skin begins 
here and there to burn and tingle, and presently the eruption, as I have already 
described it, breaks forth. It is attended with intolerable itching and pricking 
sensations, especially at night, when the patient is warm in bed, or when the 
affected surface is exposed to the air. Vomiting and diarrhcea often supervene, 
and prove the natural cure of the attack. 

We read that this disorder has sometimes proved fatal ; but this must be under 



1034 



PRURIGO. 



very unusual circumstances of weakness in the patient, or of some peculiar viru- 
lence in the exciting cause. 

The chronic form of the complaint is apt to be very obstinate and teasing. It 
comes and goes, and comes again. The evening is one of its favourite periods. 
In those who are subject to it, the itching and the wheals are readily brought on 
by scratching or rubbing the surface. This is the urticaria evanida of Willan. 
Dr. Heberden had known persons afflicted in this way for ten years together. I 
have observed nettle-rash to occur in connection with sudden and violent paroxysms 
of dyspnoea, resembling asthma fits ; so that I could not help suspecting that the 
mucous membrane of the respiratory passages was irritated after the same fashion 
with the external skin. 

Even the chronic variety of urticaria is, in some instances at least, produced by 
certain ingest® : and the peccant substance may often be detected, and the tire- 
some malady be cured, by following the simple and judicious plan recommended 
by Willan ; namely, that of instructing the patient to abstain, for a while, from all 
his customary articles of diet, one by one, in their turn. This experiment does 
not, indeed, always answer. The urticaria will sometimes abide, notwithstand- 
ing : so that although it probably depends in all cases upon some disordered con- 
dition of the stomach or bowels, we cannot say that such disorder is always the 
consequence of something that has been swallowed. 

The treatment to be adopted in the acute cr febrile nettle-rash, when it depends 
upon something recently received into the stomach, is that which common sense 
would suggest, and which nature often plainly indicates. We seek to expel the 
offending material by an emetic, and by purgatives : and this being done, the cure 
is completed. In the more chronic and recurring varieties, we endeavour, in the 
first place, by making the experiment recommended by Dr. Willan, to detect, that 
we may thenceforth interdict, any article of diet which may have caused the dis- 
order. If we fail in this attempt, our object must be to correct that faulty state 
of the digestive organs, or to neutralize that inbred poison, upon which the cuta- 
neous affection depends. Laxatives and antacids are found to be the most suc- 
cessful means of attaining these ends. They may be given together, or separately. 
Rhubarb and magnesia ; the carbonate and sulphate of magnesia ; castor-oil. The 
snake-root has obtained some repute as a remedy for urticaria. You may pre- 
scribe, therefore, if you please, a scruple each of the carbonates of magnesia and 
of soda, in the infusion of serpentaria. 

External applications seem to be of but little avail in this disease ; and those 
which do appear to be of service, act uncertainly, and produce different effects in 
different persons. The warm bath sometimes gives ease in the severer cases. 
In the more chronic form of the disorder, spirituous washes, vinegar, sea-bathing, 
are things to be tried. And cases are related in which, when every other ex- 
pedient has failed to give permanent relief, removal to a warmer climate has been 
successful. Dusting the itching surface with flour has, in my experience, af- 
forded much temporary comfort. Slill more effectual perhaps is a lotion (first 
recommended by Wilkinson, in a little work on skin diseases) composed of a 
drachm of the carbonate of ammonia, a drachm of the acetate of lead, and eight 
ounces of rose water. 

I should add, that Dr. Elliotson has found bleeding very efficacious in reliev- 
ing patients affected with acute or febrile urticaria. And you may have recourse 
to the lancet if the patient be strong and plethoric, and his pulse warrant it ; 
and if he be so impatient of the irritation as not to be willing to wait the effect of 
other treatment which would probably be quite as effectual, though not quite so 
rapid. 

Prurigo. — Itching — is a cutaneous affection bearing some analogy to urticaria, 
at least in the sensations which accompany it. And a most terrible and melan- 
choly affection it often proves to be. Sometimes the parts of the skin which 
are the seat of the itching do not present any perceptible deviation from the 



PRURIGO. 



1035 



condition of health ; but in the majority of instances, you will find, upon close 
inspection, that they are covered with papulae, which are nearly of the same colour 
with the skin itself. Willan therefore places prurigo in the order of Papulae. He 
describes several varieties of this troublesome complaint : prurigo mitis ; prurigo 
formicans ; prurigo senilis. The torment experienced by patients suffering under 
the severer forms of the malady is scarcely describable : they scratch and tear 
themselves incessantly till the blood flows, their sleep is broken, and their lives 
are rendered perfectly miserable. Sometimes this itching is diffused irregularly 
here and there over the surface ; sometimes it affects the extremities only ; and 
frequently it has a still more limited habitat, occurring round the anus, when it is 
called prurigo podicis ; or on the scrotum, prurigo scroti; or, worst form of all, 
the prurigo pudendi rnuliebris. 

All these forms of prurigo are apt to be aggravated by heat, and by exposure to 
the air ; they are, therefore, especially distressing when the patient undresses and 
goes to bed. The scratching tears away the summits of the papulae, and some 
watery fluid mixed with blood escapes, and concretes into small, thin, black scabs. 
In the prurigo formicans, the itching is combined with other painful an'd disagree- 
able sensations, which different patients describe in different terms ; the feeling is 
like the creeping of ants, or the stinging of insects, or as if hot needles were thrust 
into the skin. The prurigo senilis, occurring, as that name implies, in old persons, 
is usually very obstinate, and often effectually destroys all comfort for the rest of 
the patient's life. 

In such cases as I have now been mentioning, great care should be taken tho- 
roughly to cleanse the surface of the body : and the diet should be rigidly plain. 
All kinds of rich sauces, hot condiments, pickles, and indigestible substances, 
should be peremptorily forbidden. Various local applications have been praised; 
but they are, in most cases, used in vain : lime water, decoction of dulcamara, 
lotions composed of prussic acid in an emulsion of bitter almonds, a dilute solu- 
tion of creasote, decoction of stavesacre, and of digitals, ointments containing 
mercury, tar ointment, and a hundred others. In one instance lately, where the 
ingenuity of another practitioner had been fruitlessly exhausted, I was fortunate 
enough to effect perfect relief by smearing the itching surface with an ointment 
containing a small quantity of aconitine. Of internal remedies, sarsaparilla, alka- 
lies, arsenic, the iodide of potassium, dulcamara, are the most hopeful. When 
these means fail, opium is our best, and indeed our only resource. 

The local forms of prurigo are frequently connected with local disease, and are 
most likely to be relieved by measures directed against the primary disorder. 
Prurigo podicis is sometimes dependent on the presence of ascarides in the rectum. 
The same troublesome affection is not an uncommon symptom of internal piles : 
and it sometimes accompanies stone in the bladder. 

The prurigo pudendi rnuliebris — itching of the genitals in females — is some- 
times so constant and tormenting, and the impulse to scratch the itching part so 
urgent, as to drive the unhappy patient from society. It even gives rise, in some 
severe cases, to nymphomania. It may proceed from leucorrheea : it is fre- 
quently a sign of uterine disease. It most commonly affects women in whom 
the menstrual discharge has ceased to appear.* I have never had an oppor- 
tunity of trying the aconitine in such cases. The local application which has 
been found most serviceable is the yellow wash, which, as you probably know, 
is a solution of corrosive sublimate in lime water, in the proportion of a drachm to 
a pint.t • 

You will sometimes be consulted — at least I have b0en, on more than one 
occasion — about itching of the pubes and scrotum, produced by the presence of 

* [We have met with it just as frequently in the menstruating female as in those in whom 
the menses had ceased: some females are troubled with it during pregnancy and at no 
other period. — C] 

f [A saturated solution of borax will give, in many cases, very prompt relief; and by a 
perseverance in its use a permanent cure may often be effected.— C] 



1036 



SCABIES. 



the pediculi that are vulgarly called crab-lice. The patients are sometimes quite 
unaware of the cause of the itching. You may relieve them by the wash I have 
just mentioned ; or, by a more elegant lotion, made by dissolving corrosive subli- 
mate in a little spirit, and adding rose water. A single washing with such a lotion 
will destroy the whole colony : and the vermin become much more visible after 
this violent death, turning black, and relaxing their hold upon the skin. 

Prurigo is a convenient generic name for these cutaneous affections, of which 
the prominent feature is the teasing sensation that accompanies them. But, be- 
sides all these, there is a specific disorder, which, from the intensity of that sensa- 
tion, is emphatically termed the itch, and which deserves a short notice; for it is 
exceedingly common, and exceedingly distressing, and (what is more interesting 
still) it is easy of cure. It is one of the very few complaints for which we pos- 
sess a specific or infallible remedy. 

Scabies, or the itch, is, as everybody knows, contagious ; but it is contagious 
only in that particular sense which implies contact. It is not producible by any 
effluvia which the atmosphere can convey : it requires, for its propagation, that 
the healthy person should touch the diseased person, or some substance which 
has been in contact with his unhealthy skin. Certain parts of the skin are more 
liable to it than others. It is most common at the roots of the fingers and thumbs, 
between them as it were ; on the wrists ; between the toes ; in the flexures of the 
joints. It may spread to almost every part of the trunk or of the extremities; 
but all observers agree in stating that it is seldom or never seen upon the face and 
head ; a curious but unaccountable exemption. 

The eruption is at first papular, and then vesicular, presenting a number of 
pointed watery heads. When the inflammation is aggravated by intemperate 
habits, or by the scratching from which the patient is unable to refrain, the vesi- 
cles are liable to be converted into pustules : and this has needlessly been made a 
separate species of itch, scabies purulenta, pocky itch : you see large pustules, 
filled with a yellow viscid matter, standing on an inflamed base. If you are not 
aware of these varieties and changes, you may make unlucky errors of diagnosis; 
affront your patient by telling him he has the itch when he has it not ; or suffer 
him unconsciously to betray and shame himself by communicating it to others, 
when he has. You will easily understand how it has come to be considered a 
disgrace to have the itch ; for it is fostered and propagated in most unfashionable 
places, amidst poverty, vulgarity, and filth. Yet the most delicate and high-bred 
lady may contract the distemper; and when once it is contracted, it will go on 
indefinitely, through life, unless proper means are adopted for its cure. It never 
gets well if left to itself. 

One very curious point in this discreditable malady, is its connection with a 
peculiar insect, called accordingly the acarus scabiei. The existence of this 
ectozoon had long been affirmed and denied ; but the vexed question has at length 
been set at rest by the public demonstration of the acarus, by a M. Renucci, to a 
number of medical practitioners in Paris. It has since been often detected and 
exhibited here. Dr. Nevinson has lately assured me that he furnished Shaw, the 
naturalist, Dr. Wollaston, and others, with living itch-mites, for examination, forty 
years ago. One reason, probably, why it has often been searched for in vain is, 
that the acari are not equally numerous with the vesicles : there is not an insect 
for every vesicle. Another reason is, that persons have not known exactly where 
to look for the insect. • It is not in the pustules or vesicles ; but near them ; at 
the extremity of a short, small, superficial tunnel or furrow which runs from them. 
A third reason why the insect had so long and so often escaped detection, is to 
be found in its minuteness. It is barely visible by the naked eye ; but under the 
microscope it is seen to be a most formidable monster, in outline like a tortoise, 
and having eight legs. I show you here its portrait; not a little, but enormously 
magnified. I hope to procure for you the privilege of seeing the creature itself. 



HERPES. 



1037 



The first that I can catch I will ask Professor Jones to show you by means of his 
microscope. 

There is good reason for believing that this parasitic animal is, not merely a 
casual companion, but the veritable cause, of scabies. Various attempts have 
been made, and made in vain, to produce the disease by inoculation of the fluid 
from the vesicles. On the other hand, transportation of the acarus has always 
excited the eruption. 

These facts explain how it is that the itch, though readily communicable by 
direct contact, or by fomites, is not communicable through the medium of the air; 
that fomites long retain the contagious property ; and that the disease is curable 
by whatever destroys the acari. I believe that the complaint called the mange, 
in dogs, camels, and sheep, has the same, or a similar origin. 

N.ow sulphur is as sure to cure the itch as quinia is to stop an ague. I pre- 
sume that it kills the acarus ; but whatever may be its modus operandi, I have 
never known it fail to remove true scabies. It is applied externally ; and the only 
objections to its use are its disagreeable smell, and the dirtiness that belongs to 
ointments: but these inconveniences are far outweighed by its certain efficacy. 
Although many substitutes for this substance have been recommended, I preter- 
mit them all, and advise you to employ the sulphur ointment, of which you may 
disguise the smell by the addition of a little bergamot, and the colour by intermix- 
ing a small quantity of vermilion. 

The ointment should be carefully rubbed all over the skin, at bed-time, and 
most especially on parts visibly affected with the eruption. The patient should 
sleep enveloped in a flannel dress. The rubbing should be repeated night and 
morning, and in two or three days the complaint will be subdued. Then, thorough 
ablution with soap and warm water, and the destruction of the contaminated clothes 
by fire, will complete the purifying process. 



LECTURE XC. 

Herpes ; Eczema; Pompholix; Lepra; Psoriasis ; Impetigo ; Boils; Carbuncle; 
Purpura; Scurvy. Conclusion of the Course. 

If you look at the lists of genera and species appended to the various works 
which treat exclusively of cutaneous diseases, you will find that they are exceed- 
ingly numerous. But these disorders differ widely in their relative importance ; and 
the principles upon which their remedial management proceeds are not so greatly 
diversified as these " tables of contents" might lead you to suppose. I have 
spoken pretty fully of the most serious and interesting of these maladies — I mean 
of the febrile exanthemata ; but I have no time left for pursuing in detail the host 
of chronic affections to which the human skin is subject. Nor do I much regret 
this. To become expert, in the diagnosis of these blemishes, and in curing such 
as are curable by our art, yon must see them with your own eyes. Verbal de- 
scriptions of their changeful characters are of comparatively little service or inte- 
rest. They are among the things that require to be " oculis subjecta fidelibus." 
Even pictured representations convey but an inadequate notion of the morbid 
appearances they are designed to portray. The lecturer on skin diseases should 
have actual patients before him, to whose bodies he could point. 

In this, the final lecture of the course, I can do no more than offer you some 
very cursory remarks upon some of the genera into which nosologists have dis- 
tributed this class of disorders ; and I may premise, that the treatment of the genus 
includes, for the most part, that of the species. 

Vesicles are, as you know, small transparent elevations formed by a drop of 
aqueous fluid effused beneath the cuticle. Sometimes they are thinly scattered 



1038 



HERPES. 



over the surface ; sometimes collected into clusters : sometimes situated on a red 
patch of skin; sometimes quite free from redness. The whole crop comes out at 
once in some cases ; in others the vesicles appear in irregular succession. They 
terminate also in various ways : by the reabsorption of the liquid, and slight desqua- 
mation ; by the giving way of the cuticle, and the formation of little scabs, under 
which new cuticle is generated ; and sometimes, though rarely, by ulceration. 

Of the vesicular class of cutaneous disorders I have already described the three 
most important; namely, cow-pox, chicken-pox, and the itch. 

Another not uninteresting genus of this class is herpes. This is a transient non- 
contagious eruption, consisting of red patches of irregular form and variable size, 
upon each of which stands a crop of vesicles. The eruption runs a definite 
course; and its several periods — its beginning, its increase, its acme, and its de- 
cline — are completed, when its progress is not interfered with, in about ten d f ays. 
These characters, once known, are easily recognized : and it is of importance that 
you should recognize them. Not that the disorder itself is of any great moment ; 
nor that it is at all under the influence of remedies ; but because it may be con- 
founded with some graver malady. For example, Herpes prseputialis is a very 
common and a very trifling species, affecting the foreskin; but it might readily be 
mistaken for the result of the poison of syphilis, and so cause much alarm and 
distress to the subject of it, and entail upon him perhaps a needless course of 
mercury, and bring unmerited suspicion upon the person with whom, whether 
lawfully or unlawfully, he might have been connected. It has nothing whatever 
to do with sexual intercourse; and it requires no treatment beyond cold ablution, 
and the interposition of a piece of lint between the prepuce and the glans penis. In 
like manner another species, Herpes circinatus, the vesicular ringworm, is liable, 
when it appears upon the hairy scalp, to be mistaken for that pest of schools and 
of school-boys, ihefavus confertus, or porrigo scutulata of Willan, the common 
scald-head; a complaint which is naturally shunned as filthy, stubborn, and con- 
tagious. Herpes iris is a mere curiosity. In this species each group of vesicles 
is surrounded by four concentric erythematous rings, of different shades of colour. 
The rings form and fade in succession, one after another, by a slight extension of 
the inflammation each time. The spots constituting the eruption have been 
likened to small parti-coloured cockades. But the most singular species of all is 
the Herpes zoster, in which the separate patches lie in the direction of a band that 
encircles half the circumference of the body. Hence its names, zoster, zona, 
zona ignea, and in our vernacular tongue, the shingles ; and even this Dr. Johnson 
derives from the Latin, cingulum, a girdle. 

Most commonly the zone is confined to the trunk of the body, has a somewhat 
oblique direction like a sword belt, and occupies exactly one-half of the circle, 
lying between the linea alba and the spine on one side only. Sometimes, how- 
ever, it extends from the trunks to the limbs. Thus it may begin in the loins, pass 
obliquely across the flank, and terminate at the inner part of the thigh. Or it may 
commence from the upper part of the spine, cross the shoulder, and end on the 
arm or forearm. In the year 1833 I saw a lady affected with this strange erup- 
tion, in whom the clusters of vesicles began near the spine in the neck, passed 
over the scapula, then to the shoulder and axilla, whence the main line ran along 
the outer side of the upper arm till it reached the elbow, where it turned inwards, 
followed the inner side of the forearm, went across the palm of the hand, and ter- 
minated by two or three patches upon the palmar and inner side of the ring finger. 
Very rarely indeed it appears on the limbs only. Once I have seen it limited to 
the thigh and leg, where it corresponded to the course of the sciatic nerve. Once 
I have known it spread from the neck, behind, up to the hairy scalp. The most 
common situation of the demi-cincture is across the base of the thorax. It is a 
curious feature of this curious disorder, that, in nineteen cases out of twenty, 
according to Biett, it occupies the right half of the body. Of this singular pre- 
ference of the right side, if indeed it be a general fact, I can give you no explana- 
tion. I have seen some fifteen cases of the complaint since I began to attend to 



ECZEMA. 



1039 



that circumstance, and in ten of these the eruption was on the right side. Rayer, in 
the first edition of his book, said that eight cases in ten would be found to be on 
that side; but a longer experience has reduced that proportion. Of fifty-three 
examples seen by himself, thirty-seven only were on the right, and sixteen on the 
left. Reil states that he has always observed it on the left half of the body ; and 
Mehlis, among twenty-five patients, counted sixteen in whom the left side was 
affected. This statistical point remains, therefore, to be settled, if it be worth 
settling, by a larger induction of particular cases. The zone seldom transgresses 
the median line at either extremity, unless perhaps the redness of the extreme 
patches may extend a few lines further. It is said, however, in some exceedingly 
rare instances, to complete the circuit of the body. There is a vulgar but erro- 
neous notion, that the eruption proves fatal when it thus surrounds the whole of 
the trunk ; and this notion is as old as the time of Pliny, who says, " Zoster ap- 
pellator, et enecat si cinxerit." 

The most important, because the most distressful, of the symptoms, is an intense 
darting pain, described by the patients as being deep-seated, very acute, and shoot- 
ing through the chest. Fortunately, however, this is by no means a common inci- 
dent. I have met with it in two or three cases only. Sometimes the pain precedes 
the eruption ; more often it accompanies it; and it is apt to last in spite of remedies, 
for some time after the eruption has disappeared. Mr. North tells me that, in a 
female patient of his, this pain continued to be severe and intractable for eighteen 
weeks. That this is a rare complication of the disorder we gather from the ex- 
perience of M. Biett, who never once witnessed this symptom in more than 500 
cases of shingles. The severe and intermitting character of the pain, and the 
peculiar direction of the row of herpetic patches, lead to the belief that th& whole 
malady may arise from some fault in the nervous system. Of its causes w.e have 
no certain knowledge. It is said to attack young persons more especially, and 
those who have fine and delicate skins, and the male more frequently than the 
female sex. But I suspect that these assertions rest on a very loose foundation. 
Of the fifteen cases already mentioned, ten occurred in females. One of the 
patients was a child two years and seven months old ; another was an aged man 
of about seventy-five. In several instances I have-found, upon inquiry, that the 
patients, beingchildren, were in the nightly habit of wetting their beds. Whether this 
has been anything more than a casual coincidence, I do not know; but my attention 
was first directed that way, some years ago, by Mr. Wheeler, the apothecary at 
St. Bartholomew's Hospital, who told me that he had often noticed the same cir- 
cumstance. According to Bateman, the disorder "seems occasionally to arise 
from exposure to cold after violent exercise. Sometimes it has appeared critical, 
when supervening on bowel complaints. Like erysipelas, it has been ascribed by 
some authors to paroxysms of anger." Schwartz saw three cases which followed 
violent fits of passion ; and Plenck affirms that he had known it occur twice after 
furious anger — and a copious potation of beer. 

The duration of the eruption is from ten days to a fortnight; but it is liable to 
be considerably prolonged by troublesome ulceration, whenever the vesicles and 
crusts are prematurely chafed off" by friction or pressure. 

Very little, as you must perceive, can be done, or is requisite in the way of 
treatment. The patient is to be cautioned against rubbing off the heads of the 
vesicles. Attention should of course be paid to the state of the stomach and bow- 
els ; and the diet should be regulated. Our main business is to look on, and to 
endeavour to set right whatever may be manifestly wrong. 

Should the eruption be attended or followed by the intense shooting pain which 
sometimes, but not often, harasses the patient, it will be right to apply opiates, by 
friction, over the affected region. I would use the aconitine ointment in such a 
case. Warm baths will also be proper ; and as the pain is probably neuralgic, 
the carbonate of iron is a remedy which ought to be tried. 

Eczema is another genus of the vesicular class of diseases. It is characterized, 



1040 



ECZEMA. 



in its commencement, by an eruption of very minute vesicles, scarcely prominent, 
closely crowded together, and requiring a microscope sometimes to render them 
distinctly visible. They terminate either by the reabsorption of the fluid they 
contained, or by the formation of superficial moist excoriations. Eczema is not 
contagious. 

There are several species or varieties of this form of cutaneous disorder also. 
It is sometimes produced by great heat, and particularly by the heat of the sun ; and 
this is named eczema solare, heat-spot: sometimes by the contact of irritating 
substances with the skin, as in what is vulgarly called the grocer's itch, affecting 
the hands of those who are much conversant with sugar. Eczema often occurs 
upon the scalp, and constitutes, I believe, the most frequent form of what is com- 
monly named scald-head, porrigo, or tinea capitis. But the most severe of all its 
species is that which has received the name of Hydrargyrum, Erythema mer- 
curiale, and Eczema rubrum mercuriale. This, as these names imply, is an 
occasional consequence of mercury ; an unusual consequence, no doubt, and one 
that happens only in a few peculiar constitutions; but you ought to know it, in 
case it should follow the use of mercury prescribed by yourselves. 

The eruption begins usually in the groins and upon the thighs. It is at first 
red, and is accompanied by much heat and itching. It soon extends, in the 
severer cases, over the whole body ; and an innumerable multitude of very mi- 
nute glittering vesicles may be seen, with the aid of a magnifying glass, from the 
beginning. Like that of erysipelas, the eruption is attended with a good deal of 
swelling. The intumescence of the face is such as to close up the eyes : and the 
disorder becomes febrile, in its course ; for there is seldom much fever at the onset. 
The vesicles increase in size, turn milky, burst, and pour forth an acrid exudation, 
that irritates and inflames the skin with which it comes in contact, and thus in- 
creases the local complaint. The distress and worry occasioned to the patient 
by the fetid smell of the discharge, by the stiffening which it causes of his body- 
linen, and by the heat and itching, are, I conceive, the main causes of the febrile 
disturbance. The discharged matter is apt to become thick and hard, and to 
present the appearance of large scabs : and in this state the nature of the disease 
may very easily be misunderstood, it being impossible to say, when it is seen for 
the first time under these circumstances, whether it was originally vesicular or not. 

The duration of this harassing distemper is variable. It may be over in a fort- 
night, or it may last several weeks. It terminates by the cessation of the discharge, 
and then the cuticle detaches itself in large flakes. Sometimes in this disease also 
the epidermis falls entire from the hand, like a glove. 

Without being dangerous to life, this disorder is apt to be obstinate. It is not 
much within the control of remedies. What little can be done is chiefly palliative. 
The mildest local applications must be used : tepid water, barley-water, strained 
gruel. The warm bath, when circumstances permit. Poultices are sometimes 
of much service, in preventing the hardening of the matter that exudes, and so 
obviating one source of irritation. Flour, or powdered charcoal, may be sprinkled 
over the eruption in the slighter and early cases, for the purpose of absorbing the 
discharge. Equal parts of olive-oil and lime-water make a soothing liniment, 
which may be applied by means of a feather. The local remedies may fairly be 
varied, for sometimes one, and sometimes another, is .found to give relief. The 
patient's linen must be frequently changed, especially whenever it becomes stiff 
and hard with the exudation. 

With respect to the general treatment, opiates to procure rest, and to allay 
irritation, are probably indispensable. The bowels must be kept moderately 
open, but no severe purging should be employed, for the patient must at all events 
undergo a long and weakening process, and therefore it must be our care that the 
treatment be as little weakening as possible. In protracted cases, where there is 
much exhaustion, wine may with propriety be given ; and, almost always, good 
strong broths. As the disorder declines, some of the reputed tonics may be pre- 
scribed ; the mineral acids, quina, sarsaparilla. 



P0MPH0L1X. 



1041 



I need not say that, in such cases, you must be scrupulous in seeing that no 
more mercury is administered or applied. 

A separate class of cutaneous diseases, very analogous, however, to that which 
we have been describing, is the class of bullae, or blebs. Anatomically speaking, 
there is but little difference between the two: bullae are large vesicles. When 
the eruption is at its height, it is composed of hemispherical prominences of vari- 
ous sizes, from that of a pea to that of a hen's egg, and having the shape and 
appearance of the bubbles raised in a pool of water by a hard shower of rain. 
They are formed by the effusion of a serous, or a sero-puriform fluid, between 
the true skin- and the cuticle. You can only be sure of the diagnosis when you 
see the eruption in this stage of its progress. 

The best example of this class is that which is called by some writers Pem- 
phigus, by others Pompholix. 

It is characterized by the presence of bullae, varying in their magnitude, com- 
monly distinct, but numerous, springing up in successive crops, on one or more 
parts of the surface. At first these bullae are nearly transparent, and contain a 
thin limpid serum; but they become gradually opaque, pearl-coloured, and ulti- 
mately many of them acquire a reddish tinge. 

Pemphigus has been described as being sometimes acute, sometimes chronic. 
The acute form is attended with smart fever, the bullae rise spontaneously or in 
quick succession, run their course, and disappear; and then the disease is over. 
This is a very rare form. In general the bullae continue to come out; the com- 
plaint is spread over weeks, or months, or years ; and it is accompanied by little 
or no febrile reaction. This, on the other hand, is a common form of disease. 
It is the Pompholix diutinus of Willan and Bateman. The eruption often occu- 
pies all parts of the body at the same time, or in succession ; in other cases it is 
confined to a limited space. I have most frequently seen it on the forearms and 
legs. When the bullae are very numerous, they may give rise to some febrile 
symptoms, but not else. The complaint may be indefinitely prolonged by suc- 
cessive crops. 

The eruption begins in small red points, the formation of which is attended 
with a slight pricking sensation. Some patients have likened this sensation to 
that which accompanies the passage of the electric spark. In the centre of each 
of these spots, the cuticle becomes lifted, while the circumference of the spot 
enlarges, so that bullae are rapidly formed, often in the space of a few hours only, 
as big as a hazelnut, or a walnut: or the blebs may even be much greater than 
that. Either in consequence of their distension, or of the pressure made upon 
them by the movements of the patient, some of these bullae burst, and a straw- 
coloured serum exudes. Then the epidermis collapses into folds and wrinkles ; 
or if it be detached at a part of the margin of the bulla, it is rolled back, so as to 
expose a portion of the red, painful, and smarting surface beneath it. Towards 
the third or fourth day, when the bullae lose their transparency, and the liquid 
they contain becomes reddish, those bullae which have not been broken sink down 
and wither; the cuticle is no longer stretched; but, sodden by the serous fluid, it 
assumes a whitish hue, becomes opaque, and forms at length small brownish flat 
crusts, of no great thickness. 

In the meantime fresh bullae appear by the side of the former ones, and pursue 
the same course; so that generally you may see, in the same person, tense bullae 
containing a transparent and yellowish serum ; thin crusts ; and irregular patches 
of various size, slightly excoriated. 

This is the ordinary course of chronic pemphigus: and I say it may thus go 
on for months or years. 

The disease is most frequently observed 4n persons of debilitated habits. It is 
sometimes apparently the result of intemperance; or of the use of bad or insuffi- 
cient food. In Biett's experience it has often been coincident with the fatty liver. 
When the disorder is chronic and uncomplicated, the treatment found useful is 
66 



1042 



LEPRA. 



such as we might expect benefit from, knowing the constitutions in which the 
disease is most apt to occur, and the causes which seem at least to favour its oc- 
currence, if they do not produce it: regulation of the bowels; good nourishing 
food ; tonic medicines, bitters, and especially quina and the mineral acids. Biett 
describes this kind of treatment to have been very successful in St. Louis ; and 
that not only in old and worn-out subjects, but also in the young, especially when 
the complaint has been chronic. Bateman recommends the same general plan. 

Local applications have seldom been much employed, except some mild oint- 
ment to the excoriated parts. Biett advises emollient lotions, or even opiate 
washes when much irritation exists ; but a case recorded in the Medical Gazette, 
by Dr. Graves, of Dublin, affords a remarkable instance of a cure by local appli- 
cations alone: and it is a case worth recollecting, although, as he justly remarks, 
we ought not to generalize from a single instance. 

His patient was a boy, fourteen years old, of slender frame and delicate con- 
stitution, yet enjoying uninterrupted health, except the cutaneous disease, which 
had lasted five years. During that time the succession of bullae had seldom 
ceased. The bullae were very numerous, occupying not merely the face and ex- 
tremities, but the trunk also ; and they were in various stages of their progress, 
some healing after having burst, some of a larger size and unbroken, others small, 
and recent. 

Dr. Graves observes, that from the descriptions of Bateman, and of Biett, 
although both authors describe it correctly, we should scarcely form a notion of 
the occasional severity of this disorder. He had seen two examples of it in young 
men, where the irrritation and suffering produced by the constant exposure of 
large portions of skin denuded of epidermis, had operated most unfavourably on 
the general health, almost banishing sleep, and reducing the patients to a state of 
great debility. These cases did not yield to the method of treatment recom- 
mended by authors; and, therefore, Dr. Graves determined, whenever another 
opportunity should occur, to have recourse to a new plan. 

In the boy in question, therefore, he had all the bullae opened with a lancet, 
and the denuded surface of the corium was then touched with a stick of lunar 
caustic. The nitrate of silver was also applied to the skin around each bulla, for 
the breadth of a line; and the recent pimples, which indicated the formation of a 
future bulla, were all treated in the same way. The boy was then washed, and 
supplied with clean linen. 

This single application of the nitrate of silver had not merery the effect of en- 
tirely destroying the morbid action in the portions of the skin which were at the 
time affected, but (what was very remarkable) no fresh bullae made their appear- 
ance afterwards: none at least had appeared for four months, when he wrote his 
account. The only part where a repetition of the process was required, was the 
palm of the hand, where the thickness of the cuticle rendered it more difficult to 
expose the diseased surface of the cutis to the full action of the caustic. 

It might strike you from this cure of a long standing disorder, so readily, by 
mere local means, that the disease propagated itself from one part of the surface 
to another, by a sort of re-inoculation. But it has been fully proved that the 
disease is not contagious. A Mr. Gaitskill engrafted himself, with impunity, 
with the fluid; and analyzed it, and found it apparently like the thin serum of 
hydrocephalus. Dr. Graves, therefore, supposes that the cure was owing to the 
simultaneous destruction of all the parts of the skin that were in a state of morbid 
action: a morbid action which would have been otherwise propagated to other 
portions of the surface, by what is called the sympathy of continuity. 

The class of scaly eruptions — the squamae — is distinguished by the occurrence 
of red spots or blotches, upon which*lamina of altered cuticle form, and are thrown 
off, and constantly renewed. You will perceive that, anatomically, this class of 
cutaneous disorders has a close analogy with the rashes ; and yet it is separated 
from them by very obvious particulars. In the exanthemata of Willan and Bate- 



PSORIASIS. 



1043 



man, the redness is followed by desquamation ; in the squamae these two appear- 
ances co-exist: in the exanthemata the sequence of redness and desquamation takes 
place, in general, once only : in the squamas the morbid cuticle continues for an 
indefinite time to scale off again and again, in successive fragments from the 
abiding red patch of skin. 

Lepra, psoriasis, and pityriasis, and some syphilitic eruptions, constitute the 
principal of the squamous affections. 

Lepra is a very common disorder of this class ; hence its name, lepra vulgaris. 
It consists in red scaly patches, of various dimensions, but always affecting a 
circular or elliptical shape, and scattered over different parts of the body. It 
commonly begins on the limbs, most usually near the joints; just below the 
knees, or the elbows; and Dr. William Budd has pointed out the curious fact 
that these patches, especially when they are few, and the disease is recent, are 
distributed symmetrically, each spot on the one limb answering in situation to a 
similar spot on the fellow limb. This shows that the disease is a blood disease; 
that it depends upon some poison, introduced from without, or, more probably, 
bred within the body. By degrees the patches both enlarge in size, and multiply 
in number, and extend along the extremities to the trunk. The eruption is seldom 
seen upon the hairy scalp, or upon the hands. As the patches enlarge they some- 
times become confluent ; but even then, the outline of the confluent scaly space 
is defined by arcs of circles, and the disorder is sufficiently distinguishable from 
psoriasis. It is not easy to set these things before you in mere verbal description. 
To have seen lepra once, is to know it for ever. 

When the patches begin to get well, the restoration of the altered surface to its 
natural condition and appearance commences in the centre — i. e., in the spot first 
affected — and proceeds outwardly towards the circumference: so that the scaly 
redness assumes a ring-like arrangement. This ring becomes gradually narrower 
and narrower; at length its continuity is here and there broken; and at last it 
vanishes entirely. 

The eruption does not, however, run any definite course. Sometimes it goes 
rapidly through its phases ; in other cases it persists for a very long period. It 
is not at all contagious. 

Neither is lepra attended, in general, with much local inconvenience, nor with 
much corfstitutional disturbance. When the eruption is very copious and exten- 
sive, and especially when it is plentiful or almost continuous around the larger 
joints, it renders the movements of the limbs stiff and difficult; and even some- 
times painful, from the cracking of the inflamed surface as it is stretched in the 
bending of the joint. 

But I have seldom found lepra to exist unconnected with some disorder of the 
digestive organs. Usually the connection is that of alternation, and not of co- 
existence. The patient is dyspeptic till the eruption comes out, and then the 
dyspepsia is relieved : and it often returns as the leprous patches disappear. The 
eruption is the more unsightly : the dyspepsia is the more troublesome. This 
alternation would seem to mark the shifting location of the materies morbi. 

When the patches are small, and chronic, and white, that variety is no longer 
called lepra vulgaris, but lepra alphoides ; and there certainly is another distinct 
variety, of a more blue, or livid, or copper colour than the ordinary ; and a result 
of the poison of syphilis. It is named accordingly syphilitic lepra. This species 
will get well under the influence of mercury ; which, so far as my observations 
go, does not cure the others. 

Psoriasis is closely allied to lepra. When it occurs in distinct patches it is 
often difficult to say to which genus the eruption belongs. In general the patches 
of psoriasis are not so broad as those of lepra ; their edges are less raised, and 
their centres less depressed ; the scales adhere more firmly ; and the patches are 
less uniform and less circular. 

But psoriasis frequently spreads itself over large portions of the skin, and it 
may come to occupy nearly the whole surface of the body. It is then called 



1044 



IMPETIGO. 



psoriasis diffusa. It often renders the patient hideous to look at. The scaly 
incrustation is interspersed with chaps, furrowing the skin in all directions, and 
following particularly its natural folds and angles. These cracks, when the skin 
is put upon the stretch by the movements of the patient, are apt to bleed. In 4 
these severer cases (which are said to be examples of psoriasis inveterata), the 
laminae of altered cuticle are thick, and very abundant. They fall off perpetually, 
or are rubbed off, and may be shaken from the patient's clothes, or collected in 
handfuls from his bed. 

Both these scaly disorders, lepra and psoriasis, require the same kind of 
treatment. 

I believe that external applications are of but little use. I have tried a good 
many, and have lost all confidence in them, with the exception of the warm bath. 
Whatever lends to improve the general health, will hasten the departure of these 
eruptions. I believe that they sometimes depend upon the presence, or the gene- 
ration, of an excess of acid in the system ; and that they are often to be cured by 
alkaline remedies I am sure. I have seen many cases of psoriasis rapidly im- 
prove, and get ultimately well, under full doses of the liquor potassse; from half 
a drachm to a drachm, three or four times daily, in a glass of milk, or of water, 
or of beer. Another internal remedy from which I have seen manifest improve- 
ment result, is arsenic ; given with the cautions, and in the doses, which I have 
more than once spoken of. These are the two remedies of which I have the most 
experience ; but neither of them is infallible ; and you will have to try many things 
in succession, for patients are very desirous of getting rid of the disfiguring erup- 
tion, even when it does not interfere with their health or comfort. Now the 
Harrowgate waters, a strong decoction of dulcamara, pitch-pills (and if pitch-pills, 
I should suppose a fortiori creasote), tincture of cantharides, and the iodide of 
potassium, are remedies of some renown for these scaly diseases. Of the syphi- 
litic lepra I repeat that mercury will prove a cure. In all cases the diet must be 
regulated, and all kinds of stimulating food abstained from. Dr. Bateman knew 
a man who was always attacked with lepra if he took spices with his food, or 
drank ardent spirits: and a patient of my own got rid of long-standing and very 
troublesome psoriasis of the scrotum, upon adopting, for other reasons, a very 
abstemious and simple mode of living. 

Among the pustular diseases of the skin there is one which assumes many 
forms, and is termed impetigo. Whatever may be the minuter peculiarities of 
this eruption, its general characters are the following. It consists of crops of 
pustules, sometimes scattered irregularly, sometimes collected into groups. The 
pustules burst, or are broken, dry up, and scab over. The crusts are yellowish, 
and very friable, and resemble in appearance little masses of candied honey ; or 
sometimes they look like small pieces of dirty plaster, From beneath these 
crusts a considerable discharge continues to take place ; the crusts become thicker 
and larger, and around the margins the skin is red and raw, as it is also beneath 
them. 

We have, I say, various forms of this complaint; impetigo Jigurata, impetigo 
sparsa, &c. It often borders closely on eczema, so that authors describe an 
eczema impetiginodes, or an impetigo eczematodes. These varieties are deli- 
neated by Rayer, by Willan, and Bateman, and by others ; and knowing their 
characters, you can examine and study their appearances for yourselves. Impe- 
tigo is a non-contagious disorder. 

Sometimes this complaint occurs in an acute form, and is attended with fever. 
In such cases its removal will be accelerated by bleeding the patient ; and the 
blood drawn will be found to present the t>uffy coat. Whatever local applications 
are made should not be unctuous. It is seldom that impetigo will bear, or be the 
the better for, ointments. Purgatives and alkalies internally, and a very weak 
spirit or alkaline lotions externally, with a scrupulous diet, constitute, I believe, 
its best treatment. When the complaint is chronic, and the discharge copious, 



BOILS— CARBUNCLE. 



1045 



the oxide of zinc has often a very beneficial effect. It may be dusted over the 
affected surface, from a thin muslin bag; or it may be applied in the shape of a 
lotion — fifteen grains to an ounce of rose-water. You will find this a most useful 
lotion for that disfiguring impetiginous eruption which sometimes covers the faces 
of children like a mask, and is called crusta lactea. The phrase crusta lactea is, 
however, very loosely employed by medical men. 

There is a very common, and a very teasing pustular disease of the skin, usually 
called a boil, in some parts of England a push, and by the learned furunculus. 

First, there is a slight degree and extent of hardness to be felt, a tender knot, 
just beneath the surface, which soon begins to look red, and a small swelling 
arises, which gradually increases up to a certain size, that of a large pea, or of a 
hazelnut, or of a walnut. The tumour is painful, and undergoes a process of 
slow suppuration. Some time from the fourth to the eighth day it acquires a coni- 
cal or pointed form, and its apex becomes of a white or yellow colour. At last the 
cuticle gives way, and the patient begins to congratulate himself that the little 
abscess is ripe, and that his troubles are nearly over. But he is disappointed ; an 
insignificant quantity of pus mixed with blood escapes, and leaves visible a mass 
of dead areolar tissue — a core as it is called — of greater diameter than the opening, 
which is commonly small. At last, two or three days perhaps after this, the 
slough is expelled, in company with more pus, and a deep cup-like cavity remains, 
which soon, however, fills up, and the boil is really over. 

These little phlegmons frequent the buttocks, the thighs, the arm-pits, the nape 
of the neck, the abdomen. They may occur almost anywhere. They are apt to 
come in crops, or in a series : and any kind of irritation suffices to cause them 
when a constitutional tendency to their formation exists. I have known a piece 
of soap-plaster applied to the skin give occasion to a long succession of boils. 
Poultices, applied to promote the suppuration of any existing furunculus, are 
believed to encourage, by their warmth, the growth of others around it. In truth, 
these phlegmons belong primarily and essentially to the subcutaneous areolar 
tissue rather than to the skin. Dr. Prout corroborates the statement of Cheselden 
that they are often accompanied by a saccharine condition of the urine. You know 
probably that, in Dr. Prout's theory of assimilation, the areolar tissue represents 
the saccharine aliment. 

The individual boils are intractable ; the state of the system which engenders 
them may perhaps be corrected. Some dab them, when nascent, with a solution 
of corrosive sublimate in spirit; some support them with sticking plaster; others 
apply poultices ; and others again cut the hard tumour through while it is yet 
crude. Do what you will, you can seldom prevent or accelerate their deliberate 
course ; but I believe that by applying leeches, or cold, you may prolong, though 
yon cannot arrest, that course. 

Sarsaparilla, and the liquor potassae, and where the system is below par, the 
sulphate of quina and a generous diet, are found useful. Sugar, and saccharine 
food of all kinds, should be scrupulously avoided. 

Carbuncle, alias anthrax, is a gigantic boil ; but it is far more serious than the 
common furuncle, not only in respect to its magnitude, and to the amount of suf- 
fering which it occasions, but also on account of the constitutional vice that it 
betokens. A carbuncle is a large, flat, circumscribed, very hard, and very painful 
tumour, of a purplish red colour, and attended with a sensation of burning heai. 
Its ultimate diameter may be three or four inches, or more. It ends in the forma- 
tion of a deep slough, of more than corresponding dimensions, and the destruction 
of the skin above it. A number of pinhole openings at length present themselves 
on the dark red surface, and disclose the immense core beneath. 

This serious complaint occurs chiefly in advanced life, in corpulent males, and 
in persons who have lived fully. It is frequently attended with diabetes. The 
tumour is more often situated upon the nape of the neck, or between the shoulders, 
than elsewhere. It produces high constitutional disturbance and irritation. Sur- 
geons are in the habit of dividing the* firm mass into quarters, by deep crucial 



1046 



PURPURA— SCURVY. 



incisions. This is a sharp remedy, but it purchases speedy ease by removing 
that tension of the inflamed parts whereupon the pain chiefly depends. I am 
persuaded, however, that this severe operation is done too indiscriminately. If 
the tension be not manifest, and there is not much complaint of pain, you had 
better, in my opinion, leave these tumours to the care of nature, and address your 
remedies to the system at large. Support is often needed ; and opiates are some- 
times indispensable ; and the bowels must be kept clear by purgatives. 

I shall not attempt to discuss, even in this cursory and disjointed manner, any 
more of the inflammatory affections of the skin, whether acute or chronic : but I 
wish, before I conclude, to direct your attention to a peculiar morbid conation, of 
much greater interest and consequence than most of those which I have just been 
describing. I mean the malady which is best known by the appellation of purpura, 
or the purples, and which usually, though it must be confessed very incorrectly, 
is ranked among cutaneous disorders. It is strictly a hemorrhage. Its external 
phenomena are so obvious, and so well known, that I need not dwell upon them. 
Small round spots appear on various parts of the surface, generally upon the legs 
first and most plentifully, of a dull red, or of a deep purple colour. They are 
accompanied by no local pain, by no sensation of any kind. Pressure upon them 
does not efface the colour, nor render it fainter, as it does that of inflammatory 
spots of the skin. There is scarcely ever any prominence of the purple stigmata ; 
but they are sometimes intermixed with livid blotches, with appearances exactly 
resembling bruises : and both the circular spots and the ill-defined vibices undergo, 
before they disappear, the same changes of colour, from red to a greenish yellow, 
which a bruise undergoes. In fact the anatomical condition of a bruise is exactly 
the same with the condition of the diffused livid blotches of purpura. In each 
case the colour is the result of ecchymosis. With all this, passive hemorrhages 
from various parts, and particularly from the mucous membranes, are common. 

It is clear, therefore, that this complaint cannot be regarded as a cutaneous com- 
plaint, even in the loose sense in which that epithet is sometimes applied to affec- 
tions that are really beneath the skin, but visible through it. The hemorrhage 
takes the form of red or purple spots when the quantity of blood extravasated in 
the same place is only a drop. And the spots are not peculiar to the skin, nor to 
the subcutaneous tissues, but are found, occasionally, upon all the internal surfaces 
also, and within the substance of the several viscera. I have seen these purple 
spots on the mucous surface of the mouth, the throat, the stomach, and the intes- 
tines on the pleurae and pericardium in the chest, on the peritoneal investment of the 
abdominal organs, in the substance of the muscles, and even upon the membranes 
of the brain, and in the sheaths of the larger nerves: and I have known them to 
be accompanied with large extravasations of blood in most of the vital organs of 
the body. 

The superficial markings of purpura, the red and purple spots and livid blotches, 
exactly resemble the spots and bruise-like stains which characterize sea-scurvy: 
and I confess that I formerly regarded the two affections as being identical, or as 
mere varieties of the same disorder. But it is not so. For a very full and inte- 
resting account of scurvy, I must refer you to an essay, by Dr. Budd, in the 
Library of Practical Medicine. He has there collected from various sources, 
and exhibited in a clear light, convincing evidence that scurvy is caused — neither 
by contagion, nor by cold weather, nor by impurity of the air, nor by the con- 
tinued use of salt provisions, all of which have been alleged as sources of the dis- 
ease, but — by the privation, for a considerable length of time, of fresh succulent 
vegetables. Now purpura often makes its appearance when there has been no 
deficiency of such food, and no remarkable abstinence from it. Scurvy is most 
common in winter, or the beginning of spring ; purpura in the fruit seasons, in 
summer and autumn. In scurvy the gums are uniformly soft, and swelled, and 
spongy, and bleed readily ; this is no necessary feature in purpura. Scurvy is 
marked by extreme debility and dejection of spirits ; it is always rendered worse 
by blood-letting and by mercury ; and ifr is infallibly and rapidly cured by the 



SCURVY. 



1047 



administration of lemon-juice, or of other fresh fruits and vegetables. Purpura, 
on the other hand, often requires venesection for its cure; is not constantly nor 
surely, if ever, benefited by the anti-scorbutic juices ; is not always attended by 
sponginess of the gums, nor by feebleness of the mind and body ; and I have seen* 
it clear speedily away upon the supervention of mercurial salivation and hyper- 
catharsis. 

Lemon-juice is really a specific against scurvy, whether it be employed as a 
preventive or as a remedy. It supplies something to the blood which is essential 
to its healthy properties. Its virtues were known in this country full two hundred 
years ago, as appears by the work entitled The Surgeon's Male, or Military and 
Domestic Medicine, by John Woodall, Master in Surgery: London, 1636. But 
the merit of making the fact generally known, and of procuring the systematic 
introduction of lemon-juice into nautical diet, by an order from the Admiralty, is 
due to Dr. Blair and Sir Gilbert Blane, in their capacity of Commissioners of the 
Board for sick and wounded seamen, in 1795. " The effect (says Sir John Her- 
schel) of this wise measure may be estimated from the following facts. In 1780 
the number of cases of scurvy received into Haslar Hospital was 1457 : in 1806 
one only, and in 1807 one." He adds, " there are now many surgeons in the 
navy who have never seen the disease." 

Dr. Budd, however, has assured me that the Dreadnought hospital-ship, at 
Greenwich, is often full of cases of scurvy ; most of the patients so affected having 
just arrived in merchant-ships, from a long voyage. This surely ought not to be. 

It could not be if the owners of those vessels knew how easily, surely, and 
cheaply, this truly dreadful scourge may be averted. 

Scarcely less — if indeed less at all — of anti-scorbutic virtue, belongs, fortunately, 
to that common esculent root, the potatoe. Raw potatoes have long been in good 
repute, both for the cure and for the prevention of scurvy: but raw potatoes are 
neither palatable, nor easy of digestion ; and it is a great discovery, which we owe 
to the sagacity of Dr. William Baly, that this vegetable is equally effective for 
these purposes, when cooked. During some months of continued observation of 
the prisoners confined in the Penitentiary at Milbank, I had remarked, without 
being able to account for it, that among the small number of soldiers, committed 
for comparatively short periods, for offences against military discipline, scurvy 
was not uncommon ; whereas I noticed it in one instance only among the much 
more numerous class of convicts, whose term of imprisonment was considerably 
longer. Dr. Baly was afterwards appointed Physician to the Penitentiary, and 
the same curious fact soon caught his attention: and he has traced the cause. By 
the examination and comparison of various dietaries — those, namely, which have 
been adopted at different periods in the Penitentiary itself, those which, at the 
same period, were prescribed respectively for the military offenders, and for the 
ordinary convicts, and those in use in sundry other gaols in which scurvy has 
occurred with different degrees of frequency — he has shown, most satisfactorily, 
that the liability to that malady has a strict relation to the amount of succulent 
vegetables consumed by the prisoners, and especially of potatoes. " Wherever 
this disease has prevailed, there the diet of the prisoners, though often abundant 
in other respects, has contained no potatoes, or only a very small quantity. In 
several prisons, the occurrence of scurvy has wholly ceased on the addition of a 
few pounds of potatoes being made to the weekly dietary. There are many pri- 
sons in which the diet, from its unvaried character, and the absence of animal 
food, as well as green vegetables, is apparently most inadequate to the maintenance 
of health; and where, nevertheless, from its containing abundance of potatoes, 
scurvy is not produced." 

Now potatoes ziefood as well as medicine, and they are a cheap kind of food, 
and it may be hoped that a more general knowledge of their anti-scorbutic proper- 
ties, even when cooked, will abolish this wretched complaint, wherever a good 
supply of them is obtainable. Dr. Baly believes that from three to six pounds, 



1048 



SCURVY. 



weekly, for each person, would suffice. He thus accounts for their salutary- 
influence. 

" A glance at the chemical analysis of the potato at once explains its anti-scor- 
butic virtue. The various fruits, succulent roots, and herbs, which have the pro- 
perty of preventing and curing scurvy, all contain, dissolved in their juices, one 
or more organic acids — such as the citric, tartaric and malic acids. Sometimes 
these acids exist in the free state, but more generally they are combined with 
potash, or lime, or with both these bases. Now potatoes have been submitted 
to most elaborate chemical examination by Einhoff and Vauquelin ; and by both 
these chemists they have been found to contain a vegetable acid in considerable 
quantity. According to Einhoff, this acid is the tartaric combined with potash 
and lime. According to Vauquelin it is the citric partly in combination with those 
bases, and partly in the free state. The farinaceous seeds, as wheat, barley, oats 
and rye, which are destitute of anti-scorbutic property, contain no organic or vege- 
table acids." 

The same causes which give rise to sea scurvy will produce precisely the 
same effect on land. Of this I must give you one illustration from my own case- 
book. In August, 1830, I admitted into the Middlesex Hospital a blacksmith, 
thirty-five years old, covered with round purple spots of various sizes, and with 
irregular blotches of ecchymosis. He had vomited blood on the preceding clay. 
He was continually coughing up blood at the time of his admission, and his wife 
estimated the whole quantity that he had then lost to be more than half a pailful. 
The interior of his mouth and palate was pouring forth blood from a number of 
livid fungous tumours, formed by the extravasation of blood into the areolar tissue 
beneath the membrane, and the subsequent rupture of that membrane. He was 
passing blood by the bowels also ; and his urine was loaded with blood. 

Here were the symptoms of scurvy strongly marked. In the man's history we 
could trace its peculiar cause. He had long been subsisting on very poor and 
insufficient nutriment, seldom eating any meat, but living almost entirely on tea, 
coffee, and bread and butter. He had been too ill and weak to work regularly, 
yet he had been obliged occasionally to over-exert himself to obtain a scanty 
supply of food for himself, his wife, and a large family of children. He had been 
a settled dram-drinker, but for some time had taken much less of that stimulus ; 
merely because he had not the means of procuring it. His pulse was frequent and 
feeble. 

I had not much hope that this patient could be saved by any treatment. He 
was immediately put upon a diet of roast meat, and began to take daily half a 
pint of fresh lemon-juice diluted with a pint and half of water. This plan, with 
some tonic medicine, was commenced on the 3d of August. He improved at 
once. On the 8th all the hemorrhage had ceased ; the fungous tumours in the 
mouth had disappeared, leaving small scars in the places they had occupied ; and 
the discoloration of the skin was almost gone. The amendment was so striking 
and rapid, and so immediately consequent upon the institution of the treatment, 
that no room was left for mistaking recovery for cure. 

It is chiefly by investigating the previous history of the patient, and by noting 
the degree of strength that he possesses, and the condition of his pulse, that we 
are guided in our diagnosis of ambiguous cases. The late Dr. Parry, of Bath, 
was one of the first to point out the efficacy of abstinence, venesection, and pur- 
gatives, in some instances, at least, of purpura. I may refer you to an example 
of this kind detailed in the Medical Gazette for the 5th of April, 1828. It 
occurred in one of Dr. Latham's hospital patients ; and several of the symptoms 
were very like those I have just been relating. In particular the whole tongue was 
livid, one half of it presenting the appearance of a large, black, bleeding fungus ; 
and on the inner surface of each cheek were several black fungoid patches. The 
patient was voiding also unmixed blood from the bowels. In this case there was 
no evidence of the operation of any debilitating cause, and the pulse, though fre- 
quent, was hard. Bleeding from the arm always gave relief to his uneasy sensa- 



SCURVY. 



1049 



tions : he was purged also, and put upon low diet. Under this plan he steadily- 
improved, and in four or five days no vestige of the complaint remained except 
the fading spots. For some time afterwards, however, " the frequent use of active 
purgatives, and a rigid restriction to low diet, were necessary to obviate costive- 
ness, and to keep down the circulation, which had a tendency to become over- 
active." 

You are not to suppose that all cases of purpura bear this sthenic character, or 
require these heroic remedies. Your treatment must be guided by the previous 
circumstances and habits of the patient, by the state of his pulse, and by the other 
symptoms which accompany the purple spots. And when you are in doubt what 
plan to pursue, make a cautious tentative bleeding. Take away a couple of ounces 
at a time, into a wineglass, note carefully the appearance of the blood itself, and 
the effect of the blood-letting upon the patient ; and then go on more boldly, or 
abstain thenceforth altogether from the lancet, according to circumstances. In 
many cases your chief reliance will be placed in the watchful employment of 
purgatives. These have been highly recommended by Dr. Harty, of Dublin, as 
having proved eminently successful in his practice. The late Dr. Whitlock Nich- 
oll, and others have spoken in terms of strong praise of the oil of turpentine, 
administered in moderate and repeated doses, as a remedy in purpura. 

I have adverted to one peculiar source of danger in purpura, the hazard that 
blood may be effused in some vital organ where even a slight amount of hemor- 
rhage suffices to extinguish life. Dr. Bateman states that he had seen three 
instances in which persons were carried off, while affected with purpura, by- 
hemorrhage into the lungs. During the course of one week, in the year 1825, I 
was present at two inspections in the dead house of St. Bartholomew's Hospital, 
illustrative of the same point in respect to another vital organ, and involving a 
question in forensic medicine. The subjects of examination were both of them 
women of middle age, who had been brought into the hospital covered with purple 
spots and bruise-like discolorations, and suffering hemorrhage from the mucous 
membranes. Each of these women declared that the apparent bruises were marks 
of beatings received from her husband. One of them became suddenly hemiplegic 
a little while before she died. Of the manner of dissolution in the other case I am 
not sure. In both instances a considerable quantity of blood was spread over the 
surface of the brain, between its membranes ; and in one of them blood had been 
shed also into the cerebral substance, which it had extensively lacerated. 

It may be worth mentioning that in one of these corpses there were indications, 
either of unusually rapid putrefaction after death, or (what I think more probable) 
of some degree of decomposition even before life was extinct. This woman died 
in the evening, and the body was examined the next day, twelve or fourteen 
hours afterwards. A quantity of fetid gas escaped from the cavity of the abdo- 
men as soon as it was opened, and small bubbles of air were seen to ooze from 
the areolar tissue of various parts of the body. Even when incisions were made 
into the liver, air frothed up, as it might do, under ordinary circumstances, from 
a section of the lungs. 

I have no time left for discussing the pathology of these complaints. They are 
eminently blood-diseases. In scurvy the blood is starved of some essential ingre- 
dient, which the juice of lemons, and other fresh succulent vegetables, readily 
supplies and renews. When drawn from a vein the blood is often visibly unnatu- 
ral. A very small quantity was taken before I saw him, from the arm of the 
blacksmith whose case I just now mentioned. After standing for some time, it 
continued to fill the whole area of the vessel in which it had been received, with- 
out any apparent contraction, or separation of serum. On its flat upper surface 
was a thick, gray, semi-transparent jelly, and beneath this there was, strictly speak- 
ing, no coagulum, but a black semi-fluid substance of the consistence of syrup. 
Huxham describes similar appearances. "The blood of such persons (says he), 
when it hath been drawn off, always appears a mere gore, as it were, not separat- 
ing into crassamentum and serum as usual, but remaining in a uniform half 



1050 



CONCLUSION. 



coagulated mass, generally of a livid or darker colour than usual, though some- 
times it continues long very florid ; but it always putrefies very soon." In another 
place, when describing a particular case, he says, "I found that neither of the 
portions of the blood that had been drawn had separated into serum and crassa- 
rnentum as usual, though it had stood many hours ; but continued, as it were, half 
coagulated, and of a bluish livid colour on the top. It was most easily divided on 
the slightest touch, and seemed a purulent sanies rather than blood, with a kind 
of sooty powder at bottom." 

Dr. Budd, however, states that in some cases of scurvy the separation of blood 
into serum and clot is as perfect, and takes place as readily, as in healthy blood. 

When you recognize the disease as genuine scurvy, and trace a previous absti- 
nence, whether forced or voluntary, from fresh vegetables, the treatment is plain ; 
you must supply the kind of nutriment which has been defective, and support 
your patient's strength in such other ways as the circumstances of the case may 
dictate. 

And now, gentlemen, I must needs stop. Here ends my course. And if this 
were all I had to say, I should say it with something like glee, and you, no less 
than myself, would rejoice that at length a breathing-space and holiday had arrived. 
But I cannot feel so when I add that this is the last lecture, not of this course 
merely, but the last of any kind, that I am ever likely to deliver in King's Col- 
lege. I cannot say this without concern and regret. 

I am quite aware that my lectures have been in many respects imperfect. They 
have been very unequal to my own wishes. But they have been as full, and as 
carefully weighed, as my broken leisure, and irregular opportunities, and slender 
ability, would permit. I can only hope that at any rate I have not misled you. 
If I have been intelligible, if I have drawn such a sketch of a great and difficult 
subject as may help you in studying it for yourselves, I have achieved my task. 
I told you, in the outset, that I could not here teach you the practice of physic, 
but only its principles. It would be idle for me to speculate further upon the 
success of my endeavours. You are to be the judges of that matter. Whatever 
rules and precepts I have laid down, you will soon test by your own experience, 
and adopt or reject them accordingly. The well-known maxims of Bacon apply 
with especial truth to medical instructors and their pupils. " Etsi non displiceat 
regula, oportet discentem credere; huic tamen conjungendum est, oportet jam 
edoctum judicio suo uti; discipuli enim debent magistris temporariam solum 
fidem, judiciique suspensionem, donee penitus imbiberint artes: non autem plenam 
libertatis ejurationem, perpetuamque ingenii servitutem." 

Retiring reluctantly from this place, in obedience to the force of circumstances, 
x there are yet many things to comfort and console me. It is a great satisfaction to 
reflect that I have never had any serious disagreement with yourselves; have 
never received any but the most respectful and kind treatment either from my 
present or from any preceding class. I have reason to thank you — and I do thank 
you — for the courtesy and attention you have at all times shown me. It is a source 
of gratification also that I carry with me the good will, as I believe, of my excel- 
lent colleagues ; and that I go without having forfeited any of that confidence 
which the Council first reposed in me as their servant, when they offered me, 
without solicitation, the chair I now resign. 

Had I been a few years younger, unembarrassed by previous official engage- 
ments, and somewhat more at leisure than I am, I should have been glad and 
proud to have attached myself to the new hospital, and to have laboured still in 
the cause of King's College, and of its Medical School. But it is otherwise 
ordered : and I will mention, as the last source of consolation in taking leave of 
you, my conviction that to you my loss (if, without presumption, I may so ven- 
ture to speak of my resignation), will be more than supplied by my successor. I 
know that gentleman well. I know, indeed the world knows, his talents. He 
was highly distinguished in the Senate House at Cambridge. He has since de- 



CONCLUSION. 



1051 



voted, and will continue to devote, the powers of a very strong intellect, in the 
investigation of disease. Dr. Budd is one of the most strenuous cultivators of our 
science that I am acquainted with : and lam confident — without any affectation of 
modesty — that he will soon give a much better course of lectures than you have 
heard from me. That you may prosper in his instruction, and afterwards ; that 
by the humane exercise of our noble calling you may do good in your generation, 
to others, and so to yourselves ; is my earnest desire and prayer. I hope it is 
unnecessary for me to assure you that I shall always continue to take a lively 
interest in your welfare individually; and that it will give me sincere pleasure if 
I shall find any future opportunity of rendering you any service. Gentlemen, I 
do not like this sort of parting, and I will not further protract the pain that belongs 
to it; but bid you finally, and most cordially — Farewell, 



INDEX. 



Abdomen, diseases of the, 741, 

dropsy of the, 755. 

mode of examining, 742. 

paracentesis of the, 766. 

regions of, 742. 

tumours of the, 764. 
Abdominal dropsy, 755. 

palpation, 743. 

percussion, 743, 756. 

respiration, 532. 

tumours, 764, 922. 
Abscess, 112. 

of the brain, 264. 
liver, 858. 
lungs, 573. 
Abscesses, disseminated, 723. 
Acute inflammation, 127. 
Adhesive inflammation, 110. 
JEgophony, 538. 
Ague, 445. 

cake, 872. 
Air, impurity of a cause of disease, 78. 
Air passages, foreign bodies in the, 666, 
Albuminous urine, 894. 

nephritis, 903. 
Alveolar cancer, 140. 
Amaurosis, 218. 
Amygdalitis, 497. 
Anaemia, 43, 52. 

accidents and diseases attended by, 53. 

anatomical characters, 52. 

death by, 52. 

phenomena, 53. 
Anaesthesia, facial, 343, 349. 

of other parts, 350. 
Anasarca, 173, 904, 1021. 

cardiac, 177, 906. 

with pulmonary disease, 177, 90S. 

renal, 177, 908. 

treatment, 182. 910. 
Aneurism, thoracic, 713. 

of the heart, 672-686, 
Angina maligna, 1016. 

parotidoea, 491. 

pectoris, 691. 
Anthrax, 1045. 
Anorexia, 792. 

Antimony in inflammation, 158. 
Antiphlogistic regimen, 144. 
Anus, artificial, 808. 
Aorta, diseases of the, 673, 687, 713, 
Aphthae, 494. 

pathology of [note] , 495. 
Apncea, anatomical characters, 55. 

causes of, 54. 

death by, 53. 

diseases in which it occura as a mode of 

death, 56. 
general pathology of, 55. 
phenomena, 54. 



Apoplexy, 304. 

diagnosis, 304, 333. 

phenomena, 309, 313. 

morbid anatomy, 318. 

treatment, 333. 

pulmonary, 621 . 
Arachnitis, 243. 

Arachnoid membrane, inflammation of, 243. 
Areolar tissue, inflammation of, 122. 

induration of, 123. 

dropsy of, 173. 
Arterial tissue, effects of inflammation on, 125. 
Arthritic ophthalmia, 215. 
Artificial anus, 808. 
Ascaris lumbricoides, 841-853. 

vermicularis, 841-853. 
Asiatic cholera, 822. 
Ascites, 755. 

causes, 758. 

diagnosis, 756. 

treatment, 763. 
Asphyxia, death from, 54. 
Asthenia, anatomical characters, 52. 

death by, 52. 

diseases in which it occurs as a mode of 

dying, 53. 
phenomena, 53. 
Asthma, 631. 

associated organic changes, 732. 
grinders, 657. 
hay, 557. 

spasmodic, 631, 633, 729. 
thymic, 525. 
Atmospherical temperature a cause of disease, 
62. 

Atrophy, 31-32. 

of the brain, 268. 
Auscultation, general account of, 532. 

Bastard croup, 524. 

Bayle, granulations of, 636. 

Belladonna as a preventive of scarlet fever 

[note] , 1025. 
Bellows sound of the heart, 677. 
Belly, dropsy of the, 755. 
Biliary concretions, 866. 
Bilious remittent fever [note] , 985. 
Bleeding from lungs, 617, 648. 

stomach, 781. 
Blisters, as a remedy in inflammation, 162. 
Blood, buffy coat of, 97-105. 

diseases of, 40. 

spitting of, 648. 

state of in inflammation, 105. 

urination of, 916. 

vomiting of, 781. 
Blood-letting, as a remedy in inflammation, 145. 
Blood-vessels, state of in inflammation, 102. 
Bloody urine, 916. 

flux, 831. 



1054 



INDEX. 



Boils, 1045. 

Bowels, inflammation of, 800. 

mechanical obstruction of, 802, 803, S05. 

perforation of, 748. 
Brain and nervous system, diseases of the, 226. 

abscess of, 264. 

atrophy of the, 26S. 

cancer of the, 265. 

dropsy of the, 2S4. 

effects of pressure on the, 231, 314. 

hemorrhage in the, 303, 305, 321. 

hypertrophy of the, 266. 

induration of the, 265. 

inflammation of the, 126, 246. 

meningitis of the, 243. 

mortification of the, 126. 

softening of the, 262. 

suppuration of the, 264. 

tubercles of the, 265, 275, and [note] . 

tumours in the, 265. 

tapping, 291. 
Branks, 491. 

Breathing, abdominal, 532. 

bronchial, 538, 576. 

cavernous, 644. 

puerile, 537, 578. 

thoracic, 530. 

vesicular, 538, 542. 
Bright's kidney, 895. 

anatomical characters, 895. 

signs of, 897. 

changes in the urine, 897. 

in the blood, 899. 

course of the disease, 900. 

secondary affections, 900. 

causes, 902. 

nature, 903. 
Bronchi, dilated, 563. 
Bronchial respiration, 53S, 576. 

polypi, 124,561. 
Bronchitis, acute, 541-548. 

morbid anatomy, 549, 563. 

treatment, 547. 

chronic, 549-559. 

varieties of, 561. 

prevention, 545. 
Bronchocele, 481. 
Bronchophony, 53S, 577. 
Buffy coat of blood, 97-105. 
Bulls, 943, 1041. 

Calculi renal, 875. 
Cancer, 138. 

alveolar, 140. 

colloid, 140. 

encephaloid, 140. 

intimate structure, 141, and [note] 139. 

origin, 141. 

propagation, 142. 

treatment, 143. 

varieties, 139, and [note] . 

of the brain, 265. 
lungs, 666. 
stomach, 776. 
Canine madness, 375. 
Capillaries, state of in inflammation, 102. 
Carbuncle, 1045. 
Carcinoma of the stomach, 777. 
Cardiac dropsy, 173, 177, 906. 
Cardialgia, 794. 
Carditis, rheumatic, 695. 
Carnification of the lungs, 591. 
Catalepsy, 433. 
Causes of disease, 59. 



cold, 67. 
exciting, 60. 
heat, 63. 

hereditary predisposition 79. 

impurity of the air, 78. 

predisposing, 60. 

seasons, 76. 
Catarrh, 540. 

chronic, 559-560. 

dry, 632. 

epidemic, 551. 

senile, 549. 

summer, 557. 
Catarrhal ophthalmia, 1S5. 
Catarrhus aBstivus, 557. 
Cavernous respiration, 644. 
Cellular tissue, dropsy of, 173. 

induration of, 123. 
Cerebral diseases, 235. 

hemorrhage, 303, 305, 321. 
Chemosis, 189. 
Chicken-pox, 1013. 
Child-bed fever, 745. 
Child crowing, 525.' 
Cholera, sporadic, 819. 

epidemic, 822. 

morbid anatomy, 823. 
mode of propagation, S25. 
modes of attack, 826. 
treatment, S28. 
Chorea, 408. 

Chronic inflammation, 127. 
Chylous urine, 914. 

Circulation, disturbance of as a symptom of dis- 
ease, 92. 
Cirrhose liver, 123, 760-861. 
Coagulable lymph, 109. 
Cold, a cause of disease, 67. 

as a remedy in inflammation, 161. 
in the head, 541. 
chest, 541. 
Colic, 800-808. 

from lead, 809. 

symptoms, 812 [note] . 
treatment, 813. 
Colloid cancer, 140. 
Coma, death by, 54, 57, 304. 
phenomena, 57. 

diseases in which it occurs -as a mode of 
dying, 58. 
Concretions, biliary, S66. 

intestinal, 838. 

renal, S75. 
Congestion, 42. 

active, 46. 

local, 44. 

mechanical, 47. 

passive, 48. 

Conjunctiva, inflammation of, 185, 18S, 195, 290. 

Consumption, 636. 

Contagion, 947, 969. 

Continued fever, 954. 

Convulsions, Salaam, 423 [note] . 

Cord, spinal, general pathology of, 294. 

inflammation of, 297. 
Coryza, 541. 

Cough, a symptom of disease, 91, 531. 

hysterical, 427. 
Coup de soleil, 66. 
Crepitation, a sign of disease, 543. 
Cretinism, 486. 
Croup, 515. 

bastard, 524. 

spasmodic, 525. 



INDEX. 



Croup, causes of, 518. 

diagnosis, 525 [note] . 

prognosis, 520. 

symptoms, 516. 

treatment, 520. 

tracheotomy in, 523 [note] . 
Cutaneous diseases, 943. 
Cutaneous tissue, inflammation of, 124. 
Cynanche laryngitis, 504. 

maligna, 1016. 

parotidea, 491. 

tonsillaris, 497. 

trachealis, 515. 
Cysticercus cellulosus, S44. 

Dance of St. Vitus, 414. 
Death, sudden, pathology of, 50. 
by anaemia, 52. 

apnoea, 54. 

asthenia, 52. 

coma, 57, 304. 

inanition, 53. 

syncope, 53. 
Debility, a symptom, 90. 
Delirium of drunkards, 252. 
tremens, 252. 

treatment, 257, 261 [note] . 

in continued fever, 958. 
Devonshire colic, 810. 
Diabetes, 884. 
Diagnostic signs, 82, 85. 
Diarrhoea, 815. 

adiposa, 836. 

chronic, 817 [note] . 

crapulosa, 815. 
Diathesis, lithic, 878. 

oxalic, 881. 

phosphatic, 878. 

scrofulous, 129, 136. 
Dietetic rules for dyspeptics, 798. 
Digitalis, as a remedy in inflammation, 159. 
Disease defined, 18. 
Digestion, physiology of, 790. 
Dilatation of bronchi, 563. 

heart, 686. 

oesophagus, 739. 
Diuresis, chronic, 893. 
Disease, causes of, 59. 

hereditary tendency to, 61, 79. 
Diseases of the abdomen, 741. 

aorta, 673, 687, 713. 

blood, 40. 

brain and nervous system, 226. 

Bright's, 895. 

cerebral, 235. 

cutaneous, 943. 

eye, 184. 

fluids, 40. 

gall bladder, 871. 

heart, 670. 

intestines, 800. 

kidneys, 872. 

liver, 857. 

lungs, 540. 

oesophagus, 736. 

pancreas, 872. 

skin, 943. 

spleen, 872. 

stomach, 768. 

thorax, 529. 

veins, 720. 
Displacement of parts, 39. 
Dizziness, a symptom, 87. 
Dracunculus, 846. 



Dropsy, general pathology of, 171-173, 905 
Dropsy, varieties, 174. 

phenomena, 178. 

prognosis, 182. 

treatment, 182. 

of the areolar tissue, 173, 904. 
of the belly, 755. 
of the brain, 284. 
cardiac, 177, 906. 
chest, 590. 

ovarian, 755-761, 764. 
renal, 177. 

after scarlet fever, 1021. 
Drunkards, delirium of, 252. 
Dura mater, inflammation of, 237. 
Dying, modes of, 50. 
Dysentery, 829. 

causes, 830. 

phenomena, 831. 

morbid anatomy, 832 [note] . 

treatment, 833 [note] . 

chronic [note] , 836. 
Dyspepsia, 772, 790. 
Dyspeptics, dietetic rules for, 798. 
Dyspnoea, a symptom, 92, 530. 

general pathology, 530. 

Ecstasy, 435. 
Eczema solare, 1040. 

rubrum mercuriale, 1040. 
Effusion of serum from inflammation, 109. 

coagulable lymph, 109. 

pus, 112. 
Egyptian ophthalmia, 188, 190. 
Exhalation, hemorrhage from, 163. 
Emaciation, a symptom, 93. 
Emphysema of the lungs, 566, 628. 

interlobular, 628, 634. 

sub-pleural, 634. 

vesicular, 628. 
Empyema, 113. 
Encephalitis, 246. 

phenomena, 246. 

morbid anatomy, 248. 

treatment, 248. 
Encephalon, inflammation of, 246. 
Encephaloid cancer, 140. 
Endocarditis, rheumatic, 695. 
Endocardium, morbid states of, 688. 
Engorgement of the lungs, 572. 
Enteritis, 800. 

diagnosis, 801. 
Entozoa, 840. 

mode of production, 847. 
Epidemic catarrh, 551. 

cholera, 822. 
Epilepsy, 387. 

phenomena, 388. 

varieties, 389. 

pathology, 394. 

morbid anatomy, 395. 

treatment, 402. 

feigned, 400. 
Epistaxis, 479. 

Erysipelas, phlegmonoides, 122. 
Erysipelas, 1026. 
Erythema, 124, 1034. 

nodosum, 1034. 
Events of inflammation, 108. 
Examination of abdomen, 742. 
Exanthemata, 943, 944. 
Exciting causes of disease, 60. 
Eye, diseases of the, 184. 

Face-ache, 444. 



1056 



INDEX. 



Facial anaesthesia, 343, 349. 

neuralgia, 439. 

paralysis, 343. 
Falling sickness, 387. 
False membranes of the pleura, 588. 

of the trachea, 519. 
Fatty transformation of tissues, 37. 

liver, 643, 861. 
Fever, inflammatory, 96, 118. 

continued, 954. 

hay, 557. 

hectic, 97, 119, 649. 

intermittent, 445. 

puerperal, 744. 

remittent [note] , 985. 

scarlet, 1017. 

typhoid, 97, 954. 
Filaria medinensis, 846. 
Flatulence, 793. 
Fluids, diseases of, 40. 
Fluxes, 815. 

Fungus haematodes, 143. 
Furunculus, 1045. 

Gall-bladder, diseases of, 871. 

Gall-stones, 866. 

Gangrena Senilis, 117. 

Gangrene, from inflammation, 115-122. 

of the lungs, 574. 
Gastric hemorrhage, 781. 
Gastritis, acute, 768. 

phenomena, 769. 

morbid anatomy, 770. 

treatment, 772. 

chronic, 772. 

acute, of infants, 775, [note]. 
Gastrodynia, 795. 
Generation, spontaneous, 849. 
Giddiness, a symptom, 87. 
Glottis, oedema of, 513. 
Goitre, 481. 

Gonorrhoeal ophthalmia, 195. 
Gout, 931. 

Granulations of Bayle, 636. 
Gravel, fit of the, 875. 

different kinds of, 876. 
Gravedo, 541. 

Gray and red softening of the lungs, 573. 
Grinder's asthma, 657. 
Grippe, 551. 
Guinea worm, 846. 
Gutta serena, 218. 

Hsematemesis, 781. 

hysterical, 428. 

vicarious, 783. 
Haematuria, 916. 
Haemoptysis, 648. 

hysterical, 428. 
Hemorrhages, general pathology, 162. 

active and passive, 165. 

diagnosis, 169. 

habitual, 164. 

treatment, 169. 

vicarious, 165. 
Hemorrhage, a result of inflammation, 109. 

of the brain, 303, 305, 321. 

cerebral, 303, 305, 321. 

gastric, 781. 

nasal, 478. 

pulmonary, 617. 

spinal, 338. 

vesical, 916. 

vicarious, 165, 783, 



Hay-asthma, 557. 
Headache, sick, 796. 
Health, what is, 18. 
Heart, diseases of, 670. 

aneurisms of, 672, 686. 

bellows sound of, 677. 

dilatation of the, 685. 

dropsy from, 175. 

hypertrophy of, 671,683. 

morbid sounds of, 677. 

natural sounds of, 674. 

palpitation of, 680. 

rupture of, 686. 

valvular disease of, 687. 
Heart-burn, 794. 
Heat a cause of disease, 63-65. 

a symptom of inflammation, 99. 
Hectic fever, 97, 120, 649. 
Hemicrania, 444. 
Hemiplegia, 315, 339. 

Hepatic abscess, 858. \ 
Hepatization of the lungs, 33, 572. 
Hepatitis, acute, 857. 

treatment, 860, [note] . 

chronic, 861. 
Hereditary disposition to disease, 61, 79. 
Herpes, 1037-38. 

circinatus, 1038. 

iris, 1038. 

pra^putialis, 1038. 

zoster, 1038. 
Hobnail liver, 123, 760, 861. 
Hooping cough, 565. 

pathology of, 568, [note] . 
Hydatids, 844. 
Hydrargyrum, 1040. 
Hydrocephalus, acute, 269. 

chronic, 284. 

spurious, 282. 
Hydrophobia, 367. 

phenomena, 368. 

causes, 373. 
Hydrophobia, morbid anatomy, 382. 

in the dog, 380. 

pathology, 382. 

treatment, 382. 

prevention, 384. 
Hydrothorax, 590. 
Hyperemia, 42. 
Hypertrophy, 27-30. 

of the brain, 266. 

heart, 671, 683. 
thyreoid gland, 481. 
Hypochondriasis, 797. 
Hysteria, 423. 

phenomena, 423. 

diagnosis, 424. 

pathology, 425. 

treatment of, 431. 
Hysterical affection of joints, 428. 

cough, 427. 

heematemesis, 428. 

laryngitis, 427. 

palsy, 427. 

peritonitis, 426. 

Icterus, 863. 
Ileus, 800. 
Impetigo, 1044. 

Impure air, a cause of disease, 78. 
Inanition a cause of death, 53. 
Indigestion, 772, 790. 
Induration, 33. 

of the areolar tissue, 123. 



INDEX. 



Induration of the brain, 265. 

of the cellular tissue, 123. 
Infants, purulent ophthalmia of, 200. 
Infiltration of the lungs, purulent, 573. 

• tubercular, 639. 
Inflammation, general account of, 94. 

acute, 127. 

adhesive, 110. 

arachnoid, 243. 

areolar tissue, 122. 

arteries, 125. 

bowels, 800. 

brain, 126, 246. 

chronic, 127. 

conjunctiva, 185, 85, 95, 200. 

cutaneous tissues, 124. 

dura mater, 237. 

encephalon, 246. 

events of, 108. 

eye, 185. 

fibrous tissue, 924. 

hectic fever from, 119. 

intestines, 800. 

iris, 207. 

kidneys, 872. 

larynx, 504. 

liver, 858. 

lungs, 571. 

mucous membrane, 124. 
oesophagus, 740 [note] . 
of the several tissues, 122. 
parotid, 491. 
pericardium, 695. 
peritoneum, 743. 
phenomena, 95. 
pia mater, 243. 
pleura, 588. 
pyrexia, 118. 
retina, 219. 
serous tissue, 123. 
skin, 124. 

spinal cord, 297-299. 

state of minute blood-vessels in, 102. 

stomach, 768. 

synovial membrane, 123. 

thorax, 529. 

tonsils, 497. 

trachea, 515. 

treatment, 145. • 

typhoid fever, 120. 

varieties of, 127. 

veins, 125, 720. 
Inflammatory fever, 96, 118. 
Influenza, 551. 

Inoculation of small-pox, 1002. 

Intellect, affections of, symptom of disease, 89. 

Intermittent fever, 445. 

exciting cause, 451. 

pathology, 459. 

phenomena, 445. 

prophylaxis, 477. 

species, 447. 

treatment, 467. 
Interlobular emphysema, 628, 634. 
Intestinal concretions, 838. 

worms, 840. 
Intestines, diseases of the, 800. 

inflammation of, 800. 

perforation of, 748. 
Iritis, 207. 

syphilitic, 214. 
Ischuria renalis, 882. 
Itch, 1036. 

Itching, a symptom, 87. 
67 



Jaundice, 863. 

phenomena, 863. 
pathology, 864—868 [note.} 
prognosis, 868. 

treatment, 868 [note] , 870, text. 
Kidney, diseases of, 872. 

Bright's, 875. 

inflammation of, 872. 

suppuration of, 874. 
Laryngismus stridulus, 525. 
Laryngitis, 504 — 513. 

hysterical, 427. 
Larynx, acute inflammation of, 504. 

chronic " 513. 

syphilitic ulceration of, 513. 

warty growths of, 514. 
Laryngeal oedema, 512. 

phthisis, 624—642. 

ulceration, 513, 624, 642. 
Laryngeo-tracheitis, 515 [note] . 
Lead colic, 809. 

palsy, 810. 
Lecturer on medicine, duties of a, 24. 
Lepra, 1043. 
Life, conditions of, 50. 
Lithic diathesis, 878. 
Liver, diseases of, 857. 

abscess of, 858. 

cirrhose, 123, 760, 861. 

fatty, 643, 861. 

hobnail, 123, 760, 861. 

inflammation of, 858. 

suppuration of, 858. 
Lobular pneumonia, 573. 
Locked jaw, 359. 
Lumbricoid worms, 841 — 853. 
Lungs, diseases of the, 540. 

abscess of, 573. 

cancer of, 666. 

carnification of, 591. 

consumption of ,636. 

emphysema of, 566, 628. 

engorgement of, 572. 

gangrene of, 574. 

hemorrhage from, 517. 

hepatization of, 33, 572. 

inflammation of, 571. 

melanosis of, 662. 

oedema of, 635. 

purulent infiltration of, 573. 

red and gray, softening of, 573. 

sounds of, 532. 

splenization of, 572. 

tubercles of, 686. 

tubercular, infiltration, 639. 
Lymph, coagulable, 109. 
Maculae, 943. 
Malaria, 451. 

circumstances which influence, 46L 

condition necessary to produce, 452, 

effects of, on human body, 456. 

influence of soils in evolving, 457. 

ultimate effects of, 465. 
Malignant cholera, 822. 
Measles, 1014. 
Medicine, principles of, 22. 

duties of a lecturer on, 24. 
Melaena, 785. 
Melanosis, true, 662. 

spurious, 664. 
Meningitis of the brain, 243. 

encephalica [note] , 293. 

spine, 297. 

tubercular, 270. 



1058 



INDEX. 



Mercury, a remedy in inflammation, 154. 
Metastasis, 108. 
Mercurial eczema, 1040. 

tremor, 421. 
Miliary tubercles, 636. 
Modes of dying, 50. 
Morbilli, 1014. 
Mortification, 97, 115, 122. 

of the brain, 126. 
Mucous membrane, inflammation of, 124. 

morbid anatomy of, 563. 
Mucous rattle, 544. 
Mumps, 491. 

Murmur, respiratory, 537 — 542. 

bellows, 677. 
Muscae volitantes, a symptom, 88, 244. 
Muscular tissue, inflammation of, 125. 
Nasal hemorrhage, 478. 
Nausea, a symptom, 87. 
Nephralgia, 872. 
Nephritis, 872. 

albuminous, 903. 
Nervous system, diseases of, 226. 

physiology of, 226. 

pathology of, 230. 
Nervous tissue, inflammation of, 126. 
Nettle rash, 1033. 
Neuralgia, 436. 

facial, 439. 
Nutrition, lesions of, 39. 
Obliteration of veins, 726. 

Obstruction of bowels, mechanical, 802, 803, 805. 
CEdema, 174. 

of the glottis, 513. 

lungs, 635. 

laryngeal, 512. 
(Esophagus, diseases of, 736. 

dilatation of, 739. 

inflammation of [note] , 740. 

stricture of, 736. 
Old persons, catarrh of, 549. 
Opium, a remedy in inflammation, 160. 
Ophthalmia arthritic, 215. 

catarrhal, 185. 

Egyptian, 189, 190. 

gonorrhoeal, 195. 

purulent, 188. 

purulent in infants, 200. 

pustular, 202. 

rheumatic, 215. 

strumous, 202. 
Orthopnoea, a symptom, 91. 
Ovarian dropsy, 755, 761, 764. 
Ovaries, extirpation of, 764. 
Oxalic diathesis, 881. 
Pain, a symptom, 86, 97. 
Painter's colic, 809. 
Palpation of the abdomen, 743. 
Palpitation, 680. 
Palsy, 315, 338. 

facial, 343. 

from lead, 810. 

hysterical, 427. 

local, 342. 

shaking, 420. 
Pancreas, diseases of the, 872. 
Papulae, 943. 

Paracentesis thoracis, 606. 

abdominis, 766. 
Paralysis agitans, 420. 

facial, 343, 

from lead, 810. 

of one side, 315, 339. 

partial, 342. 



Paraplegia, 315,339. 
Parotitis, 491. 
Pathology, 26. 

of sudden death, 51. 
Pectoriloquy, 538 — 645. 
Pemphigus, 1041. 
Percussion of thorax, 533. 

of abdomen, 743, 756. 
Pericarditis, 695. 

Pericardium, diseased conditions of, 549. 
Periodicity, 459. 
Peripneumonia notha, 549. 
Peritonitis, acute, 743. 

treatment, 750. 

chronic, 754. 

hysterical, 426. 

tubercular, 754. 
Pertussis, 565. 
Petechias, 659. 

Phlegmasia dolens, 126, 175, 721. 
Phlebitis, 126, 720. 
Phosphatic diathesis, 878. 
Phrenitis, 246. 
Phthisis, 636. 

auscultatory signs, 643. 

its connection with tubercles, 636. 

diagnosis, 652. 

general symptoms, 646. 

granulations of Bayle, 654. 

intercurrent pleurisy, 641. 

laryngeal, 513, 624, 642. 

statistics, 656. 

treatment, 658. 

varieties, 653. 

vomicae, 640. 
Physician, duties and responsibilities of a, 
Pia mater, inflammation of, 243. 
Pictonum, colica, 809. 
Pimples, 943. 
Plague, 1026. 
Plethora, 42, 44. 
Pleura, inflammation of, 588. 

morbid anatomy, 588. 

false membranes of, 588. 
Pleurisy, 588. 

Pleuro-pneumonia, 575, 588. 
Pneumonia, 571. 

lobular, 573, 858. 

morbid anatomy, 574. 

prognosis, 583. 

treatment, 584. 
Pneumonia notha, 549. 

typhoid, 611 [note] . 
Pneumo-thorax, 602. 
Podagra, 931. 
Polypi, bronchial, 124-561. 
Polysarcia, 29. 
Pompholix, 1041. 

Predisposing causes of disease, 60. . 

Predisposition, hereditary, 79. 

Pressure on the brain, effects of, 231, 314. 

Principles of medicine, 22. 

Prognostic signs, 83, 85. 

Proximate causes, 59. 

Prurigo, 1034. 

Psoriasis, 1043. 

Ptyalism, spontaneous, 493. 

Puerile respiration, 537, 578. 

Puerperal fever, 745. 

Pulmonary tissue, inflammation of, 571. 

Pulmonary apoplexy, 621. 

consumption, 636. 

emphysema, 628. 

hemorrhage, 617. 



Pulmonary vesicles, dilatation of, 631. 
Pulse, indications of, in disease, 92. 
Purging, as a remedy in inflammation, 154. 
Purpura, 1046. 
Purulent ophthalmia, 188. 

of infants, 200. 

infiltration of the lungs, 573. 
Pus, 112. 
Pustular, 943. 
Pustular ophthalmia, 202. 
Pyrexia, with inflammation, 96, 118. 
Pyrosis, 795. 

Quinsy, 497. 

Rabies canina, 375, 380. 

Ramollissement of the brain, 262. 

Red and gray softening of the lungs, 573. 

Redness, a symptom of inflammation, 100. 

Regimen, antiphlogistic, 144. 

Regions of the thorax, 535. 

abdomen, 742. 
Remittent fever, 985. 
Renal dropsy, 177. 

calculi, 875. 
Resolution, an event of inflammation, 96-108. 
Respiration, abdominal, 532. 

bronchial, 538. 

cavernous, 644. 

natural sOunds of, 542. 

puerile, 537. 

thoracic, 530, 744. 

vesicular, 542. 
Respiratory murmur, 537, 542. 
Retinitis, 219. 
Revaccination, 1010. 
Rheumatic ophthalmia, 186-215. 

carditis, 695. 
Rheumatism, acute, 924. 

varieties, 925. 

connection with disease of heart, 695. 

chronic, 930. 
Rhonchus, 542-575. 
Round worms, 841. 
Rubeola, 1014. 

St. Vitus' dance, 414. 
Salaam convulsions, 423 [note] . 
Salivation, spontaneous, 493. 
Scabies, 1036. 
Scarlet fever, 1017. 

species, 1017. 

diagnosis, 1018. 

symptoms, 1018. 

sequela?, 1021. 

treatment, 1022. 

prophylaxis, 1025. 
Sciatica, 444. 
Scirrhus, 140. 

Scrofulous diathesis, 129-136. 

inflammation, 129. 

ophthalmia, 202. 
Scurvy, 1046. 

Seasons, influence of the, 76. 

Senile catarrh, 549. 

Sensations, morbid, as symptoms, 88. 

Serous tissues, inflammation of, 123. 

Serum, effusion of, 109. 

Shaking palsy, 420. 

Sibilus, 542. 

Sick headache, 796. 

Signs of disease, 84. 

Scirrhus, a symptom, 87. 

Skin, inflammation of, 124. 



m 1059 

Sloughing, 97. 
Small-pox, 996. 

complications, 998. 

diagnosis, 996. 

species, 997. 

symptoms, 997. 

treatment, 1009. 
Sneezing, a symptom, 92. 
Softening, 34-35. 
Softening of the brain, 262. 

of the heart, 686-693. 

red and gray of the lungs, 573. 

spine, 303. 

of the stomach, 771, 775 [note] . 
Solids, alterations of the, in disease, 26. 

change of situation in the, 39. 
Sore-throat, inflammatory, 497. 

malignant, 1016. 
Sounds of the lungs, 532. 

heart, 674, 677. 
Spasm, a symptom, 90. 
Spasmodic asthma, 631, 633, 729. 

cholera, 822. 

croup, 525. 

diseases, 351. 

stricture of oesophagus, 737. 
Sphacelus, 115-122. 
Specific inflammation, 128. 
Spinal cord, pathology of, 294. 

physiology of the, 294. 

inflammation of, 297, 299. 
Spinal hemorrhage, 338. 

meningitis, 297. 
Spleen, diseases of, 872. 
Splenization of the lungs, 572. 
Spontaneous generation, 849. 

salivation, 493. 
Spotted fever, 959. 
Spitting of blood, 648. 
Spurious croup, 524. 

hydrocephalus, 282. 
Squama?, 943, 1042. 
Starvation, death by, 53. 
Stomach, diseases of the, 768. 

cancer of the, 776. 

hemorrhage from the, 781. 

inflammation of the, 768. 

perforation of the, 749. 

softening of the, 771-775 [note]. 

ulceration of the, 749, 773. 
Strictures of the oesophagus, 736. 
Strongulas gigas, 847. 
Strumous diathesis, 135. 

ophthalmia, 202. 
Sub-pleural emphysema, 634. 
Succussion, 539. 
Sudamina, 659. 

Sudden death, pathology of, 51. 
Suffocation, death by, 54. 
Summer catarrh, 557. 
Suppression of urine, 882. 
Suppuration, 97, 112. 

of the brain, 264. 

diffuse of the lungs, 573. 

of the kidney, 874. 

of the liver, 858. 

of the spine, 303. 
Swelling, a symptom of inflammation, 101. 
Symptoms, general account of, 81. 

diagnostic, 82. 

prognostic, 83. 

pathognomonic, 85. 
Syncope, death by, 53. 

anginosa, 692. 



1060 



INDEX. 



Synovial membrane, inflammation of, 123. 
Syphilitic ulceration of the larynx, 513. 
iritis, 214. 

Tabes mesenterica, 132. 
Taenia, 842. 
Tape worm, 842-S54. 
Tapping the brain, 291. 

Tegumentary membranes, inflammation of, 124. 
Temperature, vicissitudes of, a cause of disease, 
71. 

Tetanus, 352. 

Thorax, diseases of, 529. 

auscultation of, 532. 

inflammation of, 529. 

paracentesis of, 606. 

percussion of, 533. 

regions of, 535. 
Thoracic respiration, 532, 744. 

aneurisms, 713. 
Thrush, 494. 
Thymic asthma, 525. 
Thyreoid glands, hypertrophy of, 481. 
Tic douloureux, 439. 
Tinnitus aurium, a symptom, 89. 
Tissues, effects of inflammation in the, 122. 

atrophy of, 31. 

hypertrophy of, 27. 

induration of, 33. 

softening of, 34. 

transformation of, 36. 
To and fro sound of heart, 699. 
Tonsillitis, 497. 
Tonsils, inflammation of, 497. 
Tonsils, enlarged, 503, and [note] . 
Tormina, 800. 

Trachea, false membranes of, 519. 

foreign bodies in, 666. 

inflamed, 515. 
Tracheitis, 515. 

Tracheotomy in croup, 523, and [note] . 

laryngitis, 506. 
Transformation of tissues, 36. 
Traumatic tetanus, 354. 
Tremor, a symptom, 91. 

mercurial, 421. 
Trembles, 421. 
Trichina spiralis, 845. 
Tricocephalus dispar, S42. 
Trismus, 353. 
Tubercle, 129. 

of the brain, 265-275, and [note] . 
lungs, 636. 
peritoneum, 754. 
Tuberculae, 944. 

Tubercular infiltration of lungs, 639. 
meningitis, 270. 

morbid anatomy, 274, and [note] . 
peritonitis, 754. 
phthisis, 636. 



Tumours of abdomen, 764, 922. 

in brain, 265. 
Typhoid fever, 97, 954. 
Typhoid pneumonia, 611, [note] . 

Ulceration, 97-114. 

laryngeal, 513, 624, 642. 

of the stomach, 749, 773. 

syphilitic, of the larynx, 513. 

tubercular " « 642. 
Urine, albuminous, 894. 

bloody, 916. 

chylous, 914. 

diabetic, 884. 

morbid conditions of, 878-SS4, S94. 
retention of, hysterical, 430. 
saccharine, 884. 
suppression of, 882. 
Urticaria, 1033. 

varieties, 1033. 
treatment, 1034. 

Vaccination, 1003. 

Valves of the heart, diseases of, 687. 

Varicella, 1013. 

Variola, 996. 

Veins, diseases of, 720. 

inflammation of, 125, 720. 

obliteration of, 726. 
Venesection, 145. 

Venous tissue, under inflammation, 125. 

Vertigo, a symptom, 87. 

Vesicular, 943, 1037. 

Vesicles of the lungs, dilated, 631. 

Vesicular emphysema, 628. 

respiration, 538, 542, 576. 
Vicarious hemorrhage, 165, 783. 
Vscissitudes of temperature a cause of disease, 
71. 

Viscera, inflammation of the, 123. 
Vomicae, 638-640. 
Vomiting, 792. 
Vomiting of blood, 781. 
hysterical, 428. 

Warmth, external, a remedy in inflammation, 
161. 

Warty growth of larynx, 514. 
Wasting, a symptom, 93. 
Water brash, 795. 

stroke, 272. 
Worms, 840. 

varieties, 840. 

round, 841. 

flat, 842. 

mode of production, 847. 
symptoms of, 853. 
treatment, 853. 
Zona ignea, 1038. 



THE END. 



LIST OP 

THE ILLUSTRATIONS 



EMBRACING 



SIX HUNDRED AND THIRTY-SIX FIGURES 

IN SMITH AND HORNER'S ATLAS. 



A HiGHLY-riNISHED VlEW OF THE BONES OF THE HEAD, 

View of Cuvier's Anatomical Theatre, 



facing the title-page 
. . . . vignette 



PART I. — BONES AND LIGAMENTS. 



Fig. 

1 Front view of adult skeleton. 

2 Back view of adult skeleton. 

3 Foetal skeleton. 

4 Cellular structure of femur. 

5 Cellular and compound structure of tibia. 

6 Fibres of compact matter of bone. 

7 Concentric lamellae of bone. 

8 Compact matter under the microscope. 

9 Haversian canals and lacunae of bone. 

10 Vessels of compact matter. 

11 Minute structure of bones. 

12 Ossification in cartilage. 

13 Ossification in the scapula. 

14 Puncta ossificationis in femur. 

15 Side view of the spinal column. 

16 Epiphyses and diaphysis of bone. 

17 External periosteum. 

18 Punctum ossificationis in the head. 

19 A cervical vertebra. 

20 The atlas. 21 The dentata. 

22 Side view of the cervical vertebrae. 

23 Side view of the dorsal vertebrae. 

24 A dorsal vertebra. 

25 Side view of the lumbar vertebrae. 

26 Side view of one of the lumbar vertebrae. 

27 Perpendicular view of the lumbar vertebrse. 

28 Anterior view of sacrum. 

29 Posterior view of sacrum. 

30 The bones of the coccyx. 

31 Outside view of the innominatum. 

32 Inside view of the innominatum. 

33 Anterior view of the male pelvis. 

34 Anterior view of the female pelvis. 

35 Front of the thorax. 36 The first rib. 

37 General characters of a rib. 

38 Front view of the sternum. 

39 Head of a Peruvian Indian. 

40 Head of a Choctaw Indian. 

41 Front view of the os frontis. 

42 Under surface of the os frontis. 

43 Internal surface of the os frontis. 

44 External surface of the parietal bone.s 

45 Internal surface of the parietal bone. 

46 External surface of the os occipitis. 

47 Internal surface of the os occipitis. 

48 External surface of the temporal bone. 

49 Internal surface of the temporal bone. 

50 Internal surface of the sphenoid bone. 

51 Anterior surface of the sphenoid bone. 

52 Posterior surface of the ethmoid bone. 

53 Front view of the bones of the face. 

54 Outside of the upper maxilla. 

55 Inside of the upper maxilla. 

56 Posterior surface of the palate bone. 

57 The nasal bones. 

58 The os unguis. 59 Inferior spongy bone, 
ot) Right malar bone. 61 The vomer. 

62 Inferior maxillary bone. 

63 Sutures of the vault of the cranium. 



Fig. 

64 Sutures of the posterior of the cranium. 

65 Diploe of the cranium. 

66 Inside of the base of the cranium. 

67 Outside of the base of the cranium. 

68 The facial angle. 69 The fontanels, 

70 The os hyoides. 

71 Posterior of the scapula. 

72 Axillary margin of the scapula. 

73 The clavicle. 74 The humerus. 
75 The ulna. 76 The radius. 

77 The bones of the carpus. 

78 The bones of the hand. 

79 Articulation of the carpal bones. 

80 Anterior view of the femur. 

81 Posterior view of the femur. 

82 The tibia. 83 The fibula. 

84 Anterior view of the patella. 

85 Posterior view of the patella. 

86 Theoscalcis. 87 The astragalus. 

88 The naviculare. 89 The cuboid bone. 

90 The three cuneiform bones. 

91 Top of the foot. 

92 The sole of the foot. 93 Cells in cartilage. 

94 Articular cartilage under the microscope. 

95 Costal cartilage under the microscope. 

96 Magnified section of cartilage. 

97 Magnified view of fibro-cartilage. 

98 White fibrous tissue. 

99 Yellow fibrous tissue. 
t00 Ligaments of the jaw. 

101 Internal view of the same. 

102 Vertical section of the same. 

103 Anterior vertebral ligaments. 

104 Posterior vertebral ligaments. 

105 Yellow ligaments. 

106 Costo-vertebral ligaments. 

107 Occipito-altoidien ligaments. 

108 Posterior view of the same. 

109 Upper part of the same. 

110 Moderator ligaments. 

111 Anterior pelvic ligaments. 

112 Posterior pelvic ligaments. 

113 Sterno-clavicular ligaments. 

114 Scapulo-humeral articulation. • 

115 External view of elbow joint. 

116 Internal view of elbow joint. 

117 Ligaments of the wrist. 

118 Diagram of the carpal synovial membrane 

119 Ligaments of the hip joint. 

120 Anterior view of the knee joint. 

121 Posterior view of the knee joint. 

122 Section of the right knee joint. 

123 Section of the left knee joint. 

124 Internal side of the ankle joint. 

125 External side of the ankle joint. 

126 Posterior view of the ankle joint. 

127 Ligaments of the sole of the foot. 

128 Vertical section of the foot. 



PART II.— DERMOID AND MUSCULAR SYSTEMS. 



129 Muscles on the front of the body, full length. 
131 Muscles on theback of the body, full length. 

130 The cellular tissue. 132 Fat vesicles. 



133 Blood-vessels of fat. 

134 Cell membrane of fat vesicles. 

135 Magnified view of the epidermis. 



Illustrations to Smith and Horner's %fltlas, continued. 



Fig. 

136 Cellular tissue of the skin. 

137 Rete mucosutn, &c, of foot. 
1-38 Epidermis and rete mucosum 

139 Cutis vera, magnified. 

140 Cutaneous papillse. 

141 Internal face of cutis vera. 

142 Integuments of foot under the microscope. 



Fig. 

180 Side view of abdominal muscles. 

181 External parts concerned in hernia. 

182 Internal parts concerned in hernia. 

183 Deep-seated muscles of trunk. 

184 Inguinal and femoral rings. 

185 Deep-seated muscles of neck. 

186 Superficial muscles of back. 



143 Cutaneous glands. 144 Sudoriferous organs. 187 Posterior parietes of chest and abdomen. 



145 Sebaceous glands and hairs. 

146 Perspiratory gland magnified. 

147 A hair under the microscope. 

148 A hair from the face under the microscope. 

149 Follicle of a hair. 150 Arteries of a hair. 

151 Skin of the beard magnified. 

152 External surface of the thumb nail. 

153 Internal surface of the thumb nail. 

154 Section of nail of fore finger. 

155 Same highly magnified. 

156 Development of muscular fibre. 

157 Another view of the same. 

158 Arrangement of fibres of muscle. 

159 Discs of muscular fibre. 

160 Muscular fibre broken transversely. 

161 Striped elementary fibres magnified. 

162 Striae of fibres from the heart of an ox. 

163 Transverse section of biceps muscle. 

164 Fibres of the pectoralis major. 

165 Attachment of tendon to muscle. 

166 Nerve terminating in muscle. 

167 Superficial muscles of face and neck. 

168 Deep-seated muscles of face and neck. 

169 Lateral view of the same. 

170 Lateral view of superficial muscles of face. 

171 Lateral view of deep-seated muscles of face. 

172 Tensor tarsi or muscle of Horner. 

173 Pterygoid muscles. 174 Muscles of neck. 

175 Muscles of tongue. 

176 Fascia profunda colli. 

177 Superficial muscles of thorax. 

178 Deep-seated muscles of thorax. 



Under side of diaphragm. 

189 Second layer of muscles of back. 

190 Muscles of vertebral gutter. 

191 Fourth layer of muscles of back. 

192 Muscles behind cervical vertebrae. 

193 Deltoid muscle. 

194 Anterior view of muscles of shoulder. 

195 Posterior view of muscles of shoulder. 

196 Another view of the same. 

197 Fascia brachialis. 

198 Fascia of the fore-arm. 

199 Muscles on the back of the hand. 

200 Muscles on the front of the arm. 

201 Muscles on the back of the arm. 

202 Pronators of the fore-arm. 

203 Flexor muscles of fore-arm. 

204 Muscles in palm of hand. 

205 Deep flexors of the fingers. 

206 Superficial extensors. 

207 Deep-seated extensors. 

208 Rotator muscles of the thigh. 

209 Muscles on the back of the hip. 

210 Deep muscles on the front of thigh. 

211 Superficial muscles on the front of thigh. 

212 Muscles on the back of the thigh. 

213 Muscles on front of leg. 

214 Muscles on back of leg. 

215 Deep-seated muscles on back of leg. 

216 Muscles on the sole of the foot. 

217 Another view of the same. 

218 Deep muscles on front of arm. 

219 Deep muscles on back of arm. 



179 Front view of abdominal muscles. 

PART III. — ORGANS OF DIGESTION AND GENERATION 



220 Digestive organs in their whole length. 

221 Cavity of the mouth. 

222 Labial and buccal glands. 

223 Teeth in the upper and lower jaws. 

224 Upper jaw, with sockets for teeth. 

225 Lower jaw, with sockets for teeth. 

226 Under side of the teeth in the upper jaw. 

227 Upper side of the teeth in the lower jaw. 

228 to 235. Eight teeth, from the upper jaw. 
236 to 243. Eight teeth from the lower jaw. 
244 to 251. Side view of eight upper jaw teeth.* 
252 to 259. Side view of eight lower jaw teeth. 
260 to 265. Sections of eight teeth. 

266 to 267. Enamel and structure of two of the 
teeth. ■ 

268 Bicuspis tooth under the microscope. 

269 Position of enamel fibres. 

270 Hexagonal enamel fibres. 

271 Enamel fibres very highly magnified. 

272 A very highly magnified view of fig. 268. 

273 Internal portion of the dental tubes. 

274 External portion of the dental tubes. 

275 Section of the crown of a tooth. 

276 Tubes at the root of a bicuspis. 

277 Upper surface of the tongue. 

278 Under surface of the tongue. 

279 Periglottis turned off the tongue. 

280 Muscles of the tongue. 

281 Another view of the same. 

282 Section of the tongue. 

283 Styloid muscles, kc. 

284 Section of a gustatory papilla. 

285 View of another papilla. 

286 Root of the mouth and soft pala ( te. 

287 Front view of the pharynx and muscles. 



288 Back view of the pharynx and muscles. 

289 Under side of the soft palate. 

290 A lobule of the parotid gland. 

291 Salivary glands. 

292 Internal surface of the pharynx. 

293 External surface of the pharynx. 

294 Vertical section of the pharynx. 

295 Muscular coat of the oesophagus. 

296 Longitudinal section of the oesophagus. 

297 Parietes of the abdomen. 

298 Reflexions of the peritoneum. 

299 Viscera of the chest and abdomen. 

300 Another view of the same. 

301 The intestines in situ. 

302 Stomach and oesophagus. 

303 Front view of the stomach. 

304 Interior of the stomach. 

305 The stomach and duodenum. 

306 Interior of the duodenum. 
S07 Gastric glands. 

308 Mucous coat of the stomach. 

309 An intestinal villus. 310 Its vessels. 

311 Glands of the stomach magnified. 

312 Villus and lacteal. 

313 Muscular coat of the ileum. 

314 Jejunum distended and dried. 

31 5 Follicles of Lieberkuhn 

316 Glands of Brunner. 317 Intestinal glands. 
318 Valvulse conniventes. 319 Ileo-colic valve. 

320 Villi and intestinal follicles. 

321 Veins of the ileum. 

322 Villi filled with chyle. 323 Peyer's glands 

324 Villi of the jejunum under the microscope. 

325 The caecum. 326 The mesocolon and colon, 
327 Muscular coat of the colon. 



Illustrations to Smith and Horner's Atlas continued. 



fig- 

328 Muscular fibres of the rectum. 

329 Curvatures of the large intestine. 

330 Mucous follicles of the rectum. 

331 Rectal pouches. 

332 Follicles of the colon, highly magnified. 

333 Folds and follicles of the stomach. 

334 Follicles, &c. of the jejunum. 

335 Villi and follicles of the ileum. 

336 Muciparous glands of the stomach. 

337 Ileum inverted, &c. 

338 Glands of Peyer magnified. 

339 Peritoneum of the liver injected. 

340 Liver in situ. 

341 Under surface of the liver. 342 Hepatic vein. 

343 Parenchyma of the liver. 

344 Hepatic blood-vessels. 345 Biliary ducts. 

346 Angular lobules of the liver. 

347 Rounded hepatic lobules. 

348 Coats of the gall bladder. 

349 Gall bladder injected. 

350 Vena portarum. 

351 External face of the spleen. 

352 Internal face of the spleen. 

353 Splenic vein. 

354 Pancreas &c, injected. 355 Urinary organs. 

356 Right kidney and capsule. 

357 Lett kidney and capsule. 

358 Kidney under the microscope. 

359 The ureter. 360 Section of right kidney. 

361 Section of the left kidney. 

362 Pyramids ofMalpighi. 

363 Lobes of the kidney. 
S64 Renal arteries, &c, injected. 

365 Section of the kidney highly magnified. 

366 Copora Malpighiana. 367 Same magnified. 
368 Tubuli uriniferi. 369 Corpora Wolffiana. 

370 The bladder and urethra, full length. 

371 Muscular coat of the bladder. 

372 Another view of the same. 

PART IV. — ORGANS OF RESPIRATION AND CIRCULATION. 

411 Front view of the thyroid cartilage. 450 The external carotid artery. 

412 Side view of the thyroid cartilage. 451 A front view of arteries of head and neck 

413 Posterior of the arytenoid cartilage. 

414 Anterior of the arytenoid cartilage. 

415 Epiglottis cartilage. 41 6 Cricoid cartilage. 
417 Ligaments of the larynx. 



Fig. 

373 Sphincter apparatus of the bladder. 

374 Prostate and vesiculce seminales. 

375 Side view of the pelvic viscera. 

376 The glans penis injected. 

377 The penis distended and dried. 

378 Section of the same. 

S79 Vertical section of the male pelvis, &c. 

380 Septum pectiniforme. 

381 Arteries of the penis. 

382 Vertical section of the urethra. 

383 Vesicula? seminales injected. 

384 Muscles of the male perineum. 

385 Interior of the pelvis, seen from above. 

386 Testis in the fcetus. 

387 Diagram of the descent of the testis. 

388 Tunica vaginalis testis. 

389 Transverse section of the testis. 

390 Relative position of the prostate. 

391 Vas deferens. 

392 Vertical section of the bladder. 

393 The testicle injected with mercury. 

394 Another view. 

395 Minute structure of the testis. 

396 Female generative organs. 

397 Another view of the same. 

398 External organs in the fcetus. 

399 Muscles of the female perineum. 

400 Side view of the female pelvis, &c. 

401 Relative position of the female organs. 

402 Section of the uterus, &c. 

403 Fallopian tubes, ovaries, &c. 

404 Front view of the mammary gland. 

405 The same after removal of the skin. 

406 Side view of the breast. 

407 Origin of lactiferous ducts. 

408 Lactiferous tubes during lactation. 

409 Minute termination of a tube. 

410 Ducts injected ; after Sir Astley Cooper. 



418 Side view of the same. 

419 The thyroid gland. 

420 Internal surface of the larynx. 

421 Crico-thyroid muscles. 

422 Crico-arytenoid muscles. 

423 Articulations of the larynx. 

424 Vertical section of the larynx. 

425 The vocal ligaments. 426 Thymus gland. 

427 Front view of the lungs. 

428 Back view of the lungs. 

429 The trachea and bronchia. 

430 Lungs, heart, &c. 

431 First appearance of the blood-vessels. 

432 Capillary vessels magnified. 

433 Another view of the same. 

434 Blood globules. 

435 Another view of the same. 

436 The mediastina. 

437 Parenchyma of the lung. 

438 The heart and pericardium. 

439 Anterior view of the heart. 

440 Posterior view of the heart. 

441 Anterior view of its muscular structure. 

442 Posterior view of the same. 

443 Interior of the right ventricle. 

444 Interior of the left ventricle. 

445 Mitral valve, the size of life. 

446 The auriculo-ventricular valves. 

447 Section of the ventricles. 

448 The arteries from the arch of the aorta. 

449 The arteries of the neck, the size of life. 



452 The internal maxillary artery. 

453 Vertebral and carotid arteries with the aorta. 

454 Axillary and brachial arteries. 

455 The brachial artery. 

456 Its division at the elbow. 

457 One of the anomalies of the brachial artery. 

458 Radial and ulnar arteries. 

459 Another view of the same. 

460 The arcus sublimis and profundus. 

461 The aorta in its entire length. 

462 Arteries of the stomach and liver. 

463 Superior mesenteric artery. 

464 Inferior mesenteric artery. 

465 Abdominal aorta. 

466 Primitive iliac and femoral arteries. 

467 Perineal arteries of the male. 

468 Position of the arteries in the inguinal canal. 

469 Internal iliac artery. 470 Femoral artery. 

471 Gluteal and ischiatic arteries. 

472 Branches of the ischiatic artery. 

473 Popliteal artery. 

474 Anterior tibial artery. 

475 Posterior tibial artery. 

476 Superficial arteries on the top of the foot. 

477 Deep-seated arteries on the top of the foot. 

478 Posterior tibial artery at the ankle. 

479 The plantar arteries. 

480 Arteries and veins of the face and seek. 

481 Great vessels from the heart. 

482 External jugular vein. 

483 Lateral view of the vertebral sinuses. 

484 Posterior view of the vertebral sinuses. 

485 Anterior view of the vertebral sinuses. 

486 Superficial veins of the arm. 

487 The same at the elbow. 



Illustrations to Smith and Horner's Atlas continued. 



Fig. 

488 The veins of the hand. 

489 The great veins of the trunk. 

490 Positions of the arteries and veins of the trunk. 

491 The vense cavse. 492 The vena portarum. 

493 Deep veins of the back of the leg. 

494 Positions of the veins to the arteries in the 

arm. 495 Superficial veins of the thigh. 

496 Saphena vein. 

497 Superficial veins of the leg. 

498 Lymphatics of the upper extremity. 



rig. 

499 The lymphatics and glands of the ax ; IIa. 

500 The femoral and aortic lymphatics. 

501 The lymphatics of the small intestines, 

502 The thoracic duct. 

503 The lymphatics of the groin. 

504 Superficial lymphatics of the uiigh. 

505 Lymphatics of the jejunum. 

506 Deep lymphatics of the thigh. 

507 Superficial lymphatics of the leg. 

508 Deep lymphatics of the leg. 



PART V.— THE NERVOl 

509 Dura mater cerebri and spinalis. 

510 Anterior view of brain and spinal marrow. 

511 Anterior view of the spinal marrow, &c. 

512 Lateral view of the spinal marrow, &e. \ 

513 Posterior view of the spinal marrow, &c. 

514 Decussation of Mitischelli. 

515 Origins of the spinal nerves. 

516 Anterior view of spinal marrow and nerves. 

517 Posterior view of spinal marrow and nerves. 

518 Anterior spinal commissure. 

519 Posterior spinal commissure. 

520 Transverse section of the spinal marrow. 

521 Dura mater and sinuses, 

522 Sinuses laid open. 

523 Sinuses at the base of the cranium. 

524 Pons Varolii, cerebellum, &c. 

525 Superior face of the cerebellum. 

526 Inferior face of the cerebellum. 

527 Another view of the cerebellum. 

528 View of the arbor vitte, &c. 

529 Posterior view of the medulla oblongata. 

530 A vertical section of the cerebellum. 

531 Another section of the cerebellum. 

532 Convolutions of the cerebrum. 

533 The cerebrum entire. 

534 A section of its base. 

535 The corpus callosum entire. 

536 Diverging fibres of the cerebrum, &c. 

537 Vertical section of the head. 

558 Section of the corpus callosum. 

539 Longitudinal section of the brain. 

540 View of a dissection by Gall. 

541 The commissures of the brain. 

542 Lateral ventricles. 

543 Corpora striata-fornix, &c. 

544 Fifth ventricle and lyra. 

545 Another|view of the lateral ventricles. 

546 Another' view of the ventricles. 

547 Origins of the 4th and 5th pairs of nerves. 

548 The circle of Willis. 

549 A side view of the nose. 

550 The nasal cartilages. 

551 Bones and cartilages of the nose. 

552 Oval cartilages, &c. 

553 Schneiderian membrane. 

554 External parietes of the left nostril. 

555 Arteries of the nose. 

556 Pituitary membrane injected. 

557 Posterior nares. 558 Front view of the eye. 

559 Side view of the eye. 

560 Posterior view of the eyelids, &c. 

561 Glandulse palpebrarum. 

562 Lachrymal canals. 

563 Muscles of the eyeball. 

564 Side view of the eyeball. 

565 Longitudinal section of the eyeball. 

566 Horizontal section ofthe eyeball. 

567 Anterior view of a transverse section. 

568 Posterior view of a transverse section. 

569 Choroid coat injected. 

570 Veins of the choroid coat. 

571 The iris. 572 Thejretina and lens. 



S SYSTEM AND SENSES. 

573 External view of the same. 

574 Vessels in the conjunctiva. 

575 Retina, injected and magnified. 

576 Iris, highly magnified. 

577 Vitreous humour and lens. 

578 Crystalline adult lens. 

579 Lens of the foetus, magnified. 

580 Side view ofthe lens. 

581 Membrana pupillaris. 

582 Another view ofthe same. 

583 Posterior view ofthe same. 

584 A view of the left ear. 

585 Its sebaceous follicles. 

586 Cartilages ofthe ear. 

587 The same with its muscles. 

588 The cranial side of the ear. 

589 Meatus auditorius externus, &c. 

590 Labyrinth and bones of the ear. 

591 Full view ofthe malleus. 592 The incus. 

593 Another view of the malleus. 

594 A front view of the stapes. 

595 Magnified view ofthe stapes. 

596 Magnified view ofthe incus. 

597 Cellular structure of the malleus. 

598 Magnified view of the labyrinth. 

599 Natural size of the labyrinth. 

600 Labyrinth laid open and magnified. 

601 Labyrinth, natural size. 

602 Labyrinth of a foetus. 

603 Another view of the same. 

604 Nerves of the labyrinth. 

605 A view of the vestibule, &c. 

606 Its soft parts, &c. 

607 An ampulla and nerve. 

608 Plan of the cochlea. 

609 Lamina spiralis, &c. 

610 The auditory nerve. 

611 Nerve on the lamina spiralis. 

612 Arrangement of the cochlea. 

613 Veins of the cochlea, highly magnified. 

614 Opening of the Eustachian tube in the throat 

615 Portio mollis of the seventh pair of nerves, 

616 The olfactory nerves. 

617 The optic and seven other pairs of nerves. 

618 Third, fourth and sixth pairs of nerves. 

619 Distribution ofthe fifth pair. 

620 The facial nerve. 

621 The hypo-glossal nerves. 

622 A plan of the eighth pair of nerves. 

623 The distribution of the eighth pair. 

624 The great sympathetic nerve. 

625 The brachial plexus. 

626 Nerves of the front ofthe arm. 

627 Nerves of the back of the arm. 

628 Lumbar and ischiatic nerves. 

629 Posterior branches to the hip, &e. 

630 Anterior crural nerve. 

631 Anterior tibial nerve. 

632 Branches of the popliteal nerve. 

633 Posterior tibial nerve on the leg. 

634 Posterior tibial nerve on the foot. 



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WORKS ON 



MEDICINE, SURGERY, 

ANATOMY, MIDWIFERY, 

AND THE COLLATERAL SCIENCES, 

PUBLISHED BY 

LEA & BLANCHARD, 
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AND FOR SALE BY ALL BOOKSELLERS. 



MIDWIFERY ILLUSTRATED. 

THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINF AND 
SURGERY, IN REFERENCE TO THE PROCESS OF PARTURITION; 
ILLUSTRATED BY ONE HUNDRED AND FORTY-TWO FIGURES. BY 
FRANCIS H. RAMSBOTHAM, M.D., Physician to the Royal Maternity Charity, 
and Lecturer on Midwifery at the London Hospital, &c. Second American edition, 
revised, in one large octavo volume. 

" Among the many literary undertakings with which the Medical press at present teems, there are few 
that deserve a wanner recommendation at our hands than the work — we might almost say the obstetrical 
library, comprised in a single volume— which is now before us. Few works surpass Dr. Ramsbotham's in 
beauty and elegance of getting up, and in the abundant and excellent Engravings with which it is illus- 
trated. We heartily wish the Volume the success which it, merits, and we have no doubt that before 
long it will occupy a place in every Medical Library in the kingdom. The Illustrations are admirable ; 
they are the joint production of Bagg and Adlard; and comprise, within the series, the best Obstetrical 
Plates of our best obstetrical authors, ancient and modern. Many of the Engravings are calculated to 
fix the eye as much by their excellence of execution and their beauty as works of art, as by their fidelity 
to nature and anatomical accuracy." — The Lancet. 

"It is a good and thoroughly Practical Treatise ; the different subjects are laid down in a clear and 
perspicuous form, and whatever is of importance is illustrated by first-rate Engravings. As a work 
conveying good, sound, practical precepts, and clearly demonstrating the doctrines of Obstetrical Science, 
we can confidently recommend it either to the Student or Practitioner. — Edinburgh, Journal of Medical 
Science. 



DUNGLISON'S PRACTICE OF MEDICINE. 

THE PRACTICE OF MEDICINE; OR A TREATISE ON SPECIAL 
PATHOLOGY AND THERAPEUTICS; BY ROBLEY DUNGLISON, M.D., 
Professor of the Institutes of Medicine, &c, in the Jefferson Medical College, Phila- 
delphia; Lecturer on Clinical Medicine, and attending Physician at the Philadelphia 
Hospital, &c. ; containing, the Diseases of the Alimentary Canal — the Diseases of the 
Circulatory Apparatus — Diseases of the Glandular Organs — Diseases of the Organs 
of the Senses — Diseases of the Respiratory Organs — Diseases of the Glandiform Gan- 
glions — Diseases of the Nervous System — Diseases of the Organs of Reproduction — 
Diseases involving various Organs, &c, &c. In two volumes, octavo. 

The object of this work is to place before the Practitioner and Student a Treatise on the various Dis- 
eases of the Human Organism, which shall comprise the Symptoms, Causes, Prognostics and Treatment, 
in such form as to be easy of reference, and a trustworthy guide in practice. It contains not only the 
Views of the Author, on all those points, derived from extensive opportunities for observation, but those 
of the distinguished observers of the day in every part of the world; and treats of a greater number of 
Diseases than perhaps any other " Practice of Medicine." 



BERZELIUS ON THE KIDNEYS, ETC. 

THE KIDNEYS AND URINE, BY J. J. BERZELIUS. Translated from 
the German by M. H. Boye, and F. Learning, M. D. In one Volume, 8vo. 



LEA & BLANCHARD'S 



PUBLICATIONS. 



A MEDICAL LIBKAKY 

FOR THE PRACTITIONER AND STUDENT. 

A SYSTEM OF PRACTICAL MEDICINE, Comprised in a Series of Original 
Dissertations, arranged and edited by ALEXANDER TWEEDIE, M.D., F.R.S., 
&.c, &c. The whole revised, with Notes and Additions, by W. W. GERHARD, 
M.D., Lecturer on Clinical Medicine to the University of Pennsylvania. The second 
American Edition, now complete in Three large Volumes. 

The design ofthisworkis to supply the want, generally admitted to exist in the Medical Literature 
of Great Britain, of a comprehensive System of Medicine, embodying a condensed, yet ample view of the 
Ptesent State of the Science. The desideratum is more especially felt by the Medical Student, and by 
many Members of the Profession, who, from their avocations and other circumstances, have not the 
opportunity of keeping pace with the more recent improvements in the most interesting and useful 
branch of human know ledge. To supply this deficiency is the object of the LIBRARY OF MEDICINE ; 
and the Editor expresses the hope, that with the assistance with which he has been favoured by contri- 
butors, (many of great, eminence, and all favourably known to the Public), he has been able to produce a 
work, which will form a Library of General Reference on Theoretical and Practical Medicine, as well as 
a Series of Text-Books for the Medical Student. 

Advertisement of the American Publishers to their New Edition in Three V olumes. 
The matter embraced in the Three Volumes now presented, was published in London in Five separate 
volumes, and at intervals republished in this country. The rapid sale of these volumes, embracing as 
they do, a History of Practical Medicine, is the best evidence of the favour with which it has been re- 
ceived by the Physicians of the United States. Embodying as it does the most recent information on 
nearly every Disease, and written by men who have specially devoted themselves to the study of the 
Disorders which form the subject of their Articles, the work is the most valuable for Reference within 
the reach of a Practitioner. The arrangement of the Library into Classes of Diseases, grouped accord- 
ing to the cavities of the body, is much more agreeable to the reader than the alphabetical order, and 
netirly as convenient for reference. 

DISEASES OF CHILDREN. 

A TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF 
CHILDREN, BY WILLIAM P. DEWEES, M.D., late Professor of Midwifery in 
the University of Pennsylvania, &c. &c. The Eighth Edition, brought up to 1843, 
in 1 vol. 8vo. 

This edition embodies the notes and additions prepared by Dr. Dewees before his death, and will be 
found much improved. 

The objects of this work are, 1st, to teach those who have the charge of children, either as parent or 
guardian, the most approved methods of securing and improving their physical powers. This is attempted 
by pointing out the duties which the parent or "the guardian owes for tliis purpose, to this interesting but 
helpless class of beings, and the manner by which their duties shall be fulfilled. And 2d, to render avail- 
able a long experience to those objects of our affection when they become diseased. In attempting this, 
the author has avoided as much as possible, " technicality;" and has given, if he does not flatter himself 
too much, to each disease of which he treats, its appropriate and designating characters, with a fidelity 
that will prevent any two being confounded together, with the best mode of treating them, that either 
his own experience or that of others has suggested. Physicians cannot too strongly recommend the use 
of this book in all families. 

A NEW WORK, — DUNGLISON'S 
THERAPEUTICS AND MATERIA MEDICA. 

GENERAL THERAPEUTICS AND MATERIA MEDICA, ADAPTED FOR 
A MEDICAL TEXT-BOOK, BY ROBLEY DUNGLISON, M.D., Professor of 
Institutes of Medicine, &c, in 2 vols. 8vo. — Just ready. 

A second edition of the work on General Therapeutics, being called for by the publishers, the author 
has deemed it advisable to incorporate with it an account of the different articles of the Materia Medica. 
To this he has been led by the circumstance, that the departments of General Therapeutics and Materia 
Medica are always associated in the Medical Schools. The author's great object has been to prepare a 
work which may aid the Medical Student in acquiring the main results of modern observation and reflec- 
tion ; and, at the same time, be to the Medical Practitioner a trustworthy book of reference. 

Throughout, he has adopted the Nomenclature of the last edition of the Pharmacopoeia of the United 
States, a work which ought to be in the hands of every practitioner as a guide in the preparation of 
medicines; and he has endeavoured to arrange the articles in each division, as nearly as he could, in the 
order of their efficacy as Therapeutical agents. 

DEWEES' MIDWIFERY. 

A COMPENDIOUS SYSTEM OF MIDWIFERY, chiefly designed to facilitate 
the inquiries of those who may be pursuing this branch of study. Illustrated by occa- 
sional cases, with many plates. The tenth edition, with additions and improvements, 
by W. P. DEWEES, M. D., late Professor of Midwifery in the University of Penn- 
sylvania, in one volume 8vo. 



LEA AND BLANC HARD'S PUBLICATIONS. 



A NEW WORK ON PRACTICAL SURGERY, 
With over Two Hundred and Fifty Illustrations. 



A SYSTEM OF PRACTICAL SURGERY, 

BY PROFESSOR WILLIAM FERGUS SON, 

OF KING-'S COLLEGE, LONDON. 

ILLUSTRATED BY OVER TWO HUNDRED AND FIFTY SPLENDID CUTS, 

EXECUTED BY GILBERT, FROM DESIGNS BY BRAGG ,* 

WITH NOTES AND ADDITIONS, 

BY GEORGE W. NORRIS, M.D. 

One of the Surgeons to the Pennsylvania Hospital. In One Volume, 8vo. 
The object and nature of this volume are thus described by the author:—" The present work has 
not been produced to compete with any already before the Profession ; the arrangement, the manner 
in which the subjects have been treated, and the illustrations, are all different from any of the kind 
in the English language. It is not intended to be placed in comparison with the elementary syetems 
of Cooper, Burns, Liston, Svmes, Lizar, and that excellent epitome by Mr. Druitt. It may with 
more propriety be likened to the Operative Surgery of Sir C. Bell, and that of Mr. Averill, both excel- 
lent in their day ; or the more modern production of Mr. Hargrave, and the Practical Surgery of Mr. 
Liston. There are subjects treated of in this volume, however, which none of these gentlemen have 
noticed; and the author is sufficiently sanguine to entertain the idea that this work may in some 
degree assume that relative position in British Surgery which the classical volumes of Valpeau and 
Malgaigne occupy on the Continent." 

The publishers commend this work to the attention of the Profession as one combining cheapness 
and elegance, with a clear, sound, and practical treatment of every subject in surgical science. No 
pains or expense have been spared to present it in a style equal, if not superior, to the London edition, 
and to match the edition of " Wilson's Anatomy," lately published, and " Churchill's System of Mid- 
wifery," and " Carpenter's Physiology." 

CHURCHILL'S MIDWIFERY, 

WITH ONE HUKDRED AND SIXTEEN ILLUSTRATIONS. 



THEORY AND PRACTICE OF MIDWIFERY, 

BY FLEETWOOD CHURCHILL, M.D., M.R.I.A., 

Licentiate of the College of Physicians in Ireland ; Physician to the Western Lying-in Hospital, 
Lecturer on Midwifery, &c. in the Richmond Hospital School of Medicine, 
Author of " A Treatise on the Diseases of Females," &c. &c. 

WITH NOTES AND ADDITIONS, BY ROBERT M. HUSTON, M.D. 
Professor in the Jefferson Medical School of Philadelphia ; 
WITH 116 ILLUSTRATIONS FROM DRAWINGS BY BAGG AND OTHERS, 
ENGRAVED BY GILBERT, 
" This is incontestably one of the very best books, on the important subject on which it treats. The 
author has had great experience, and is, withal, an able and accomplished writer; well read in his 
profession, and gifted with a vigorous and condensing mind; while the American editor is known 
as a skilful practitioner of obstetrics, and well acquainted with every thing that has been said or 
done in that department. The notes which he has added bear ample testimony to his possessing 
those qualifications. The work does not consist simply of the ipse dixit of the author. It embraces 
a brief statement, well expressed, of the views of the best authorities, and is illustrated, as the title 
sets forth, with numerous wood-cuts, which, by the way, are beautifully executed. The book is 
altogether well 'got up,' and we can conscientiously recommend it most strongly as an excellent 
accompaniment to the tyro in his studies, and to the practitioner when beset with doubts or diffi- 
culties. It forms a fit accompaniment to Wilson's Anatomy, and Fergusson's Surgery." 

PROUT ON THE STOMACH. 
ON THE NATURE AND TREATMENT OF STOMACH AND RENAL DISEASES; 

Being an Inquiry into the Connexion of Diabetes, Calculus, and the other Affections of 
the Kidney and Bladder, with Indigestion ; 

BY WILLIAM PROUT, M.D., F.R.S. 

FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, & C . 

From the Fourth revised London Edition ; with Coloured Plates. 

"This treatise was received with so much favour by the medical profession in England, that within hree yeara 
from the publication of the third edition of it, a fourth was made necessary by the increasing demand. Too 
much ean hardly be said in its praise, as a practical essay upon a class of derangements but little studied, and 
less understood, though of frequent occurrence among us: for every enquiring student of these affections will 
find in its pases valuable precepts for their management, and many satisfactory explanations of the obscure and 
complex phenomena usually attending them." — Jim. Medical Journal. 



LEA AND BLANCHARD'S PUBLICATIONS. 



A NEW TEXT-BOOK ON CHEMISTRY. 

THE ELEMENTS OF CHEMISTRY: 

INCLUDING THE APPLICATION OF THE SCIENCE TO THE ARTS I 

With numerous Illustrations. 
By THOMAS GRAHAM, F.R.S.,L. & ED., 

Professor of Chemistry in the University College, London, President of the Chemical Society, &c. &c. 

WITH NOTES AND ADDITIONS, BY ROBERT BRIDGES, M,D, 

Professor of General and Pharmaceutic Chemistry in the Philadelphia College of Pharmacy, and one 
of the Editors of the American Journal of Pharmacy. In one vol. 8vo. 

The great advancement recently made in Chemistry has called for a new and perfect treatise on 
the present state of the science. Such this work is presumed to be, while an attempt is made to 
apply it to the elucidation of the great questions of vegetable and animal physiology. Jt fully repre- 
sents the progress of the science up to the date of publication. 

The publishers have endeavoured to make this revised edition worthy of the eminent character of the 
author, and it will be found to have numerous additional cuts to illustrate the various subjects. 

It is already introduced as a Text-book into several Colleges, and has universal approbation. 

SIR ASTLEY COOPER'S WORK 
ON FRACTURES AND DISLOCATIONS, WITH CUTS, ETC. 

A TREATISE ON DISLOCATIONS AND FRACTURES OF THE JOINTS. 

By Sir Astley Cooper, Bart., F. R. S., Sergeant Surgeon to the King, &c. 

A new edition much enlarged ; edited by BRANSBY B. COOPER, F. R. S., Surgeon to Guy's Hospi- 
tal, with additional Observations from Professor John C. Warren, of Boston. With numerous en- 
gravings on wood, after designs by Bag?, a memoir and a splendid portrait of Sir Astley. In 1 vol. 8vo. 

The peculiar value of this, as of all Sir Astley Cooper's works, consists in its eminently practical 
character. His nephew, Bransby B. Cooper, from his own experience, has added a number of cases. 
Beside this, Sir Astlev left behind him verv considerable additions in MS. for the express purpose of 
being introduced into this edition. The volume is embellished with ONE HUNDRED AND THIRTY- 
THREE WOOD CUTS, and contains the history of no less than three hundred and sixty-one cases, 
thus embodying the records of a life of practice of the Author and his various editors. There are also 
additional Observations from notes furnished by John C.Warren, M. D., the Professor of Anatomy and 
Surgery in Harvard University. 

WILLIAMS' PATHOLOGY.— BY CLYMER, 

PRINCIPLES OF MEDICINE, COMPRISING GENERAL PATHOLOGY 
AND THERAPEUTICS, and a brief general View of Etiology, Nosology, Semeiology, 
Diagnosis, and Prognosis. By CHARLES J. B. WILLIAMS, M.D., F.R.S., Fellow 
of the Royal College of Physicians, ccc. With Additions and Notes, by MEREDITH 
CLYMER, M.D., Lecturer on the Institute of Medicine, &c. One Vol.'8vo. 

" With many excellent and elaborate treatises on the details of Medicine, we have scarcely any 
which treat of those genera! principles in the nature and treatment of disease, which are really funda- 
mental in the practice of medicine. We therefore think that the " Principles " of Dr Williams is enti- 
tied to assume a station along with the works of Chomel and Dubois, in the French, and Neumann, 
in the German. It is without a competitor in our language, and fills most successfully a decided gap 
in our medical literature. The actual state of our science is very fairly represented, and besides a 
free appropriation from the writings of his contemporaries, the Author has drawn largely from his 
own experience; ' a continual observation of disease for the last twenty years in Hospital and private 
practice,' affording him abundant opportunity for its accumulation." 

BRODIE ON THE JOINTS. 

PATHOLOGICAL AND SURGICAL OBSERVATIONS ON THE DISEASES 
OF THE JOINTS. By Sir Benjamin C. Brodie, Bart., F. R. S., Sergeant Surgeon 
to the King, &c. &c. From the Fourth London Edition, with the author's alterations 
and additions. In one volume Svo., cloth. 

To both the practical physician and the student, then, this little volume will be one of much service, 
inasmuch as we have here a condensed view of these complicated subjects thoroughly investigated by 
the. aid of the light afforded by modern Pathological Surgery. — JV. T. Journal of Medicine. 

WALSHE ON~THE LUNGS. 

THE PHYSICAL DIAGNOSIS OF THE DISEASES OF THE LUNGS. By 
Walter Hayle Walshe, M. D., Professor of Pathological Anatomy in University College, 
London, &c. &c. In one volume 12mo., extra cloth. 

The British and Foreign Medical Review, edited by Dr. John Forbes, the translator and annotator 
of Laennec's immortal work, says, " we do not hesitate to say that there exists in no language any 
work on the physical diagnosis of diseases of the lungs, suited for students, so clear and precise, and 
at the same time so comprehensive and practical as this. It is one which no learner in auscultation 
can fail to possess, without losing advantages elsewhere unattainable ; and it is one which very few 
even among the most experienced auscultators will consult without adding something to their previ« 
ous stock of knowledge." 



LEA & BLANCHARD'S PUBLICATIONS. 



SIR ASTLEY COOPER ON HERNIA, 

WITH ONE HUNDRED AND THIRTY FIGURES IN LITHOGRAPHY. 

THE ANATOMY AND SURGICAL TREATMENT OF ABDOMINAL 
HERNIA, BY SIR ASTLEY COOPER, BART. Edited by C. Aston Key, Sur- 
geon to Guy's Hospital, &c. 

This important work of Sir Astley is printed from the authorised second edition, published in London, 
in large super-royal folio, and edited by his nephew, Professor Key. It contains all the Plates and all the 
Letterpress — there are no omissions, interpolations, or modifications — it is the complete work in 
ONE LARGE IMPERIAL OCTAVO VOLUME, WITH OVER 130 FIGURES ON TWENTX-SIX 
PLATES, AND OVER 400 LARGE PAGES OF LETTER-PRESS. The correctness of the plates is 
guaranteed by a revision and close examination under the eye of a distinguished Surgeon. 

The value of this work of Sir Astley Cooper's is so universally acknowledged by all medical men, that 
in presenting; this edition to the American profession, the publishers nave only to state that they have 
used their utmost endeavours to render the mechanical execution of the work worthy its exalted reputa- 
tion, and to put it in such a form and at such a price as to place it within the reach of those who have 
been prevented from obtaining it by the size and rarity of former editions. 



WATSON'S PRACTICE OF PHYSIC. 

NOW COMPLETE. 

LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC, DE- 
LIVERED AT KING'S COLLEGE, LONDON, BY THOMAS WATSON, M. 
D., Fellow of the Royal College of Physicians, Physician to the Middlesex Hospital, 
&c. &c, embracing- Ninety Lectures — complete in one octavo volume of over nine 
hundred large and condensed pages; well bound in leather. 

In presenting the following, from numerous commendations of this work, the publishers would state 
that it is among the cheapest volumes ever offered to the profession. 

" By the publication of this work, the medical literature of this country has been enriched by a work 
of standard excellence, which we can proudly hold up to our brethren of foreign countries, as a repre- 
sentative of the natural state of Britsh medicine, as professed and practiced by our most enlightened 
physicians.— We hesitate not to declare our belief that for sound, trustworthy principles, and substantial, 
good practice, it cannot, be paralleled by any similar production in any other country.— We would advise 
no one to set himself down in practice, unprovided with a copy."— British # Foreign Med. Review. 

" We know of no other work better calculated for being placed in the hands of the student, and for a 
text-book, and as such we are sure it will be very extensively adopted." — J}m. Med. Journal. 

" Open this huse and well-finished volume wherever we may, the eye immediately rests on something 
that carries value on its front. We are impressed at once with the strength and depth of the lecturer's 
views, and he gains on our admiration in proportion to 1 be extent of our acquaintance with his profound 
researches. Whoever owns this book will have an acknowledged treasure, if the combined wisdom of 
the highest authorities be appreciated." — Boston Med. and Surg. Journal. 

CONDIE ON CHILDREN. 

A NEW WORK, NOW READY. 

A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN, BY D. 
FRANCIS CONDIE, M.D., Fellow of the College of Physicians, Member of the 
American Philosophical Society, &c. &c. In one volume, 8vo. 

" Dr. Condie has studiously endeavoured to be understood by students, who need to have the elements 
of Therapeutics presented to them in a comprehensible form. 

The volume is methodically arranged in two parts. In Part I. are considered the hygienic manage- 
ment of children ; the peculiarities of organization and functions in infancy and childhood ; pathology 
of infancy and childhood ; and the semeiology of the diseases of infancy and childhood. In Part 11. are 
embraced diseases of the digestive organs ;" the mouth, throat, oesophagus, stomach, intestines, respira- 
tory organs, nervous system, the skin, eruptive fevers, cutaneous eruptions, nutritive functions, and uri- 
nary organs ; and lastiy, congenital affections, and accidents occurring soon after birth. But this is only 
an outline of the subjects brought under special notice." — Boston Med. and Surg. Journal. 

" Regarding this treatise as a whole, it is more complete and accurate in its descriptions, while it is 
more copious 'and judicious in its therapeutical directions than any of its predecessors, atid we feel per- 
suaded that the American medical profession will very soon regard it, not only as a very good, but as 
the very best ' Practical Treatise on the Diseases of Children.' "—Am. Med. Journal. 

" An excellent Practical Treatise on the Diseases of Children, and a very safe guide to the juvenile 
practitioner and student." — Med. Examiner. 

HARRISON ON THE NERVES. 

AN ESSAY TOWARDS A CORRECT THEORY OF THE NERVOUS 
SYSTEM, BY JOHN HARRISON, M.D., Professor of Physiology and Pathology 
in the Medical College of Louisiana. In one volume 8vo. 



LEA AND BLANCHARD'S PUBLICATIONS. 



SIXTH EDITION OF 

• SPECIAL ANATOMY AND HISTOLOGY, 

BY WM. E. HORNER, M.D. 

PROFESSOR OF ANATOMY IN THE UNIVERSITY OF PENNSYLVANIA, MEMBER OF THE IMPERIAL 
ME^DICO-CHIRTJRGICAL ACADEMY OF ST. PETERSBURG, OF THE AM. PHIL. SOCIETY, &C. 

In Two Volumes, 8vo. 

This edition has undergone a complete revision by Prof. Horner, and perfected from recent sources 
of information. The portion on Histology and Histogeny is two-thirds new, and a new chapter on 
Glandular Structure has been added. The author has deemed it advisable to have an Atlas of Ana- 
tomical Plates prepared, to illustrate his lectures. This has been undertaken under his supervision, 
by Dr. H. H. Smith, and forms an additional volume. 

A TREATISE ON THE DENTAL ART, 

FOUNDED ON ACTUAL EXPERIENCE. 

ILLUSTRATED BY TWO HUNDRED AND FORTY-ONE FIGURES IN LITHOGRAPHY, 
AND FIFTY-FOUR WOOD CUTS \ 

BY B. F. MAURY, DENTIST OF THE ROYAL POLYTECHNIC SCHOOL. 
Translated from the French, with Notes and Additions, 
BY J. B. SAVIER, D O C T O R O F DE N T A L SURGERY. 
One Volume, 8vo. 

This work is used as a Text-book in the Baltimore College of Dental Surgery, and commends itself 
to the Profession from the great reputation of the author, and as embracing the latest information on 
the subject. Its steady demand is the best testimony of the general favour with which the profession 
has received it. It is in fact a Cyclopaedia of the science. 

CARPENTER'S PHYSIOLOGY, 

WITH OVER ONE HUNDRED SPLENDID WOOD CUTS. 



PRINCIPLES OF HUMAN PHYSIOLOGY, 

With their chief applications to Pathology, Hygiene, and Forensic Medicine. Especially 
designed lor the use of Students ; with over One Hundred Illustrations. 

BY WILLIAM B. CARPENTER, M.D., 

LECTURER ON PHYSIOLOGY IN THE BRISTOL MEDICAL SCHOOL, &C. 
FIRST AMER. EDITION, WITH ADDITIONS BY THE AUTHOR, AND NOTES AND ADDITIONS 

BY MEREDITH CLYMER, M.D. 

Lecturer on the Institutes of Medicine, Physician to the Philadelphia Hospital, 
Fellow of the College of Physicians, &e. One Volume, Octavo. 

$5=" This edition of Carpenter's Physiology has been most carefully prepared by Dr. 
Clymer, at the request of Professor Jackson, for his lectures at the University of Penn- 
sylvania. 

"Though the resources of the author's comprehensive mind are apparently devoted to the advance- 
ment of new beginners in study, there is a splendid exhibition of the powers of analysis, an 
uncommon degree of success in making abstruse objects clear, and in forcibly impressing upon others 
the laws of life, which he so well understands himseif, which will give eclat to Dr. Carpenter's repu- 
tation, when he will be insensible to praise. All who can afford to have a good system of Physiology, 
should possess this; and those who are abte to keep pace with the progress of science should not be 
without it. There are 618 pages, laree size octavo, on good paper, with a type as distinctly made as 
it can be executed. Probably"this edition does not cost more than one. third the price asked for it ia 
England, and yet it is superior ia very many respects."— Boston Medical and Surgical Journal. 

WILSON'S DISSECTOR, 

WITH NUMEROUS CUTS. 

THE DISSECTOR, OR PRACTICAL AND SURGICAL ANATOMY. By Erasmus Wilson, 
author of a System of Human Anatomv, &c, edited and re-arranged by Paul Beck Goddard, M.D.. 
Demonstrator of Anatomy, &c, in the University of Pennsylvania ; in one large 12mo. volume, With 
numerous Illustrations. 



LEA & BLANCHARD'S PUBLICATIONS. 



A NEW WORK ON ANATOMY, 

WITH ONE HUNDRED AND SEVENTY ILLUSTRATIONS. 

A SYSTEM OF HUMAN ANATOMY, GENERAL AND SPECIAL, BY 
ERASMUS WILSON, M.D., Lecturer on Anatomy, London. - The American edi- 
tion, edited by Paul B. Goddard, A.M., M.D., Demonstrator of Anatomy in the Uni- 
versity of Pennsylvania, feci ; with one hundred and seventy illustrations on wood, by 
Gilbert, from designs prepared expressly for this work, by Bagg, printed from the 
second London edition, in 1 vol. 8vo. — Just ready. 

" An elegant edition of one of the most nsoful and accurate Systems of Anatomical Science, which 
has been issued from the press. The illustrations are really beautiful, and their execution reflects the 
highest credit on the able American artist who copied them for this edition of the work. In its style the 
work is extremely concise and intelligible. Dr Goddard has added a number of valuable notes, and has 
made some judicious alterations of names. No one can possibly take up this volume without being 
struck with the great beauty of its mechanical execution, and the clearness of the descriptions which it 
contains is equally evident. Let Students, by all means, examine the claims of this work on their 
notice, before they purchase a text-book of the vitally important science which this volume so fully and 
easily unfolds." — Lanctt. 



HOPE ON THE HEART — WITH PLATES. 

A TREATISE ON THE DISEASES OF THE HEART AND GREAT VES- 
SELS, AND ON THE AFFECTIONS WHICH MAY BE MISTAKEN FOR 
THEM, COMPRISING THE AUTHOR'S VIEW OF THE PHYSIOLOGY 
OF THE HEART'S ACTION AND SOUNDS, AS DEMONSTRATED BY 
HIS EXPERIMENTS ON THE MOTIONS AND SOUNDS IN 1830, AND 
ON THE SOUNDS IN 1834-5, BY J. HOPE, M.D., F.R.S., of St. George's 
Hospital; formerly Senior Physician to the Marylebone Infirmary; Extraordinary 
Member, and formerly President, of the Royal Medical Society of Edinburgh, &c. 
First American from the Third London Edition, with Notes and a detail of recent 
Experiments, by C. W. Pennock, M.D., Attending Physician to the Philadelphia 
Hospital, Blockley. In 1 vol. 8vo. 

" The addition of one-third of new matter to the present volume, and the care with which the whole 
has been revised and corrected, will, I trust, sufficiently prove my respect for the favourable opinion of 
my professional brethren, as evinced, not in this country only, but also on the European and American 
continents, by the sale of no less than six or seven editions and translations in as many years."— Ex- 
tract from Preface. 

MEDICAL REMEDIES. 

NEW REMEDIES. THE METHOD OF PREPARING AND ADMINIS- 
TERING THEM; THEIR EFFECTS UPON THE HEALTH AND DISEASED 
ECONOMY, &c. &c, BY PROFESSOR ROBLEY DUNGLISON. Fourth edi- 
tion, brought up to 1843. In one volume octavo. 

This work contains articles that have been recently introduced into the Materia Medica ; or old articles> 
that have received new applications, some of these are in the general works on Materia Medica, but 
their properties are only briefly referred to. In this work, the experience of individuals is extensively 
given, with reference to the original papers. Under Iodine, for example, all the information — pharma- 
ceutical and therapeutical — up to the time of the publication of the work, is afforded, with the prescrip- 
tions that have been proposed by various observers; each successive edition has incorporated with it the 
result of recent experience, and is therefore " new." 



MIDWIFERY WITH CUTS, A LATE WORK. 

A SYSTEM OF MIDWIFERY, WITH NUMEROUS WOOD CUTS, BY 
EDWARD RIGBY, M.D., Physician to the General Lying-in Hospital, Lecturer on 
Midwifery at St. Bartholomew's Hospital, &c, with notes and additional Illustrations, 
by an American Practitioner. In one volume. 

The late Professor Dewees, into whose hands this volume was placed a few weeks before his death, in 
returning it, expressed the most favourable opinion of its merits. The judgment of such high authority 
should commend it to general favour. 

DISEASES OF FEMALES. 

A TREATISE ON THE DISEASES OF FEMALES, WITH NUMEROUS 
ENGRAVINGS, BY THE LATE PROFESSOR W. P. DEWEES, in one volume 
8vo — the Eighth Edition, revised and corrected. 



LEA & BL ANC HARD'S PUBLICATIONS. 



MEDICAL LEXICON, BROUGHT UP TO 1844. 

A NEW DICTIONARY OF MEDICAL SCIENCE ; Containing a concise 
account of the various Subjects and Terms, with the French and other Synonymes, and 
Formula? for various Officinal and Empirical Preparations, &c. Fourth Edition, brought 
up to 1844. BY ROBLEY DUNGLISON, M.D., Professor in the Jefferson Medical 
College, &c. In One Volume, royal 8vo. 

" The present undertaking was suggested by the frequent complaints, made by the author's pupils, that 
they were unable to meet with information on numerous topics of Professional Inquiry, — especially of 
recent introduction, — in the medical dictionaries accessible to them. 

" It may, indeed, be correctly affirmed, that we have no dictionary of medical subjects and terms which 
can be looked upon as adapted to the state of the science. In proof of this the author need but to remark, 
that he has found occasion to add several thousand Medical Terms, which are not to be met with ii" the 
only medical lexicon at this time in circulation in this country. 

" The present edition will be found to contain many thousand Terms more than the first, and to have 
experienced numerous Additions and Modifications. 

" The author's object has not been to make the work a mere lexicon or dictionary of terms, but to 
afford, under each, a condensed view of its various medical relations, and thus to render the work an 
epitome of the existing condition of Medical Science." 

This New Edition includes, in the body of the work, the Index or Vocabulary of Synonymes that was 
in the former Editions piintcd at the end of the Volume, and embraces many Corrections, with the addi- 
tion of over Two Thousand New Words and Terms. 

PEREIRA'S MATERIA MEDICA, 

EDITED BY DR. CARSON, WITH NEAR THREE HUNDRED ENGRAVINGS ON WOOD. 

ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS; COMPRE- 
HENDING THE NATURAL HISTORY, PREPARATION, PROPERTIES, 
COMPOSITION, EFFECTS, AND USES OF MEDICINES, BY JONATHAN 
PEREIRA, M.D., F.R.S., Assistant Physician to the London Hospital, &c. 

Part I, contains the General Action and Classification of Medicines, and the Mineral Materia Medica. 
Part II, the Vegetable and Animal Kingdoms, and including diagrams explanatory of the Processes of 
the Pharmacopoeias, a Tabular view of the History of the Materia Medica, from the earliest times to the 
present day, and a very copious index. From the Second London Edition, which has been thoroughly 
revised, with the Introduction of the Processes of the New Edinburgh Pharmacopoeia, and containing 
additional articles on Mental Remedies, Light, Heat, Cold, Electricity, Magnetism, Exercise, Dietetics, 
and Climate, and many additional Wood Cuts, illustrative of Pharmaceutical Operations, Crystallogra- 
phy, Shape and Organization of the Feculas of Commerce, and the Natural History of the Materia Medica. 

The object of the author has been to supply the Medical Student with a Class Book on Materia Medica, 
containing a faithful outline of this Department of Medicine, which should embrace a concise account 
of the most important modern discoveries in Natural History, Chemistry, Physiology, and Therapeutics 
in so far as they pertain to Pharmacology, and treat the subjects in the order of their natural historical 
relations. 

This great Library or Cyclopedia of Materia Medica has been fully revised, the errors corrected, and 
numerous additions made, by DR. JOSEPH CARSON, Professor of Materia Medica and Pharmacy in 
the "College of Pharmacy," and forms Two Volumes, octavo, of near 1600 large and closely-printed 
pages; and it may be fully relied upon as a permanent and standard work for the country,— embodying, 
as it does, full references to the U. S. Pharmacopea and an account of the Medicinal Plants indige- 
nous to the United States. 

PRINCIPLES AND PRACTICE OF SURGERY, WITH CUTS. 

THE PRINCIPLES AND PRACTICE OF MODERN SURGERY, BY RO- 
BERT DRUITT. From the Second London Edition, illustrated with fifty wood en- 
gravings, with notes and comments by Joshua B. Flint, M.D., in one volume 8vo., at 
a low price. 

EXTRACT FROM THE AUTHOR'S PREFACE. 

" The arrangement of a work of this kind ought not, as I conceive, to be regarded as a matter of mere 
indifference, or at most of convenience, but it ought to embody in it something of a principle; and I 
believe that the arrangement of this work may be useful to the student, by showing him in what order 
he may best prosecute his researches into the principles of his profession. 

" Of the five parts into which it is divided, the first two are more especially devoted to the principles, 
and the three others to the practice of surgery. The first part treats of the disturbances of the constitu- 
tion at large, that may be produced bv injury or disease of a part ; beginning with the simple faintness 
or collapsethat follows a blow, and proceeding to consider the varieties of fever and tetanus. 

"The second part describes what may be called the elements of local disease; that is to say, 
morbid changes of structure or function", which are produced either immediately by external cam 
secondarilv, throueh some deviation from health, &c. , . , . . 

" The third part treats of the various kinds of injuries, beginning with the simplest mechanical inju- 
ries ; then proceeding to the effects of chemical agents, and lastly, considering the effects of animal 

P °» S> The fourth part considers the various tissues, organs 4 and regions of the body in order, and describes 
the various accidents they are liable to, &c. 

" The fifth part describes such of the operations as were not included m the former parts, &c. 

" To the whole is appended a collection of formula), the number of which is very much increased in 
this edition." 



those 
causes, or 



LEA & BLANC HARD' S PUBLICATIONS. 



FEVERS OF f HE UNITED STATES. 

THE HISTORY, DIAGNOSIS AND TREATMENT OF TYPHOID AND 
TYPHUS FEVER, WITH AN ESSAY ON THE DIAGNOSIS OF BILIOUS 
REMITTENT AND OF YELLOW FEVER, BY ELISHA BARTLETT, M.D., 
Professor of the Theory and Practice of Medicine in the Transylvania University. 
In one volume 8vo; a new work. 

Notice has already been given of the appearance of this work : we have become satisfied of its sterling 
value, and, therefore, without hesitation, feel justified in again recommending it to the immediate no- 
tice of practitioners. — Boston Medical and Surgical Journal. 

MULLER'S PHYSIOLOGY. 

ELEMENTS OF PHYSIOLOGY; BY J. MULLER, M.D., Professor of Ana- 
tomy and Physiology in the University of Berlin, &c. Translated from the German 
by William Baly, M.D., Graduate in Medicine of the University of Berlin. Ar- 
ranged from the Second London Edition by John Bell, M.D., Lecturer on Materia 
Medica and Therapeutics, &c, &c. In One Volume, 8vo. — Just ready. 

In arranging the Volume now offered to American readers, from the materials furnished in Muller's 
Elements of Physiology, the Editor has endeavoured to procure reduction in size, of this latter, with- 
out any abstraction of its vitality and mind. With this view he has omitted, for the most part, mere 
disquisitions, many details of experiments, matters of physics and natural philosophy, including mechan- 
ics under the head of locomotion, acoustics and the theories of music under voice and hearing, and of 
optics under vision, — much of the minutiae of comparative physiology, and metaphysics or metaphysico- 
physiology. But, while excluding details on collateral topics, the Editor has been particularly careful to 
preserve Physiology Proper, which, resting on the basis of Histogeny and General Anatomy, derives 
important aid from Organic Chemistry and Microscopical Observations, and in its turn serves to illus- 
trate Hygiene, Pathology and Therapeutics. Thus aided and thus applied, in the manner exhibited by 
Miiller himself, Physiology will invite the attention of the Student in these pages. 

It will soon be discovered that, although this volume is an abridgement, of the large work of Miiller, it 
may rightfully claim to be considered a complete system of Physiology, exceeding in copiousness and 
comprehensive details, any other work on the same subject which has yet emanated from the London 
press. .v/vwvw 

ELEMENTS OF PHYSICS — WITH WOOD-CUTS. 

ELEMENTS OF PHYSICS, OR NATURAL PHILOSOPHY, GENERAL 
AND MEDICAL. A New Edition, complete in One Volume, written for universal 
use, in plain and non-technical language, and containing New Disquisitions and Prac- 
tical Suggestions; comprised in Five Parts: 1. Somatology, Statics and Dynamics. 
2. Mechanics. 3. Pneumatics, Hydraulics and Acoustics. 4. Heat and Light. 
5. Animal and Medical Physics. By NEIL ARNOTT, M.D., of the Royal College 
of Physicians. A New Edition, revised and corrected from the last English Edition ; 
with additions by Isaac Hays, M.D., and numerous Wood-cuts. 



PEACTICAL MINERALOGY AND GEOLOGY-WITH CUTS. 

A TEXT-BOOK OF GEOLOGY AND MINERALOGY, WITH INSTRUC- 
TIONS FOR THE QUALITATIVE ANALYSIS OF MINERALS. BY 
JOSHUA TRIMMER, F.G.S., with Two Hundred and Twelve Wood-cuts. A 
handsome Octavo Volume, bound in embossed cloth. 

This is a Systematic Introduction to Mineralogy and Geology, admirably calculated to instruct the 
Student in those sciences. The Organic Remains of the various Formations are well illustrated by 
numerous Figures, which are drawn with great accuracy. 

ELLIS'S MEDICAL FORMULARY IMPROVED. 

THE MEDICAL FORMULARY OF DR. ELLIS; being a COLLECTION 
OF PRESCRIPTIONS, derived from the Writings and Practice of many of the most 
eminent Physicians in America and Europe. To which is added an Appendix, con- 
taining the usual Dietetic Preparations and Antidotes for Poisons ; the whole accom- 
panied with a few brief Pharmaceutic and Medical Observations. By BENJAMIN 
ELLIS, M.D. The Seventh Edition, completely revised, with many Additions and 
Modifications, and brought up to the present improved state of the Science; by Samuel 
George Morton, M.D., Professor in the Pennsylvania College of Medicine, &c., &c. 
In One Octavo Volume. 



LEA & BLANCHARD'S PUBLICATIONS. 



PRINCIPLES OF'MEDICINE. 

THE FIRST PRINCIPLES OF MEDICINE, BY ARCHIBALD BILLING, 
M.D., A.M., Member of the Senate of the University of London, Fellow of the Royal 
College of Physicians, &c, &c. In One Volume, 8vo. First American from the 
Fourth London Edition. 

" We know of no book which contains within ihe same space so much valuable information, the result 
not of fanciful theory, nor of idle hypothesis, but of close, persevering Clinical Observation, accompanied 
with much soundness of judgment, and extraordinary clinical tact." — Medico- Ckirurgicul Review. 



A DISSERTATION ON THE DISEASES OF THE MAXILLARY SINUS. 
By Chapin A. Harris, M.D., D.D.S. In one volume, 8vo. 

COATES'S POPULAR MEDICINE, OR FAMILY ADVISER, consistii g of 
Outlines of Anatomy, Physiology, and Hygiene, with such Hints on the Practice of 
Physic, Surgery, and the Diseases of Women and Children, as may prove useful in 
families when regular Physicians cannot be procured: being a Companion and Guide 
for intelligent Piincipals of Manufactories, Plantations, and Boarding Schools; Heads 
of Families, Masters of Vessels, Missionaries, or Travellers; and a useful Sketch for 
Young men about commencing the Study of Medicine. By Reynell Coates, M.D. 

This work is designed to supply the place of Ewells' Medical Companion, which is 
now entirely out of print. 

OUTLINES OF A COURSE OF LECTURES ON MEDICAL JURISPRU- 
DENCE. By Thomas Stewart Traill, M.D., with notes and additions. A small volume. 

A PRACTICAL TREATISE ON MEDICAL JURISPRUDENCE, with so 
much of Anatomy, Physiology, Pathology, and the Practice of Medicine and Surgery, 
as are Essential to be known by Members of the Bar and Private Gentlemen; and all 
the Laws relating to Medical Practitioners; with Explanatory Plates. By J. Chitty, 
Esq., second American edition, with notes and additions adapted to American Works 
and Judicial Decisions. In One Volume Octavo. 

ABERCROMBIE ON THE BRAIN. Pathological and practical Researches on 
Diseases of the Brain and Spinal Cord. New edition, 1 vol. 8vo. 

A PRACTICAL TREATISE ON THE HUMAN TEETH, showing the causes 
of their destruction and the means of their preservation, by William Robertson. With 
plates. First American from the second London Edition. In one volume octavo. 

ANATOMY, PHYSIOLOGY, AND DISEASES OF THE TEETH. By 
Thomas Bell, F.R.S., F.L.S., &c. Third American edition. In one volume octavo, 
with numerous plates. 

DISSERTATIONS ON NERVOUS DISEASES. By Drs. James Hope, J. C. 
Prichard, John Hughes Bennett, Robert H. Taylor and Theophilus Thomson. In one 
volume octavo. 

DISSERTATIONS ON DISEASES OF THE ORGANS OF RESPIRATION. 
By Drs. Williams, Theophilus Thomson, W. B. Carpenter, and W. Bruce Joy. In 
one volume octavo. 

DISSERTATIONS ON FEVERS, GENERAL PATHOLOGY, INFLAMMA- 
TION, AND DISEASES OF THE SKIN. By Drs. Symonds, Allison, Christison, 
&c. &c. In one volume octavo. 

DISSERTATIONS ON DISEASES OF THE DIGESTIVE, URINARY AND 
UTERINE ORGANS. By Drs. Joy, Symonds, Thomson, Ferguson, &c. &c. In 
one volume octavo. 

DISSERTATIONS ON H HEMORRHAGES, DROPSY, RHEUMATISM, 
GOUT, SCROFULA, &c. &c. By Drs. Burrows, Watson, Shapter, Joy, &c. &c. 
In one volume octavo. 

The above five volumes are from the Library of Practical Medicine, edited by Dr. 
Tweedie, with notes by Dr. Gerhard. Each volume is complete within itself, and is 
for sale separately. 

A TREATISE ON PROTRACTED INDIGESTION AND ITS CONSE- 
QUENCES. Being the application to the' practical department of Medicine of the 
> Results of an Inquiry into the Laws of the Vital Functions. By A. P. W. Philip, M.D., 
F.R.S., &c. &c. From the Eighth London Edition. In 1 vol, 8vo, 



LEA & BLANC HARD' S PUBLICATIONS. 



DISEASES OE FEMALES, PREGNANCY AND CHILDBED. 

THE PRINCIPAL DISEASES OF FEMALES, TOGETHER WITH THE 
DISEASES INCIDENT TO PREGNANCY AND CHILDBED, CHIEFLY FOR 
THE USE OF STUDENTS, BY FLEETWOOD CHURCHILL, M.D., Lecturer 
on Midwifery and Diseases of Women and Children, in the Richmond Hospital, School 
of Medicine, &c. &c, with Notes and Additions by R. M. Huston, M.D., Professor, &c. 
in the Jefferson Medical College. Second American Edition, in 1 vol. 8vo.— Just ready. 

DUNGLISON'S PHYSIOLOGY - WITH ILLUSTRATIONS. 

HUMAN PHYSIOLOGY, ILLUSTRATED WITH THREE HUNDRED 
ENGRAVINGS ON WOOD ; BY PROFESSOR ROBLEY DUNGLISON; the 
fifth edition with numerous additions and modifications, in 2 vols. 8vo. 

This work is occupied with the functions executed by healthy man. It embraces a genera! exposition 
of the functions ; the new views entertained in regard to the formation of the tissues ; but is especially 
intended to give an accurate view of the actions of the different organs, as an introduction to the study 
of .pathology, hygiene and therapeutics. It treats moreover, of the anatomy of the organs so far as is 
necessary for a full understanding of the functions; and is largely illustrated by appropriate engravings. 
The last edition contains ninety additional illustrations to elucidate either topics that have been already 
touched upon in the work, or such as are new. Every effort has been made to place the work, in all 
respects, on a level with the existing state of the science. 

THE DISEASES OF THE EYE. 

A TREATISE ON THE DISEASES OF THE EYE, BY W. LAWRENCE, 
Surgeon Extraordinary to the Queen, &c, from the last London Edition, with numerous 
additions, and sixty-seven Illustrations, many of which are from original drawings. 
By Isaac Hays, M.D., Surgeon to the Wills Hospital, &c, &c., in 1 vol. 8vo.— 
Just ready. • 

The character of this work is too well established to require a word of commendation— it is justly 
considered the best on the subject. The present is a reprint of the last London Edition, which appeared 
in 1841, completely revised and greatly enlarged by the author— and to it considerable additions have 
been made by the editor. Several subjects omitted in the original are treated of in this edition, on which 
occasion free use has been made of the work of Mackenzie, to which is added the editor's own experi- 
ence, derived from many years' attention to the subject. 



THE URINARY ORGANS, &c. 

LECTURES ON THE DISEASES OF THE URINARY ORGANS, BY SIR 
B. C. BRODIE, BART. F.R.S. From the Third London Edition, with alterations 
and additions, a small 8vo. volume. — Now ready. 

The work has throughout been entirely revised, some of the author's views have been modified, and a 
considerable proportion of new matter has been added, among which is a Lecture on the Operation of 
Lithotomy. ^aaa.^^v 

RICORD ON VENEREAL. 

A PRACTICAL TREATISE ON VENEREAL DISEASES; OR, CRITICAL 
AND EXPERIMENTAL RESEARCHES ON INOCULATION, APPLIED TO 
THE STUDY OF THESE AFFECTIONS; WITH A THERAPEUTICAL 
SUMMARY AND SPECIAL FORMULARY, BY PH. RICORD, M.D., Surgeon 
of the Venereal Hospital of Paris, Clinical Professor of Special Pathology, &c. 
Translated from the French, by Henry Pilkington Drummond, M.D., in one volume. 
— AW ready. -'' 

LAWRENCE ON RUPTURES. 

A TREATISE ON RUPTURES, BY W. LAWRENCE, F.R.S., Author of a 
Treatise on the Diseases of the Eye, &c. &c, from the Fifth London Edition, consi- 
derably enlarged. In 1 vol. 8vo. — Now ready 

The peculiar advantage of the treatise of Mr. Lawrence is, that he explains his views on the anatomy 
of hernia, and the different varieties of the disease, in a manner which renders his book peculiarly useful 
to the student. It must be superfluous to express our opinion of its value to the surgical practitioner. 
As a treatise on hernia, presenting a complete view of the literature of the subject, it stands in the first 
rank. — Edinburgh Medical and Surgical Journal. 



WORKS FOR SCHOOLS AND COLLEGES. 



LEA AND BLANC HARD 

PUBLISH AND HAVE FOR SALE THE FOLLOWING VALUABLE AND USEFUL 
WORKS FOR ACADEMIES AND COLLEGES. 

ARNOTT'S PHYSICS. 

ELEMENTS OF PHYSICS; OR, NA1URAL PHILOSOPHY, 

GENERAL AND MEDICAL. 

Written for universal use in plain, or non-technical language, by Niell Arnott, M.D. A 
new edition, by Isaac Hays, M.D. Complete in one octavo volume, with nearly two hundred 
wood-cuts. 

This standard work has been long and favourably known as one of the best popular expositions of the interesting 
science it treats of. It is extensively used in many of the first seminaries. 

BUTLER'S ANCIENT ATLAS. 

AN ATLAS OF ANCIENT GEOGRAPHY, 

By Samuel Butler, D.D., late Lord Bishop of Litchfield ; containing Twenty-one Coloured 
Maps, and a complete Accentuated Index. In one octavo volume, half bound. 

BUTLER'S ANCIENT GEOGRAPHY. 

Geographia Classica, or the application of Ancient Geography to the Classics, by Samuel 
Butler, D.D., F.R.S. Revised by his Son. Fifth American, from the last London edition; 
with Questions on the Maps, by John Frost. In one octavo volume, half bound, to match 
the Atlas. 

WHITE'S UNIVERSAL HISTORY. 

Elements of Universal History, on a new and systematic plan; from the^earliest times to the 
Treaty of Vienna; to which is added a summary of the leading events since that period. For 
the use of Schools and private Students, by H. White, B.A.. Trinity College, Cambridge ; 
with Additions and Questions, by John S. Hart, A.M., Principal of the Philadelphia High 
School, &c, in one volume, large 12mo., neatly half bound. 

This work is arranged on a new plan, which is believed to combine the advantages of those formerly in use. It is 
divided into three parts, corresponding with Ancient, Middle, and Modern History ; which parts are again subdivided 
into centuries, so that the various events are presented in the order of time, while it is so arranged that the annals of 
each country can be read consecutively, thus combining the advantages of both the plans hitherto pursued in works 
of this kind. To guide the researches of the student, there will be found numerous synoptical tables, with remarks 
and sketches of literature, antiquities, and manners, at the great chronological epochs. 

The additions of the American editor have been principally confined to the chapters on the history of this country. 
The series of questions by him will be found of use to those who prefer that system of instruction. For those who 
do not, the publishers have had an edition prepared without the questions. 



HERSCHELL'S ASTRONOMY. 

A Treatise on Astronomy, by Sir John F. W. Herschell, F.R.S., &c. ; with numerous 
plates and wood-cuts. A new edition, with a Preface and a series of Questions, by S. C. 
Walker. In one volume, 12mo. 

BREWSTER'S OPTICS. 

Elements of Optics, by Sir David Brewster ; with Notes and Additions, by A. D. Bache, 
LL.D., Superintendent of the Coast Survey, &c. In one volume, 12mo., with numerous 
wood- cuts. 

BOLMAR'S FRENCH SERIES. 

New editions of the following works, by A. Bolmar, forming, in connection with "Bolmar's 
Levizac," a complete series for the acquisition of the French language. 

A SELECTION OF ONE HUNDRED PERRIN'S FABLES, accompanied by a 
Key, containing the text, a literal and free translation, arranged in such a manner as to point 
out the difference between the French and English idiom, &c, in 1 vol., 12mo. 

A COLLECTION OF COLLOQUIAL PHRASES, on every topic necessary to 
maintain conversation, arranged under different heads, with numerous remarks on the peculiar 
pronunciation and uses of various words ; the whole so disposed as considerably to facilitate the 
acquisition of a correct pronunciation of the French, 1 vol., 18mo. 

LES A VENTURES DE TELEMAQUE PAR FENELON, in 1 vol., 12mo., accom 
panied by a Key to the first eight-books, in 1 vol., 12mo., containing, like the Fables, the text, 
a literal and free translation, intended as a sequel to the Fables. Either volume sold separately. 

ALL THE FRENCH VERBS, both regular and irregular, in a small volume. 



CYCLOPAEDIA OF PRACTICAL MEDICINE. 



LEA AND BLANCHARD, 

PHILADELPHIA, 
HAVE LATELY PUBLISHED 

THE CYCLOPEDIA 
OF PRACTICAL MEDICINE; 

COMPRISING- 
TREATISES ON THE 

NATURE AND TREATMENT OF DISEASES, 
MATERIA MEDICA AND THERAPEUTICS, 
MEDICAL JURISPRUDENCE, &c. &c. 

EDITED BY 

JOHN FORBES, M.D.,F.R.S. 

Physician in Ordinary to her Majesty's Household, &o. 

ALEXANDER TWEEDIE, M.D.,F.R.S. 

Physician to the London Fever Hospital, and to the Foundling Hospital, &c. 

JOHN CONOLLY, M.D. 

Late Professor of Medicine in the London University, and Physician to the Hanwell 

Lunatic Asylum, &c. 



THOROUGHLY REVISED, WITH ADDITIONS, 
BY ROBLEY DUNGLISON, M.D. 

Professor of the Institutes of Medicine, &c. in the Jefferson Medical College, Philadelphia % 
Lecturer on Clinical. Medicine, and Attending Physician at the Philadelphia 
Hospital j Secretary of the American Philosophical Society, &c. 



TERMS OF PUBLICATION. 

THE WORK IS PRINTED WITH A NEW AND CLEAR TYPE, ON FINE WHITE PAPER, 

FORMING 

FOUR LARGE SUPER-ROYAL OCTAVO VOLUMES, 

STRONGLY AND BEAUTIFULLY BOUND; 
EMBRACING- 

THIRTY-TWO HUNDRED UNUSUALLY LARGE PAGES, 

IN DOUBLE COLUMNS. 
IT MAT ALSO BE H A D*I N 

TWENTY FOUR PARTS, AT FIFTY CENTS EACH. 



A E&AGmnCETOT MD CHEAP WOKS, 

SMITH & HORNER'S ANATOMICAL ATLAS. 

Just Published, Price Five Dollars in Parts. 



AN 

ANATOMICAL ATLAS 
ILLUSTRATIVE OF THE STRUCTURE OF THE HUMAN B033Y. 

BY HENRY H. SMITH, M. D., 

Fellow of the College of Physicians, 8;c. 
UNDER THE SUPERVISION OF 

WILLIAM E. HORNER, M. D., 

Professor of Anatomy in the University of Pennsylvania. 

In One large Volume, Imperial Octavo. 

This work is but just completed, having been delayed over the time intended by the great difficulty in giving 
to the illustrations the desired finish and perfection. It consists of five parts, whose contents are as follows : 
Pakt I. The Bones and Ligaments, with one hundred and thirty engravings. 
Part II. The Muscular and Dermoid Systems, with ninety-one engravings. 

.Part III. The Organs of Digestion and Generation, with one hundred and ninety-one engravings. 

Part IV. The Organs of Respiration and Circulation, with ninety-eight engravings. 

Part V.-The Nervous System and the Senses, with one hundred and twenty-six engravings. 
Forming altogether a complete System of Anatomical Plates, of nearly 

SIX HUNDRED AND FIFTY FIGURES, 
executed in the best style of art, and making one large imperial octavo volume. Those who do not want it in 
parts can have the work bound in extra cloth or sheep at an extra cost. 

This work possesses novelty both in the design and the execution. It is the first attempt to apply engraving 
on wood, on a large scale, to the illustration of human anatomy, and the beauty of the parts issued induces the 
publishers to natter themselves with the hope of the perfect success of their undertaking. The plan of the 
work is at once novel and convenient. Each page is perfect in itself, the references being immediately under 
the figures, so that the eye takes in the whole at a glance, and obviates the necessity of continual reference 
backwards and forwards. The cuts are selected from the best and most accurate sources ; and, where neces- 
sary, original drawings have been made from the admirable Anatomical Collection of the University of Penn- 
sylvania. It embraces all the late beautiful discoveries arising from the use of the microscope in the investi- 
gation of the minute structure of the tissues. 

In the getting up of this very complete work, the publishers have spared neither pains nor expense, and they 
now present it to the profession, with the full confidence that it will be deemed all that is wanted in a scientific 
and artistical point of view, while, at the same time, its very low price places it within the reach of all. 

It is particularly adapted to supply tlie place of skeletons or subjects, as.the profession will see by examining the list 
of plates now annexed. 



"These figures aTe well selected, and present a complete and accurate representation of that wonderful fabric, 
the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its 
superb artistical execution, have been already pointed out. We must congratulate the student upon the 
completion of this atlas, as it is the most convenient work of the kind that has yet appeared ; and, we must 
add, the very beautiful manner in which it is ' got up' is so creditable to the country as to be nattering to our 
national pride." — American Medical Journal. 

"This is an exquisite volume, and a beautiful specimen of art. We have numerous Anatomical Atlases, 
but we will venture to say that none equal it in cheapness, and none surpass it in faithfulness and spirit. We 
strongly recommend to our friends, both urban and suburban, the purchase of this excellent work, for which 
both editor and publisher deserve the thanks of the profession." — Medical Examiner. 

"We would strongly recommend it, not only to the student, but also to the working practitioner, who, 
although grown rusty in the toils of his harness, still has the desire, and often the necessity, of refreshing his 
knowledge in this fundamental part of the science of medicine." — New York Journal of Medicine and Surg. 

" The plan of this Atlas is admirable, and its execution superior to any thing of the kind before published in 
this country. It is a real labour-saving affair, and we regard its publication as the greatest boon that could be 
conferred on the student of anatomy. It will be equally valuable to the practitioner, by affording him an easy 
means of recalling the details learned in the dissecting room, and which are soon forgotten." — American Medi- 
cal Journal. 

" It is a beautiful as well as particularly useful design, which should be extensively patronized by physicians, 
surgeons and medical, students." — Boston Med. and Surg. Journal. 

" It has been the aim of the author of the Atlas to comprise in it me valuable points of all previous works, to 
embrace the latest microscopical observations on the anatomy of the tissues, and by placing it at a moderate 
price to enable all to acquire it who may need its assistance in the dissecting or operating room, or other field 
of practice." — Western Journal of Med. and Surgery. 

''These numbers complete the series of this beautiful work, which fully merits the praise bestowed upon the 
earlier numbers. We regard all the engravings as possessing an accuracy only equalled by their beauty, 
and cordially recommend the work to all engaged in the study of anatomy." — New York Journal of Medicme 
and Surgery". 

" A more elegant work than the one before us could not easily be placed by a physician upon the table of 
his student." — Western Journal of Medicine and Surgery. 

"We were much pleased with Part I, but the Second Part gratifies us still more, both as regards the attract- 
ive nature of the subject, (The Dermoid and Muscular Systems,) and the beautiful artistical execution of the 
Illustrations. We have here delineated the most accurate microscopic views of some of the tissues, as, for 
instance, the cellular and adipose tissues, the epidermis, rete mucosum and cutis vera, the sebaceous and 
perspiratory organs of the skin, the perspiratory glands and hairs of the skin, and the hair and nails. Then 
follows the general anatomy of the*nuscles, and, lastly, their separate delineations. We would recommend 
this Anatomical Atlas to our readers in the very strongest terms."-*^V"«0 York Journal of Medicine and Sw 
gery. 



